How much should I bump my pressure?

Jason --

From what I have read on this forum, the goal of a titration is to find the minimum pressure that eliminates apneas, hypopneas and RERAs (Respiratory Event Related Arousals) in any position. The supine position requires the highest pressures in most people.

RERAs are events with less flow limitation than hypopneas but which still cause arousals. It is desirable that all arousals be eliminated.

DoriC wrote:Jason, that's how we were able to determine my husband's best pressure setting, by using an auto on various settings and having the software to analyze events, leaks, snores,etc. (I must say we had a lot of help with that from the pros). He was titrated at a pressure at 13cm so we started with an 11-15cm range, making adjustments for several months until we determined that the changing auto pressures disturbed his sleep and the daily reports showed that cpap at 12cm gave him his best AHI. In our case, we were lucky that the titration was pretty accurate, but as I've learned here, many sleep studies are way off the mark and don't show the whole picture.

I'm curious why you feel you were "lucky" that your titration was accurate. It would seem to me a sleep study lab with its sophisticated equipment and multitude of sensors would be far more accurate than a single sensor CPAP machine with software. It is true a sleep study is only one night, but I didn't have a problem sleeping and the technician reported to me she got a good titration (I didn't ask her). So I really have no call to question a titration done by a professional in a sophisticated lab environment when the alternative is my own home testing and experimentation.

I'm not sure how much a new APAP machine with software would cost, but I can envision a few scenarios:

1. like your husband, abrupt changes in pressure could disrupt my sleep rather than enable it
2. the end result of experimental pressure testing with software analysis ends up being the same as my original titration and therefore I have throw X amount of dollars down the drain.

Jason S. wrote:I'm curious why you feel you were "lucky" that your titration was accurate. It would seem to me a sleep study lab with its sophisticated equipment and multitude of sensors would be far more accurate than a single sensor CPAP machine with software. It is true a sleep study is only one night, but I didn't have a problem sleeping and the technician reported to me she got a good titration (I didn't ask her). So I really have no call to question a titration done by a professional in a sophisticated lab environment when the alternative is my own home testing and experimentation.

I'm not sure how much a new APAP machine with software would cost, but I can envision a few scenarios:

1. like your husband, abrupt changes in pressure could disrupt my sleep rather than enable it
2. the end result of experimental pressure testing with software analysis ends up being the same as my original titration and therefore I have throw X amount of dollars down the drain.

Morning Jason,
I wish you the best in your endeavor to improve the way you feel without the aid of software to guide you. In some ways I do understand what you are saying about being able to judge effectiveness by the way you feel. I have the software and I can usually tell by the way I feel if my data is going to be good or not.

Can I comment on sleep titration studies? Not everyone gets a "good study" done for any number of reasons. Not everyone has a sleep tech that is forthcoming with what they consider adequate testing and data. Yes, in theory they should give us the best case scenario with the availability of direct eyes and hands on pressure changes by the tech. In my case I wanted punch the guy in the face that did mine. Holier than God attitude and told me that sleep titration results would likely be much better than what I got at home for a while because he had just the advantages you talk about at his disposal. He also told me that the software wasn't need to judge therapy effectiveness. He told me to go by the way I feel each morning. So the morning after the titration study (full night not split study) I wake up with my usual massive headache. I asked him did we get good data and did the numbers show that I should feel good. He told me "oh yes, you did very well and you should feel much better". So I asked him how come the massive usual headache if I did so well? Hmmm.... he was strangely silent.

Come to find out the titration study itself was sorely limited. I slept 175 minutes out of 400. Sleep efficiency was only 44%. It took me 123 minutes to get to Rem sleep where I had 53 events per hour in the initial study. I spent only 30 minutes in REM sleep. Not really much time to really address my worst case scenario. It was mentioned that I spent 100% of the time asleep on my back so that potential positional factor was already in place.

I was prescribed CPAP at 8 cm of pressure. At home with this pressure I had zero improvement of symptoms despite not all that bad AHI's (7-9 per hour and very decent leak rates). I had already purchase my current M series with C flex APAP because it was what I wanted. I got the software and set the machine to 8 min and higher max and watched what was happening. I was having 10-20 events in little clusters about 2 hours apart and not much else going on any other time. Overall nightly AHI averages weren't so bad but those clusters were making me feel awful. I adjusted my pressure. I seem to need a minimum pressure of 10 cm to prevent the majority of those event clusters. 90% of my events are apneas. I don't have many hypopneas. I don't have any history of centrals.

Sometimes (like last night) I find that my maximum pressure will climb to 15 cm or above. I can see from the graphs that it climbs in response to events and not leaks or snores so it wasn't chasing ghosts. This doesn't happen often but it does happen. These pressure increases never wake me. The changes are not all that "abrupt" and not everyone has a problem with the increases.

I don't know if you ever posted your actual sleep titration study results so I cannot comment on how "good" the data might have been that you were given to start your therapy. As you can tell from my experience, it wasn't a good indication of how I normally sleep. It got me in the ball park but I needed fine tuning.

The data provided by my software is priceless to me for my peace of mind. Do I chase numbers? No. I use it to see if there is a possible reason behind why I might feel like crap somedays. I have already learned that even the LCD averages shown can be skewed a bit. My mind set is such that this is something I value. You don't yet see the value in it. You may never feel like there is enough value in monitoring data to justify the expense. Each to their own thinking. Good luck to you on your quest. I wouldn't have had the patience to try all my experiments flying blind.

As to #1, our experimenting taught us a lot about this whole business of what constitutes "good sleep" such as if my husband could have tolerated the changing pressures he would be sleeping at 11cm most of the night ,yet on straight cpap at that pressure he has a much higher AHI and needs more pressure to prevent events. I feel that knowledge like this and much more has given us the power to succeed. As for #2, that's the luck I was talking about.

Pugsy wrote: I don't know if you ever posted your actual sleep titration study results so I cannot comment on how "good" the data might have been that you were given to start your therapy. As you can tell from my experience, it wasn't a good indication of how I normally sleep.

I'm fairly certain I never saw the detailed results of the titration study. My polysomnogram I did get the report.

Sleep efficiency 71% low
Sleep onset time 30 min normal
REM sleep latency 114 min normal
RDI 32/hr
AHI 26/hr
RDI during REM 46/hr
RDI during REM supine 50/hr
Max oxygen saturation 100%
Avg SaO2 in sleep 96%
Min. SaO2 during sleep 87%
SaO2 was under 90% for 1% of sleep time
frequent moderately loud snoring
Leg movements absent
cardiac - unremarkable

Diag - Moderate OSA syndrome (327.23) by AHI with severe sleep fragmentation, worse while supine and in REM.

I'm glad you got a good titration JasonS. So many of us did not!

I had a PSG and the following sleep study in 2002. I was given a straight cpap machine. I used it for 5+ years. In 2008 I had another retitration because I was feeling more fatigue and wanted things checked out. I had such a wait (October to April) to get the retitration that I bought an APAP with software and reader online in February of 2008.

I got my therapy working well on the APAP with help from members of this forum, with an AHI usually below 1.

When I finally got to my retitration I slept very little (as was the case with my PSG and my original titration). They only attempted to get my AHI below 5 (actually 4.2). Given how little sleep I got, I think they only worked to get my AHI just below 5. I knew I felt better at a higher setting because of my experience with the auto and the data told me I was doing well too.

When I finally got ALL my sleep study results (PSG, titration and retitration), I discovered that I barely slept 4 hours for ANY of them and had very little REM sleep during any of them.

For some, it's like my situation. Some people just do not sleep well under those circumstances. I sleep very well almost every night at home.

As I said, I'm glad yours was better than many here.

Jason S. wrote: I'm not sure how much a new APAP machine with software would cost, but I can envision a few scenarios:

1. like your husband, abrupt changes in pressure could disrupt my sleep rather than enable it
2. the end result of experimental pressure testing with software analysis ends up being the same as my original titration and therefore I have throw X amount of dollars down the drain.

1. If you discover that pressure variations disrupt your sleep, then set the APAP to CPAP mode. In my opinion, the extra cost of an APAP is worth it if you can afford it, but the crucial feature you need is a data capable machine to track efficacy.
2. It's not money down the drain. Even if your titration pressure is on the money today, it might not be at some point in the future. Aging, losing weight, gaining weight, hormonal changes, etc., all affect your pressure requirements, and it's important to see this happening BEFORE you have an accident or health issue.

El Pap wrote:
1. If you discover that pressure variations disrupt your sleep, then set the APAP to CPAP mode. In my opinion, the extra cost of an APAP is worth it if you can afford it, but the crucial feature you need is a data capable machine to track efficacy.
2. It's not money down the drain. Even if your titration pressure is on the money today, it might not be at some point in the future. Aging, losing weight, gaining weight, hormonal changes, etc., all affect your pressure requirements, and it's important to see this happening BEFORE you have an accident or health issue.

Good points. How much would a new APAP go for?

Jason S. wrote:I'm fairly certain I never saw the detailed results of the titration study. My polysomnogram I did get the report.

You might consider getting a copy of the titration study and comparing the 2 studies. There are just so many variables that can affect how we feel. At least you would have as much information available to you as is possible right now. O2 saturation is one variable. In my initial study I dropped to 73% and I notice on my titration study that it mentions I spent 10% of my 175 minutes below 88%. When I see clusters of events on my graphs I would bet money that I am also having significant O2 level drops. When I see clusters I wake up with headache that will go away in an hour or so. When I don't see clusters I don't have a headache when I wake up. No money to buy Pulse ox now but later I will just to satisfy my curiosity. Desaturations cause damage and I want to know for sure if my assumptions are correct so that I can quickly try to address whatever seems to be causative factor in the clusters. I already know that they are REM related as they were well documented in the first study. Positional factors may also be involved.

I am too much of a newbie to remotely suggest what may be going on with you and why you feel like you aren't doing as well as you did initially. I can only suggest to get your hands on whatever data is available and look closely to see if you spot something that might be a contributing factor. You already know that you were worse on your back but do you have real proof that the titration study really addressed supine sleeping effectively and even then remember a one night titration doesn't mirror real life? Just how good was your sleep efficiency at your titration study? It might not have been as good of an indicator as it could have been if you still had only 71% efficiency. Just a thought rambling through my little pea brain. My sleep efficiency was total crap on both studies. Its a wonder that I got what I did in the way of any results.

Jason S. wrote:Good points. How much would a new APAP go for?

What brand of machine would you want to try?
Cpapauction has some new APAPs available. I have the Respironics M series Auto with C Flex. I don't need CFlex and the pressure changes throughout the night have never once woke me up. I don't like the LCD information that is given. AHI, leak rate in 7/30 day averages (but you can reset to zero each night) is all you get besides therapy hours. Find my posts with data reports and you will see graphs. If I absolutely wasn't going to ever use software I would get a ResMed because they offer more detailed data on the LCD screen.

Prices vary but somewhere between $400 - 600 new, depending on what you want at auction.

My unit with humidifier sells for $649 through cpap.com , A Flex is only slightly more. Less if you already have humidifier.

Pugsy wrote:

Jason S. wrote:Good points. How much would a new APAP go for?

What brand of machine would you want to try?
Cpapauction has some new APAPs available. I have the Respironics M series Auto with C Flex. I don't need CFlex and the pressure changes throughout the night have never once woke me up. I don't like the LCD information that is given. AHI, leak rate in 7/30 day averages (but you can reset to zero each night) is all you get besides therapy hours. Find my posts with data reports and you will see graphs. If I absolutely wasn't going to ever use software I would get a ResMed because they offer more detailed data on the LCD screen.

Prices vary but somewhere between $400 - 600 new, depending on what you want at auction.

My unit with humidifier sells for $649 through cpap.com , A Flex is only slightly more. Less if you already have humidifier.

Those numbers are hard to believe because my bottom-of-the-line machine was $1700 new. Are we talking new or refurbished? I was assuming it would be more that $3000 for a new, data-capable APAP. Also, can the humidifier I have on my cheap-ass machine be transferred to another machine? Are they modular or integrated?

You can use your M Series humidifier with any M Series machine. It is integrated but they do come apart. It's hard to tell that and when you take them apart you think you have broken something but the machine "snaps" out. It isn't breaking. You just snap your new machine in.

Having the humidifier will cut costs for you if you buy an M Series auto. Check it on cpap.com.

Jason S. wrote:Those numbers are hard to believe because my bottom-of-the-line machine was $1700 new. Are we talking new or refurbished? I was assuming it would be more that $3000 for a new, data-capable APAP. Also, can the humidifier I have on my cheap-ass machine be transferred to another machine? Are they modular or integrated?

We are talking brand new not refurbished. Your humidifier (if it is the same one showing in your profile) would work on the new Respironics M series data capable machines (either cpap or auto).

You cannot compare DME prices with what we can get online. DME's jack up the prices for any number of reasons. Part to include "service", part to allow for what they will eventually write off if insurance disallows a certain amount. Depending on insurance, co-pays, deductibles and such it often is less out of pocket to just bite the bullet and purchase from online supplier.

What did your cheap ass machine actually cost you out of pocket? Remstar M series DS100 cpap which I think is what you have is available from cpap.com for $199.95. You do the math. Our hosts are making money at $199 and we don't fault them for making money, your DME screwed either you or your insurance company big time.

I bought my machine from an individual. Zero hours of use on it (I checked because blower hours can't be hidden)
I paid $480 (included the humidifier). This was actually less out of pocket than my co-pays would have been for a basic cheap ass machine my DME wanted to give me and I got the auto unit that I wanted which they couldn't do because script was for CPAP.

Get a copy of your CPAP prescription to our hosts here at cpap.com and it will allow you to purchase an auto Cpap if you wish or any data capable regular CPAP of your choice from either their stock or a good deal at the auction.

PM me if you wish to consider the Encore viewer software.

Jason S. wrote:..........
Those numbers are hard to believe because my bottom-of-the-line machine was $1700 new. Are we talking new or refurbished? I was assuming it would be more that $3000 for a new, data-capable APAP. Also, can the humidifier I have on my cheap-ass machine be transferred to another machine? Are they modular or integrated?

I recently checked a quote at cpap.com for a bundle of Respironics A-Flex machine/heated humidifier/card reader/Encore Viewer software for $898 including shipping and everything is new. That would be everything you need and if you shop around you might find it cheaper (cpap.com matches prices).

$898 is a good price for that bundle. If you don't need the humidifier, I would ask them to quote a bundle without humidifier.

From readings here, I have concluded that all brands of machines have significant bad design features and I have my complaints about my A-Flex. But it does get the job done well and I recommend it exclusively.

Once you get the software you will never want to be without it again.

rooster wrote:

Jason S. wrote:..........
Those numbers are hard to believe because my bottom-of-the-line machine was $1700 new. Are we talking new or refurbished? I was assuming it would be more that $3000 for a new, data-capable APAP. Also, can the humidifier I have on my cheap-ass machine be transferred to another machine? Are they modular or integrated?

I recently checked a quote at cpap.com for a bundle of Respironics A-Flex machine/heated humidifier/card reader/Encore Viewer software for $898 including shipping and everything is new. That would be everything you need and if you shop around you might find it cheaper (cpap.com matches prices).

$898 is a good price for that bundle. If you don't need the humidifier, I would ask them to quote a bundle without humidifier.

From readings here, I have concluded that all brands of machines have significant bad design features and I have my complaints about my A-Flex. But it does get the job done well and I recommend it exclusively.

Once you get the software you will never want to be without it again.

That's doable but I don't need the humidifier if I buy M-series and I don't think I need a "Flex" option although they probably are standard with the higher-end machines.