Min pressure of 4 effective?

NightMonkey wrote about me in another thread:

"Somebody please help this dear lady. You experts know almost no one gets good therapy with a min pressure of 4!

Help her get the software and see what is going on and get the proper titration.

Thank you."

That thread seems to have run its course, and I would love it if someone could let me know what software I could get, where I could get it, and how to determine for myself what the correct titration might be.


Here is the relevant information from the original post:

Me: I find that I am waking up about 2 hours after falling asleep. I fall asleep on my side, but wake up on my back with the machine huffing at me at my highest pressure setting, 9. The mask leaks when I'm on my back, but not when I'm on my side.

I know I could take steps to prevent my rolling onto my back, but I want to be able to be able to do so: it keeps my bottom hip from aching, it helps my bottom sinus to drain, and I think it's healthy to move how I want to move in my sleep.

NM: You need to ask Rooster about positional sleep apnea. If I understand you correctly, your machine goes to the max pressure setting when you are on your back. The waking up could be because the pressure is not high enough to prevent events when supine and the events are waking you. What is the min pressure setting? What pressure were you titrated at?

Me: I asked my dr. about this at my last visit. She said that rarely do I reach 9, my max, and I don't stay there long. She thought that by increasing my pressure she would not be doing me any favors. The way she said it made sense at the time, like it would cause other problems. My titration range is 4-9. But is it logical to conclude that it doesn't stay at 9 for long because I wake up and take the mask off?

Thank you.

Many people have positional apnea that is worse on their back than on their side. I understand about sleeping on your back because of hip pain. I spend part of the night like that. My prescribed pressure is 8 IPAP/ 4 EPAP. Try to wear the mask and use the machine a little longer every night. Many folks recommend wearing the mask during the day while reading or watching TV to help get used to the mask. You really need to use the machine all night if possible.
Everyone needs a different pressure and if four is sufficient for you I wouldn't give it a thought. Those who are used to higher pressures would probably find four not enough.
You should be able to get used to a pressure of nine- that is really not that high though it might feel high to you.
You can buy the software at any online CPAP supply store. Our sponser- cpap.com- carries it for about $100. I don't know if your machine is data capable or not- meaning I don't know if the LCD screen can give you leak, AI and AHI.
Good luck. Stick with it.

What does the display indicate for your 90% pressure level? Turn the machine off, lift the lid, press the right arrow button until it shows you "90% pressure level."

Your machine will do "all right" when doing auto, but you will have to go through several apnea events before it adjusts up. Then repeat every time you turn the unit off and back on.

Please clarify which machine you use. You show M series machine and PR System one humidifier. They don't go together.

Software is available.
EncoreViewer 2.0 $99 patient version of the software. Simple and easy to use. No waveform data though.
EncorePro 2.4 Doctor/clinic version of the software. Big, bulky and often PITA to install and use. Available by request.

M series machines need a very pricey special card reader. Unusual that this machine would have been dispensed as it has been discontinued for some time.

PR System One machines use a SD card. Much simpler. Does your machine look like the one I have in my profile?

I can help with the software and/or you can use the Onkor online analyzer if you are using a PR S1 machine.
http://www.onkor.net/

Pugsy wrote:Please clarify which machine you use. You show M series machine and PR System one humidifier. They don't go togeth

I use a Philips Repironics REMstar Auto A-Flex with a Philps Respironics System One Heated Humidifier. The mask is a RESMED Quattro FX Full Face Mask. I did have a hard time choosing from the equipment list. It does have an SD card.

archangle wrote:What does the display indicate for your 90% pressure level? Turn the machine off, lift the lid, press the right arrow button until it shows you "90% pressure level."

I'm not sure how to lift the lid. The lid of the humidifier lifts up easily, but I don't see how to do it for the A-Flex side. Can I get rough with it? I worry about breaking it.

http://www.apneaboard.com/PR-System-One ... -Setup.htm

There is nothing to lift on the PR System One APAP LED screen. Look at above link for how to navigate into the clinician menu and all your settings are there. If you can't see normal choices that the above picture shows, then your DME has locked you out of that but you can fix that easily in the clinician menu.

I have the clinician manual for my machine (like yours) in pdf form. Send me a private message with your regular email address and I will send the manual to you as attachment (can't do it on forum email) or you can request it here.
http://www.apneaboard.com/CPAP%20Adjustment.htm. Still involves email though and I am online now to send it now. It will help you get around in that LED screen much easier and explains things better.

You can use the Onkor online analyzer or you can decide on software.

Once you see your settings and data, then you will understand things more. That 4 cm pressure? Not much air moving, heck even my titration sleep study started out at 5 cm.

napstress wrote:

archangle wrote:What does the display indicate for your 90% pressure level? Turn the machine off, lift the lid, press the right arrow button until it shows you "90% pressure level."

I'm not sure how to lift the lid. The lid of the humidifier lifts up easily, but I don't see how to do it for the A-Flex side. Can I get rough with it? I worry about breaking it.

The "lift the lid" comment is only for the M series machine, which you had listed in your profile at that time, I think. There is no lid on the PR System one machine you now say you have. Just look at the display on top of the blower unit.

Your body is dynamic, but the mask fit is not. So you have to mimic what some machines do with the touch of a button using the "mask fit feature". Unfortunately, PR S1's do not have that feature. So this is what you need to do:

1. Using the manual Pugsy pointed you to, L
learn how to get into the clinician's menu and set your machine in CPAP mode at a straight pressure of 9. Make sure ramp is OFF.
2. Now, with the machine on at the full pressure of 9, lie on your back, and adjust the mask for that position and pressure. Remember, if you tighten it too much, air cannot fill the cushion and you will have MORE leaks instead of fewer. Read my post for "Taming the Mirage Quattro" to help you understand the fitting technique.
3. Once you have the mask adjusted for the pressure of 9, go back into the clinician's menu and set the pressures they way they were before. Now your mask should hold even if you roll onto your back.

Thank you, everyone, I am learning a lot.

OK, Thanks to Pugsy, I have the manual. I have learned how to move around the menus.

Janknitz wrote:set your machine in CPAP mode at a straight pressure of 9. Make sure ramp is OFF.

As I flipped through the menus and read what they meant in the manual, I could not see how to do either of these things. The manual said something like certain options not being visible if the pressure is set to 4. Is that why I cannot follow this advice? Would anyone be willing to break it down for me a bit more than the manual does?

Janknitz wrote:Read my post for "Taming the Mirage Quattro" to help you understand the fitting technique.

Excellent article! Thank you! My sleep dr. only tested it with me sitting up—and only tested with 7 cm pressure, which I found out a few weeks later when she made her report. I don't know much about this, but if I had known she was only going up to 7—when she recommends 9 as my max—I would have asked her to go up to 9!!

Incidentally, in my travels around my machine, I found the following info. If anyone notices anything about the information that might shed light on why I can only get 1-2 hours on the machine, I'd be glad to know about it. That I have no large leaks, an AHI below 5, and my 90% is below 9 seems good to me. Am I right in my interpretation? According to these numbers, my only problem is the waking up/insomnia and the continued, over-the-top exhaustion, right?


Large leak: 0%/0% (7 days/30 days)
AHI: 3.5/4.2
90%: 7.7/7.4
Days >4 hrs.: 1/6
Therapy hours: 3.00/2.24

Mary Z wrote:Many folks recommend wearing the mask during the day while reading or watching TV to help get used to the mask.

I have read this many times, here. Wouldn't doing that skew my numbers? If I'm sitting up awake watching TV, my airway wouldn't collapse the way it does when I'm lying down, asleep, right?

archangle wrote:the M series machine, which you had listed in your profile at that time, I think.

Yes, now that I am beginning to grasp the lingo, I put up the correct description for the machine I have. Thank you.

It's safe to say that your AHI is not accurate if you are only able to use it for the first 1-2 hours. Most people hit REM at around 90 minutes. Did you have more apneas in REM during your studies? When you get the software you will see when the events occur and at what pressure.

Options not available at lower pressures may be the Auto Start/Stop. My Resmed won't do that below 7cm.

Lizistired wrote:Most people hit REM at around 90 minutes. Did you have more apneas in REM during your studies?

In one report, the dr. wrote, "CPAP pressure of 8- cm H2O was therapeutic during supine non-REM sleep, however this pressure was not therapeutic during supine REM sleep. CPAP pressures of 6-8-cm H2O were therapeutic in all stages of lateral position sleep." In another report, she wrote, "...no optimal pressure found for (supine) REM sleep."

What does this mean? Maybe I never reached REM stage on my back so they couldn't find a good pressure for me in that state?

That's what it sounds like. Did you do a split night study or a seperate titration study?
Do you have the graphs with the report. That would show you the pressures that they tried and what position you were in at the time and what sleep stage you were in.
Do you take any sleep meds? I think I have read that some anti-depressants can interfere with REM sleep.

Lizistired wrote: Did you do a split night study or a seperate titration study?

The two studies were separate. Why do you ask?

Lizistired wrote:Do you have the graphs with the report. That would show you the pressures that they tried and what position you were in at the time and what sleep stage you were in.

Yes, but I can't really make heads or tails of them.

Lizistired wrote:Do you take any sleep meds? I think I have read that some anti-depressants can interfere with REM sleep.

I take Xanax once in a great while. I took it during both the original sleep study and the titration b/c I couldn't get to sleep for love or money. That was atypical: normally I fall asleep the instant my head hits the pillow, but wake up in the middle of the night. But I couldn't fall asleep those nights so I took the Xanax. I don't take it very often b/c I have noticed bouts of anger the day after. I wonder if that's connected with disrupted REM sleep...?

set your machine in CPAP mode at a straight pressure of 9. Make sure ramp is OFF.
As I flipped through the menus and read what they meant in the manual, I could not see how to do either of these things. The manual said something like certain options not being visible if the pressure is set to 4. Is that why I cannot follow this advice? Would anyone be willing to break it down for me a bit more than the manual does?

In the clinician's set up menu, you should be able to set the pressure at 9 and turn off the ramp. You can't turn ramp on below 7, because the ramp lowers the pressure 0-3 cm during exhalation, and the lowest the machine will go is 4. But at 9, all the options should be available.

Do NOT assume you don't have leaks because the LCD screen reports 0% "large leaks". Note that the large leaks reported are 7 and 30 day AVERAGES. It takes a HUGE and very long leak to show up on the screen. The only way to know for sure if leaks are an issue is with the software. If you don't want to invest in Encore Viewer, check out Onkor by searching on this forum. It's free!

I have read this many times, here. Wouldn't doing that skew my numbers? If I'm sitting up awake watching TV, my airway wouldn't collapse the way it does when I'm lying down, asleep, right?

Don't worry about skewing the numbers--the averages may be skewed, but if you can view your stats on the software they will not be skewed as you'll be able to see when you were wearing it while awake. Also, who cares? You MUST get used to the machine and start using it more. If you are using it less than 4 hours a day you may lose the machine because you are not meeting compliance requirements. These hours will help up your compliance.AND your ability to use the machine longer at night.

napstress wrote:

Lizistired wrote: Did you do a split night study or a seperate titration study?

The two studies were separate. Why do you ask?...?

I wondered if they just ran out of time, that they didn't get you titrated to REM.

Lizistired wrote:Do you take any sleep meds? I think I have read that some anti-depressants can interfere with REM sleep.

napstress wrote:I take Xanax once in a great while. I took it during both the original sleep study and the titration b/c I couldn't get to sleep for love or money. That was atypical: normally I fall asleep the instant my head hits the pillow, but wake up in the middle of the night. But I couldn't fall asleep those nights so I took the Xanax. I don't take it very often b/c I have noticed bouts of anger the day after. I wonder if that's connected with disrupted REM sleep...?

That's interesting because the first thing I noticed after I started using my machine, was that I wasn't angry. Like it had been constant and suddenly just dissolved.
Most of my events were in REM, so I apparently hadn't been getting any for a long time.