Ongoing journey to tweak my APAP range

Wulfman · Post by **Wulfman** » Sun Dec 06, 2009 12:45 pm

GaryG wrote:
Wulfman wrote:An AHI of 1.0 or less (or there-abouts) is fine......but you indicated that you were still tired. The amount of time on the hose has something to do with that, but IF the pressure changes are keeping you from going into deep sleep or REM, you need to take that into consideration.
Den, how can I tell if I'm having REM sleep or not? I mean, after all, I'm sleeping ok (or I think I am). I'm not aware of waking up at higher pressure changes. I see my 95 percentile numbers make 10 a reasonable CPAP range to try, but I'm trying to understand why you'd recommend CPAP over APAP.

Well, you really CAN'T tell if you're in REM or deep sleep stages. However, according to the information available about sleep stages, they go through cycles during the night......roughly 70 - 120 minutes (depending on which article you read). If a person sees in their nightly reports that their apneas occur or increase at around that interval, there's a CHANCE that that's when they're occurring.

Here's what jumped out at me in your first post:

GaryG wrote:So if I were feeling great, this would be the end of the story. But my problem is I don't. I'm still tired - not as tired.

Here are some links about sleep stages:

http://helpguide.org/life/sleeping.htm

http://www.sleepdex.org/stages.htm

http://en.wikipedia.org/wiki/Sleep

If you're having events during deep sleep stages or REM, the pressure changes can disrupt that restorative sleep. You may not wake up, but you may end up in a different sleep stage and thus throw off the sleep cycles. You may also end up spending more time in stage 2 (a lighter stage) and not get enough deeper sleep. Ever have the alarm clock wake you up and you're disoriented and feel like crap for quite awhile? It woke you out of a deep sleep stage and you didn't get to cycle through them like if you'd have awakened "naturally" (without interuptions). That's possibly what happens if you're sleeping along and go into a cycle where you're inclined to have apneas and then the machine changes pressures due to the flow limitations or snores......if your system (subconscious) is prone to being sensitive to pressure changes, that machine could be like that alarm clock.

In my own situation, I was prescribed a pressure of 18 cm......couldn't handle that, although I TRIED it for about an hour and then did an "Eenie, Meenie, Minie, Moe"......read that 10 cm. was about the "average" pressure.....and tried it. Not too low and not too high. My first month and a half (I started in mid-May), I had an AHI average of 1.6. The following months they were all < 1.0. The only thing that made me move up to 12 (a year later) was to decrease my snore numbers (my AHI actually saw no improvement).

AND, I had the software from "Day One", so I was prepared to alter my settings from the beginning.......but found I didn't really need to.

Den

kteague · Post by **kteague** » Sun Dec 06, 2009 1:28 pm

Gary, I am one who found getting an apap to be very useful in getting my treatment on track, and didn't feel the pressure changes had anything to do with my shattered sleep. My doc wanted me to go back to cpap so we could know we had eliminated all identifiable possible contributors. I couldn't tell that the switch helped my wakeups, but then again, many arousals we are not even aware of so how would one know if they'd been corrected? With going to cpap I did have more air in the belly trouble, but I've not felt compelled to go back to apap. Got very similar excellent AHI numbers from both (and the auto was a ResMed ), though occasional 0.0 AHI nights have become a norm on cpap. That could have been more related to finding a good fitting non leaking mask and adding a chin strap.

In all the discussions here about apap vs cpap, one thought has nagged me. During the process of apap recognizing impending events and responding, has the body's adrenaline response already begun? Or is the adrenaline issue only with apneas and not flow limitations or hypopneas? I mean, if a machine can detect and respond to impending danger, how much more so might our magnificent brains and bodies? If anyone knows the answer to if flow limitations and/or hypopneas cause an adrenaline response, please let me know.

Another thing to keep in mind when evaluating your reports, Gary, is the length of time of your events. Count is one measurement, but not necessarily a reliable indicator of an acceptable level of treatment. Even % of Time in Apnea can be tricky because if its decrease corresponds to a lower AI, it doesn't necessarily mean the duration of your events is any better.

Best wishes as you continue to strive to optimize your treatment.

Kathy

rested gal · Post by **rested gal** » Sun Dec 06, 2009 2:50 pm

One more thought -- even if a person has their CPAP/APAP therapy optimized, and the machine is doing its part of the job like a champ, it's always possible that other health issues completely unrelated to sleep disordered breathing, sleep hygiene issues, med side effects, etc. can make a person continue to feel tired or worn out.

Might be something as simple as a mattress that needs replacing, or a need for vitamin/mineral supplements, or... anything. Low thyroid, whatever. Things that have nothing to do with how well CPAP is keeping the airway open for easy breathing during sleep.

I'm not saying you're doing this, Gary, but for other readers I want to mention that sometimes we think of CPAP as a magic bullet that should relieve any tiredness no matter what the cause.

It's good to work on making CPAP as effective as we can. That can eliminate sleep disordered breathing from why we might still not feel not-so-great. But when CPAP is keeping our airway open very well, we have to be our own detectives and look for other reasons if we continue to feel tired or sleepy in the daytime.

I do think it's always a good idea to at least try straight CPAP with an autopap -- just to see if CPAP leaves one feeling more refreshed in the morning. Me -- I do well with either mode, auto or cpap, but some people do see a difference in how they feel with one or the other mode.

timbalionguy · Post by **timbalionguy** » Sun Dec 06, 2009 2:58 pm

As far as trying to interpret one's data, here is what I believe and what I do. Your mileage may vary.

There is a certain pressure (you probably already know this) that effectively suppresses most apnea events. It is generally easy to find this. If you lower your pressure, say, by 1 cm and apneas (not hypopnas) go up sharply, this pressure is too low for you under any circumstances. In general though, using pressures below 7 cm will not work for many people, so this is the lowest I would consider going in a quest for minimum pressure to effectively stop apneas.

Hypopnas are a different story. Although it may be easy to get the airway to stay splinted open by pressure as described above, the opening might not be enough, so you experience hypopnas. It generally takes more pressure to minimize hypopnas than it does apneas, quite possibly because the pressurized air has to also work to keep the constantly-changing volume of your lungs filled. Hypopnas are somewhat less of a concern because you are still breathing at least a little bit. For many people here, myself included, controlling hypopnas is the harder job. How hard you have to pursue hypopnas is kind of related to how big your oxygen desatrations are. If you are having little or no desats, you could live with a higher HI and enjoy the less-disturbed sleep. But if HI is high enough to be causeing desats, then using the pressure range capability of an autoadjust might be helpful.

In the long run, most folks are recommending a narrow pressure range of 3-4 cm H2O. If you find that you have reached your minimum pressure to stop apneas, but still have a lot of significant hypopnas, try opening up your pressure range to be 4 cm above your minimum apnea-stopping pressure. Next, start looking at your graphs. Where is your average pressure in that range? If you are maxing out a lot, you need more pressure overall. Some machines, like the IntelliPAP, have a tendency to have 'runaway pressure' when your pressure is too low.

If you find that you are seeing high average pressures, or pressure 'runs away' and goes to max and stays there, try moving your pressure bracket up by 1 cm at a time. When increasing pressure, I usually raise maximum pressure first, wait a few days, and then increase minimum pressure. On lowering, I lower minimum pressure first, followed by max a few days later.

You should find a point where one or both of the following occur: First, your HI goes down significantly. Second, your average pressure is well below maximum pressure (or your 90 precent pressure is almost always less than max pressure). For most people, I think this is a good setting. If you find that you are seeing a lot of pressure swings at this point (but not a lot of maxing out), you can raise your minimum pressure only by 1 cm or so. Hopefully, this will reduce pressure swings. If it does, good. You will have less of a tendency to be awoken by pressure changes. Some people can narrow their 'pressure bracket' to 3 and sometimes 2 cm.

Possible problems: If pressure swings wake you up, you might try using your EPR feature if your machine has one. Then, you should be able to narrow your pressure bracket, and slowly raise your overall pressure until you have adequately suppressed hypopnas and tendencies for big pressure fluctuations. You may find you actually do better on straight CPAP. Another possible problem is the emergence of central apneas with increased pressure. Occasional centrals are normal, and one or two of these 'non-responding events' is usually not of much concern. But if you find that you see a lot more of the 'nonresponsive events', then you may be experiencing pressure-induced centrals. It is possible that if you stay at this pressure for a few days, these NR events will go away. But if they don't or get worse, lower you max pressure, and if necessary, your minimum pressure. Problems with centrals need to be discussed with your doctor. If you are not otherwise getting good therapy before centrals arise, you may need a different class of machine.

If you grasp the basic principles here, trying to figure out what to do based on your results is not particularly challenging, especially if you have 'plain vanilla' OSA.

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:22 pm

carbonman wrote: Get outside the box.....throw leery to the wind.
These are the unforeseen benefits that OSA and cpap bring to us.
The opportunity to expand our horizons.

I just had an hour and 40 minute nap with CPAP at 10. AI = 0.0 AHI 0.6. Can't wait until bedtime tonight.

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:30 pm

Wulfman wrote:
GaryG wrote: Well, you really CAN'T tell if you're in REM or deep sleep stages. However, according to the information available about sleep stages, they go through cycles during the night......roughly 70 - 120 minutes (depending on which article you read). If a person sees in their nightly reports that their apneas occur or increase at around that interval, there's a CHANCE that that's when they're occurring.

Well, mine seem to occur throughout the night

Wulfman wrote: Here's what jumped out at me in your first post:

GaryG wrote:So if I were feeling great, this would be the end of the story. But my problem is I don't. I'm still tired - not as tired.

Gotcha.

Wulfman wrote:In my own situation, I was prescribed a pressure of 18 cm......couldn't handle that, although I TRIED it for about an hour and then did an "Eenie, Meenie, Minie, Moe"......read that 10 cm. was about the "average" pressure.....and tried it. Not too low and not too high. My first month and a half (I started in mid-May), I had an AHI average of 1.6. The following months they were all < 1.0. The only thing that made me move up to 12 (a year later) was to decrease my snore numbers (my AHI actually saw no improvement).

Oh, so you went from 10 and no EHI to 12 and EHI = 2 to reduce the HI's.

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:34 pm

kteague wrote:Gary, I am one who found getting an apap to be very useful in getting my treatment on track, and didn't feel the pressure changes had anything to do with my shattered sleep. My doc wanted me to go back to cpap so we could know we had eliminated all identifiable possible contributors. I couldn't tell that the switch helped my wakeups, but then again, many arousals we are not even aware of so how would one know if they'd been corrected? With going to cpap I did have more air in the belly trouble, but I've not felt compelled to go back to apap. Got very similar excellent AHI numbers from both (and the auto was a ResMed ), though occasional 0.0 AHI nights have become a norm on cpap. That could have been more related to finding a good fitting non leaking mask and adding a chin strap.

Kathy, I don't know. 0.0 is different than 0.4 or 0.8. But why question here is did you notice any different in how you felt on CPAP vs APAP?

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:37 pm

rested gal wrote:One more thought -- even if a person has their CPAP/APAP therapy optimized, and the machine is doing its part of the job like a champ, it's always possible that other health issues completely unrelated to sleep disordered breathing, sleep hygiene issues, med side effects, etc. can make a person continue to feel tired or worn out.

I know RG, and that's been part of getting me down. Thinking, what else can it be that's got me down?

rested gal wrote: Might be something as simple as a mattress that needs replacing, or a need for vitamin/mineral supplements, or... anything. Low thyroid, whatever. Things that have nothing to do with how well CPAP is keeping the airway open for easy breathing during sleep.

Good point. Many many variables.

rested gal wrote: I do think it's always a good idea to at least try straight CPAP with an autopap -- just to see if CPAP leaves one feeling more refreshed in the morning. Me -- I do well with either mode, auto or cpap, but some people do see a difference in how they feel with one or the other mode.

Yes, after a short nap on CPAP, I do feel more alert. But I think I need more data than 1 hour 40 minutes

Wulfman · Post by **Wulfman** » Sun Dec 06, 2009 3:39 pm

GaryG wrote:
Wulfman wrote:In my own situation, I was prescribed a pressure of 18 cm......couldn't handle that, although I TRIED it for about an hour and then did an "Eenie, Meenie, Minie, Moe"......read that 10 cm. was about the "average" pressure.....and tried it. Not too low and not too high. My first month and a half (I started in mid-May), I had an AHI average of 1.6. The following months they were all < 1.0. The only thing that made me move up to 12 (a year later) was to decrease my snore numbers (my AHI actually saw no improvement).
Oh, so you went from 10 and no EHI to 12 and EHI = 2 to reduce the HI's.

I'm not sure what you mean by EHI. It was actually to reduce the snoring (SI) index. My AHI actually remained the same.......less than 1.0.

Den

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:49 pm

timbalionguy wrote: If you find that you have reached your minimum pressure to stop apneas, but still have a lot of significant hypopnas, try opening up your pressure range to be 4 cm above your minimum apnea-stopping pressure. Next, start looking at your graphs. Where is your average pressure in that range? If you are maxing out a lot, you need more pressure overall.

Tim, I see this, but then again, my numbers went down when I switched my range from 11-15 down to 6-12, so I never really readjusted upward. But I get the point here, and on 6-12, I do hit the max on occasion, but I am spending most of my time around 10, so a switch to CPAP seems worth a try.

timbalionguy wrote: If you find that you are seeing high average pressures, or pressure 'runs away' and goes to max and stays there, try moving your pressure bracket up by 1 cm at a time. When increasing pressure, I usually raise maximum pressure first, wait a few days, and then increase minimum pressure. On lowering, I lower minimum pressure first, followed by max a few days later.

timbalionguy wrote: You should find a point where one or both of the following occur: First, your HI goes down significantly. Second, your average pressure is well below maximum pressure (or your 90 precent pressure is almost always less than max pressure).

Tim, these are both very interesting Tim. If my CPAP experiment falls short, I will definitely keep this in mind.

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:52 pm

Wulfman wrote:
GaryG wrote:
Wulfman wrote:In my own situation, I was prescribed a pressure of 18 cm......couldn't handle that, although I TRIED it for about an hour and then did an "Eenie, Meenie, Minie, Moe"......read that 10 cm. was about the "average" pressure.....and tried it. Not too low and not too high. My first month and a half (I started in mid-May), I had an AHI average of 1.6. The following months they were all < 1.0. The only thing that made me move up to 12 (a year later) was to decrease my snore numbers (my AHI actually saw no improvement).
Oh, so you went from 10 and no EHI to 12 and EHI = 2 to reduce the HI's.
I'm not sure what you mean by EHI. It was actually to reduce the snoring (SI) index. My AHI actually remained the same.......less than 1.0.

Den

EPR Whoops.

GaryG · Post by **GaryG** » Sun Dec 06, 2009 3:57 pm

Thanks to everyone posting here. This has been a great help to me. Lots of information, lots of outstanding suggestions. I can't wait until I get to sleep tonight.

timbalionguy · Post by **timbalionguy** » Sun Dec 06, 2009 6:30 pm

GaryG wrote:
timbalionguy wrote: If you find that you have reached your minimum pressure to stop apneas, but still have a lot of significant hypopnas, try opening up your pressure range to be 4 cm above your minimum apnea-stopping pressure. Next, start looking at your graphs. Where is your average pressure in that range? If you are maxing out a lot, you need more pressure overall.
Tim, I see this, but then again, my numbers went down when I switched my range from 11-15 down to 6-12, so I never really readjusted upward. But I get the point here, and on 6-12, I do hit the max on occasion, but I am spending most of my time around 10, so a switch to CPAP seems worth a try.

That nicely validates you brief experiment of 10 cm CPAP during your nap. Naps IMHO, are probably not the best test case, as you may not experience all stages of sleep. In any case, your plan to try that for a few days is right on track.

What I think here is that 11-15 is too high, and 6-12 is too low. If you find you are comfortable with a minimum pressure of 6, more power to you. Based on your tendency to hover around 10 cm, you might consider 8-12 or 9-12.

One thing I should have mentioned is that if the minimum pressure is too high, it seems to degarde therapy, perhaps because the lungs work harder at higher pressure. I just finished an experimental course at 14-18, and was not pleased with the results. I was able to breathe quite comfortably against those pressures, but my AHI was worse on average. There was a dramatic improvement in comfort, etc. just backing down to 13-18. I am going to keep these numbers for a week to 10 days, and see what happens. I am thinking that my long-term numbers for this setup will be 12.5-17 or 18. With pressures in this range, I have seen as much as six days straight with a 7 day average AHI under 5 (LOT of work to do yet!). That said, and as much as I like the IntelliPAP, I may not have the best machine for my particular situation.

brain_cloud · Post by **brain_cloud** » Sun Dec 06, 2009 7:25 pm

Wulfman wrote: Well, you really CAN'T tell if you're in REM or deep sleep stages.

Actually, for a man, there is an easily observable physical response that correlates extremely well with REM sleep. And I'm not talking about the darting eyes. Seems like it shouldn't be that hard to find a way to harness that signal.

roster · Post by **roster** » Sun Dec 06, 2009 8:07 pm

GaryG wrote:
rooster wrote:What position(s) are you sleeping in?
I generally try to sleep on my side, but sometimes I find myself sleeping on my back. So, mostly on the side.

It is common to need a higher pressure to control sleep apnea when sleeping on your back as compared to sleeping on your sides or tummy. I agree on raising the minimum pressure, but you might also see if you can correlate sleeping position with higher AI. But don't lose any sleep over it.

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