How do I titrate myself?

SleepingUgly · Post by **SleepingUgly** » Thu Jan 07, 2010 7:42 am

I recently switched to CPAP from Auto-PAP mode because the pressure changes were disturbing me. How do I know if I'm at the ideal pressure, or if my therapy could be improved by adjusting it?

Do I use the average 90% pressure that the Auto-PAP was telling me (which varied from download to download)? And then bump it up by 1cm each week (or down?)?

Thanks!

rjjayrt · Post by **rjjayrt** » Thu Jan 07, 2010 7:48 am

I don't know if this is an iindustry wide method or not but the sleep doc in my area usually sets the pressure 2cm above the 90% pressure for 2 weeks then adjusts based on download of the equipment. Usually there is no adjustment necessary. As I said don;t know if this is standard way of doing it or not but seems to work for us...

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 8:16 am

SleepingUgly wrote:I recently switched to CPAP from Auto-PAP mode because the pressure changes were disturbing me. How do I know if I'm at the ideal pressure, or if my therapy could be improved by adjusting it?

Do I use the average 90% pressure that the Auto-PAP was telling me (which varied from download to download)? And then bump it up by 1cm each week (or down?)?

Thanks!

I can relate to that.

Do you actually HAVE Encore Pro 2? Trying to monitor one's therapy with an Auto and no software can be an exercise in frustration. If you actually have EP 2, you should be able to see what was affecting the pressure changes (how it determined the 90% number)......snores, flow limitations, leaks, hypopneas or apneas. Leaks can particularly throw that number out of whack.

I'm not sure if "rjjayrt" meant to say "above" the 90% or not. I'd actually start with 1 or 2 cm. BELOW the 90%......or "just pick a starting pressure" (eenie, meenie, minie, moe) and go from there. You can always make tweaks from that point.

Den

SleepingUgly · Post by **SleepingUgly** » Thu Jan 07, 2010 8:35 am

rested gal · Post by **rested gal** » Thu Jan 07, 2010 8:43 am

rjjayrt wrote:I don't know if this is an iindustry wide method or not but the sleep doc in my area usually sets the pressure 2cm above the 90% pressure for 2 weeks then adjusts based on download of the equipment. Usually there is no adjustment necessary.

I can understand why a doctor would adopt a routine of prescribing a pressure 2 cm above the 90% number, since that number means the autopap did have to use more pressure 10% of the time. Sounds to me like a very good way to go about picking an initial pressure number after an autopap trial.

If a person wants to titrate himself/herself and has the software to do their own download (they can monitor themselves sooner at home than by waiting two weeks) Den's suggestion of starting 2 cm below the 90% number is also as good a starting point as any.

Me, I'd start by setting the single pressure right on the 90% pressure and go up or down from there depending on what my downloads showed.

Any way you choose to go about it (and if software downloads are being done) -- I agree with Den...it's a matter of:

Wulfman wrote:just pick a starting pressure" (eenie, meenie, minie, moe) and go from there. You can always make tweaks from that point.[

jnk · Post by **jnk** » Thu Jan 07, 2010 8:52 am

rjjayrt wrote:I don't know if this is an iindustry wide method or not but the sleep doc in my area usually sets the pressure 2cm above the 90% pressure for 2 weeks then adjusts based on download of the equipment. Usually there is no adjustment necessary. As I said don;t know if this is standard way of doing it or not but seems to work for us...

Consider yourself to have just received a good-sportsman-conduct man-hug, rjjayrt. You have found your home.

jeff

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 8:57 am

SleepingUgly wrote:
Wulfman wrote:Do you actually HAVE Encore Pro 2?

No, I don't have Encore Pro 2 yet. I have a wired modem that sends the data in, and once a week I ask my DME to email me the download from the previous week (the daily detail data is lost after a week.) I don't think this can go on indefinitely, and actually they had told me I could only have the modem for a month. My compliance, which was 100%, dropped significantly due to nose bridge issues, so maybe they are waiting until I am compliant for a month and then they will take it away from me. I'm not sure if there is something I can see on the software that I can't see on the emailed download. I thought the ad says you can see every breath that the patient takes, and I can't see that on the download.

I can see summary statistics for each night, including vibratory snores, flow limitations, apneas, RERAs, etc. The AHI varies, even with the same mask and the same pressure.

I'm not sure if "rjjayrt" meant to say "above" the 90% or not. I'd actually start with 1 or 2 cm. BELOW the 90%......or "just pick a starting pressure" (eenie, meenie, minie, moe) and go from there. You can always make tweaks from that point.
So start with 90% minus 1 or 2 cm, and then use what to gauge adjustments? Increase the pressure by 1cm a week at a time and try to reduce the average weekly AHI? Or try to reduce RERAs (which I think are not factored into the AHI, and are not treated, with Auto-Pap at least)?

BTW, I just noticed that there is an "Average Hypopnea Index" and an "Average AHI". Are they the same except the latter includes apneas and the former doesn't? What do I do with those numbers?

Thanks!!

Thanks for clarifying your source for your data information.

Yes, AHI is the total of all of your apnea and hypopnea events divided by the number of hours. It's the average per hour index number. Same thing with the Average Hypopnea Index.........only it's just hypopneas and no apneas.

The main thing you'll have to go by in CPAP mode is the AHI number and to some degree, the Snore Index, if that is shown (to determine how effective that pressure is). If leak numbers are in the reports, that would help, too. (high leak numbers can tend to skew the data)

Here's a fairly recent thread on RERAs:

viewtopic/t41584/Respiratory-Effort-Rel ... -RERA.html

Den

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 9:05 am

My reasoning for starting slightly below the 90% number (especially if you do NOT have full, detailed, data-reports from software) is that you do not know precisely what caused the pressure increases. If leaks are skewing that number, then it would probably be higher than necessary. In the detailed reports, there is usually an "average" pressure reported, too. I've typically found that the "best" pressure is somewhere between the average and 90% numbers.

Den

SleepingUgly · Post by **SleepingUgly** » Thu Jan 07, 2010 9:29 am

So wherever it is I start, am I RAISING the pressure WEEKLY by 1CM and trying to lower the AHI? Lower the RERAs? And keep raising it until it's down as far as it would go? (I assume I'm also watching to make sure that Clear Airway aka Centra Apneas don't increase) Or just gauging it by how sleepy I feel during the day and keep raising it until I feel as good as I can get it?

It sounds good in theory, although with the variability of my AHIs, I don't know if a clear pattern will emerge.

I went up to 8.0 last night, and I woke up having swallowed a significant amount of air. I can't tell anything about how last night went because the LCD only shows 7 day and 30 day averages.

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 9:52 am

SleepingUgly wrote:So wherever it is I start, am I RAISING the pressure WEEKLY by 1CM and trying to lower the AHI? Lower the RERAs? And keep raising it until it's down as far as it would go? (I assume I'm also watching to make sure that Clear Airway aka Centra Apneas don't increase) Or just gauging it by how sleepy I feel during the day and keep raising it until I feel as good as I can get it?

It sounds good in theory, although with the variability of my AHIs, I don't know if a clear pattern will emerge.

I went up to 8.0 last night, and I woke up having swallowed a significant amount of air. I can't tell anything about how last night went because the LCD only shows 7 day and 30 day averages.

Well, I'd say kind of a combination of all of those. Typically, Centrals don't show up until one gets above the 10 cm. threshold, but that's not a hard and fast number, either.

If you're mouth-breathing (swallowing air), try nasal cleansing before bedtime to keep the nasal passages open and try to train your tongue to stay to the roof of your mouth. "Aerophagia" (swallowing air) can be caused by a number of factors, including GERD.

I was thinking there was a way to clear the numbers on the PR machines, so nightly numbers are available.......but don't have that information readily available for that (if it is indeed possible).

Den

SleepingUgly · Post by **SleepingUgly** » Thu Jan 07, 2010 10:48 am

Wulfman wrote:I was thinking there was a way to clear the numbers on the PR machines, so nightly numbers are available.......but don't have that information readily available for that (if it is indeed possible).

Do you think I need info on a day to day basis, or I should make adjustments based on weekly averages?

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 11:02 am

On a night to night basis, you would have a more distinct picture of those nights. "Averages" can make the picture less clear.
You can always put the nightly numbers into a spreadsheet if you want to average them or see "trends".

Den

SleepingUgly · Post by **SleepingUgly** » Thu Jan 07, 2010 11:20 am

Right now I do see daily details (as long as I get the download every week), but I only see them weekly. Is there something I would need to know on a nightly basis, rather than retrospectively looking back on a particular night in the previous week? I guess this speaks to downloading the SD card daily vs. weekly, when there is a card involved.

Wulfman wrote:On a night to night basis, you would have a more distinct picture of those nights. "Averages" can make the picture less clear.
You can always put the nightly numbers into a spreadsheet if you want to average them or see "trends".

Den

Wulfman · Post by **Wulfman** » Thu Jan 07, 2010 11:37 am

SleepingUgly wrote:Right now I do see daily details (as long as I get the download every week), but I only see them weekly. Is there something I would need to know on a nightly basis, rather than retrospectively looking back on a particular night in the previous week? I guess this speaks to downloading the SD card daily vs. weekly, when there is a card involved.

Wulfman wrote:On a night to night basis, you would have a more distinct picture of those nights. "Averages" can make the picture less clear.
You can always put the nightly numbers into a spreadsheet if you want to average them or see "trends".

Den

There is an "Info" screen available in the LCD (accessible through the provider/setup menu). That would allow you to view some of the information contained in the reports. HOWEVER......if you're being monitored for 30 days(nights), resetting/clearing that data would probably not be a good idea at this time.

If you're getting a "Full Details" report from your DME (and not just a summary), that should be sufficient for now......even though you only get to see it on a weekly basis.

Den

riveredge1 · Post by **riveredge1** » Thu Jan 07, 2010 11:38 am

Look at PR system one reset i just posted --i figured out how to reset the machine a clear numbers--i to am playing the figure it out game until or IF software comes--i also ordered a backup machine with software as i want to know and NOW not weeks down the road when i turn blue--

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