Help! Specialist Rxed CPAP Pressure So High that AHI Went Up

I have been on CPAP since mid-December. The sleep study report says that I had 65.3 events per hour (AI+AHI+RERAs) in the two hours before they started CPAP titration. My CPAP treatment is not working well. I see two potential reasons and am seeing an M.D. tomorrow who I hope will be willing to write a prescription to clear things up.

1.Pressure Set Too High:
In reviewing the portion of my sleep study with CPAP titration, I found the following:

Pressure
Level AI / AHI
4 -- 0
5 -- 0
6 -- 0
7 -- 3
8 -- 3.2
10 -- 3.1
11 -- 0
12 -- 2
13 -- 21.4

The sleep specialist prescribed CPAP for pressure of 13. The jump from 2 to 21.4 AHIs in the list above from pressure 12 to 13 is NOT a typo. My experience since getting the CPAP machine is I have been waking up frequently at night with the air blowing so fast I cannot breathe to keep up, so I take off the mask for the night and wake up in the morning exhausted. I seem to be fine until the pressure ramps up to the top pressure.

The DME checked the machine yesterday (before I discovered the above information on the sleep study) and said the machine is working as set--ramping from 4 to 13. However, the DME said they need an M.D.'s prescription to change the pressure, not necessarily a sleep specialist, but any M.D. that treats me. My dentist, who treats skeep apnea, said that clearly, the setting of 13 is too high, based on the AHIs. The DME says it cannot accept a dentist's prescription.

I am going to the M.D. tomorrow who ordered the sleep study. I have never seen the sleep specialist. I hope my doctor will write a prescription that will help correct the situation. I see two alternatives:

1. CPAP with top pressure changed to 11 or 12, which did not produce high AHIs.
2. Change to APAP, with a pressure range so that the pressure can change as needed throughout the night.

Does anyone have any advice on which may be best? From what I understand, both are within the capabilities of my machne but I don't know how to change these settings, so I have to get a prescription to take to the DME to get the seetings changed. I have valiantly tried to use the CPAP machine and have used it every night since i got it, but I am so exhausted that people who know me tell me they have never seen me look so tired, and i have been chroniquely fatigued for many years. I feel worse than before I started using CPAP, even though the first few mornings after CPAP, I did feel more rested. I want my use of CPAP to work, but I feel as if I am fast becoming a vegetable.

2. Masks, although I think my major problem is too high a pressure setting.

I have had some problems with masks (two types of nasal pillows masks), but I think the major problem is the pressure set too high. A printout from the CPAP machine's usage data yesterday for my first 38 days of use shows I have used it every day for an average of 4 hours, 17 minutes. The average time in large leak per day is 27 seconds and the average AHI is 4.6, which the DME rep said is the average AHI per hour the CPAP machine has been used with CPAP pressure of 13 cmH20.

The DME rep iniitially said he thought I neded a full-face mask instead of a nasal pillows mask because he thought I would have trouble keeping my mouth shut and we have been trying to reach the sleep specialist for more than a month to get the prescription changed. The sleep specialist has not returned any phone calls. His web site says he is the best sleep specialist according to a local magazine. I would hate to encounter the worst!!

Meantime, I started with an OptiLife nasal pillows mask, which had a strap sitting over a crown on my lower teeth that caused the crown to loosen and hurt. As soon as the DME found that out, he changed the mask to Resmed Activa LT for Her, medium pillows. The pain with the crown has recurred twice since then but with the OptiLife mask, it was a constant problem. The dentist is going to re-cement the crown.

Should I ask for a prescription for a full face mask, just in case? My insurance allows me to get new nasal pillows every month and a new mask every 3 months. The DME provided new nasal pillows yesterday.

I have the full sleep study and a printout of my usage stats for 38 days through yesterday, when things were especially bad.

Thank you in advance for any and all advice and suggestions. I have learned so much from reading this forum.

Maryland CPAPer

Pressure too high can cause central apenas--this is likely what is happening to you. Setting your pressure to 11 or 12 sounds like a good plan--either that or APAP. I have personally fared better on APAP, but some have done better with CPAP... it all depends on your particular physiology and reaction to the treatment. You may want to try each for a period of a couple of weeks each see what works best for you. You can change these settings yourself, but I'm not familiar with your machine--I'm sure others on this forum can give you instructions. You do not need a prescription for a specific mask type... a CPAP, APAP, etc prescription is good for any mask type.

Since you probably don't have the Encore Pro v. 2 software to monitor your therapy (hardly anybody does), I'd recommend setting the machine in CPAP mode at 10 or 11. If you NEED to use the Ramp feature, start it a few centimeters lower and for a relatively short duration. (most people find they don't really need it)
Trying to use an APAP without software is basically an exercise in frustration.

I'm also fond of full face masks.

The bottom line is to take control of your own therapy. Try to get your hands on the software (Pro or Viewer) if you can. There are mixed rumors that there MAY or MAY NOT be a user version of the Encore (Viewer) software coming out this spring. The existing version of Encore Viewer (v. 1.0 ) will not work with the new PR series machines.

Den

The question in my mind would have to be determined from your sleep study: which of the 2 pressure ranges 4-6 or 10-11 given all the info from all the data collected was actually the ideal pressure range?

MarylandCPAPer wrote:...Level AI / AHI
4 -- 0
5 -- 0
6 -- 0
7 -- 3
8 -- 3.2
9 -- 3.1
10 -- 0
11 -- 0
12 -- 2
13 -- 21.4

You might try swapping out the sizes on the pillows (you should have all the sizes) to see is one is any better than the Medium.

Hi, the trouble with high pressures is that they're more likely to aggravate mouth breathing issues, i.e. the harder the air's pumped in one end (your nose) the harder it is to keep your mouth closed, which of course is counterproductive. I personally would want a FF mask anyway, because so many need it in the end and because it's so helpful if you e.g. catch a cold and can't breathe through your nose. My instinct here is to just tell you how to lower your pressure yourself (as most of us do all the time, or raise it) but why not see what your MD says tomorrow. Hopefully he has some training in OSA/Cpap issues, though unfortunately probably the majority of GP's don't understand it very well. The business about needing a script for the DME to change your pressure is because of course if anything at all were to come up, he'd be professionally liable, whereas when we do it ourselves, it's obviously on our own heads . We certainly can help with your problems, so why not come back here after your appointment and let us know how it went.

Welcome to the forum. I don't feel qualified to make any recommendations, but am wondering if you are using exhale relief, which reduces the exhale pressure to make it easier to breathe. That might make whatever pressure you use, feel more comfortable.

For example, (taking into account that I have a different cpap device) my pressure is set at 10.4, with an exhale relief of 2, so when I exhale, I am exhaling at 8.4, rather than 10.4.

Thank you to those who posted. I do not know how to change the top pressure, only the starting pressure.

I also don't have software. The DME said the printout they gave me yesterday, which showed daily compliance data and averages, was all the data that could be obtained from the machine by anyone. I asked if there was software that a professional helping me could use to access daily data, but was told there isn't. I don't know if that is true or not.

The prescription states C-Flex/EPR is 2.

The prescription is for a Medium Opti Life Mask (nasal pillows). The DME switched it out to an Activa LT for Her when I had problems with the strap over the tooth and said he could do that without a prescription change because both were nasal pillows types of masks. He said that a doctor's prescription was needed to change from a nasal pillows to a full-face mask because of liability reasons. The DME has seemed very helpful to me but they can only change certain settings based on a doctor's prescription. Yeterday, they changed the ramp from 20 minutes to 45 minutes to give me time to fall asleep before the machine gets to full pressure. I think that may have been somewhat helpful. I am comfortable with the lower pressure. Several times, when it has gotten to full pressure before I go to sleep, I have set it back to ramp at least twice because I can't keep up breathing with the full pressure (13).

The M.D. I am seeing tomorrow is at least someone literate in reading sleep studies, so I don't think there will be any trouble getting him to prescribe a lower pressure. i'm just wondering if APAP would be better. I don't know how to set the machine to APAP.

I plan on taking the prescription back to the DME to have them change the settings. At the moment, the DME seems to be helping me as much as they legally can. As I learn more about the machine and find software for it (if available), I will be much more confident in making changes.

Thank you for your suggestions and comments.

Check your equiptment, and use what you have as your profile, looks to me you have a APAP and PRo 1 Hh missmatch. What you really have makes a difference in our answers. It is true you are set up to fail with that range. Jim

This is the CPAP machine I have:

http://www.sleepservicecenter.com/REMst ... ES0001671/

This is what the link to your machine says it records: Data Storage, Detection & Reporting (SD Card more than 1 year) >> Hours of Use, Visual Inspection Compliance, Apnea Hypopnea Index, Flow Limitation, Respiratory Effort Related Arousal, Snore, Leak, Clear Airway Apnea, Obstructed Airway Apnea, Hypopnea, Periodic Breathing.

I think it's time to go to them and see if their lips are moving, if they are they are lieing. The software they SHOULD HAVE, should show all the above data. Jim

I can understand why there are 0's by some numbers, as this shows up on some of the studies I do. I will have a Pt. on a pressure of 4, and they are not sleeping well, so I will raise it to 5. then they sleep and no issues, so 5 has a 0. then they go onto their back and the apnea shows up, so pressure are increased..then they roll over and I now have a 0 again. Does it say what postion you were in or sleep stages during each of those pressures?

montana user wrote:I can understand why there are 0's by some numbers, as this shows up on some of the studies I do. I will have a Pt. on a pressure of 4, and they are not sleeping well, so I will raise it to 5. then they sleep and no issues, so 5 has a 0. then they go onto their back and the apnea shows up, so pressure are increased..then they roll over and I now have a 0 again. Does it say what postion you were in or sleep stages during each of those pressures?

My issue is not with the zeros. My issue is why did the sleep specialist prescribe a pressure of 13 when that pressure raised the AHIs to 21.4 and there were only 2 AHis at 12 and 0 at 11.

The sleep study shows state while at presures 6, 8, 12 and 13 as "R" and BPOS at 6 as "L" and 8, 12 and 13 as "S." I am missing detailed charts for pressures 7, 10 and 11. I think the chart for 11 is definitely missing, as there appears to be a gap in timing.

I have just spent 2 hours fighting the CPAP, trying to sleep. The bottom line is that I can't breathe with the machine when the pressure is 13, so the CPAP is unusable due to the pressure being set to high. I might as well have an actual vacuum cleaner attached to my nose going full blast.

So, would I be better off with the pressure set at 11 or 12, or in APAP mode? Is there software for this machine that will provide more daily data than just hours of usage per day, Avg. Flex (2) and humidifier setting (4)?

The only other data I got from the DME printout was summary complance datea and sleep therapy statistics with averages over the time of use (38 days).

I am going to go back to bed and try another CPAP session, but this is my nightly experience and I usually do not get up and go back to try another battle with the CPAP. I just go back to sleep without it. The lack of quality sleep is ruining my health. I know I need treatment for severe sleep apnea and want to make the CPAP treatment work, but my quality of life is worse now than before CPAP, when I could sleep 100% of the time and never feel refreshed.

Thank you for your response.

I'm surprised that they will not lower your pressure to say 12cmH2O and see how you do in a few weeks. Our doctors will suggest a pressure of 12 (just throwing out numbers) but then also say " continue CPAP at above pressure of 12, if sleepiness persists then raise pressure one cm weekly" Looks like the doctor just went with the last number without looking further into the data??? Not sure..

Is there some reason why you can't download the manual for your machine so you can learn how to adjust the pressure yourself? I did that the second day I had my machine so I could vary my pressure (within the prescribed pressure limits set by my dr) without returning to the DME every second day.

I'm surprised to hear that your DME will not allow you to get another type of mask... my understanding is that is not a legal requirement and any xPAP prescription is good for any mask. In any case, it would be a good idea to ask your doctor to write the prescription to include "patient choice" for masks so you can choose what works best for you.