Adjusting Intellipap Auto w Smartflex

I need help on how to interpret and update for better therapy. Just switched from fixed CPAP at 10 to Intellipap Auto on 4-10.

After entering the code in the Devilbiss report generator, I get a 1 day, 7.8 hour readout of: AHI 5.0, 95% is 6.5, 90% 5.5, 0 high leak, NRI 0.5, EPI - 0.

Using Mirage Quattro full face mask

Wife says I am snoring and she hasn't been saying that on the fixed level machine.

I can get into the settings, but where would you recommend adjusting?

The minimum pressure is not quite enough to prevent the snores. AHI of 5 is technically very close to being acceptable since we like for AHI to be under 5. Your 90% pressure is only 5.5. So think you are very close and probably only need that minimum increased just a bit. Since your pressure needs seem to be very low I would think about using 6 minimum or maybe 5 minimum. I expect the reason your wife never heard snores on the fixed cpap at 10cm was because that pressure was a worst case scenario pressure and you may not need 10 cm all the time.

Your 90% and 95% pressure numbers mean you were either at or below that pressure for that % of the night.

Was 10 your titrated pressure? With your 95% at 6.5, I think I'd set the auto range at 6-10 and see if that helps a bit. Generally speaking we use the pressure you were titrated at in your study and set the auto range at 2 below and 2 above that, but it remains to be seen if last night's results were a fluke or if you should be lower. Try 6-10 tonight and let's see how that works. An AHI of 5 isn't awful, but shooting for something lower is better. I maintain an AHI of 1.5 or below all the time in my IP. The fact that you started to snore again indicates you aren't getting enough pressure to stent open your airway. Moving up the 4 to a 6 may be all you need, but you have to experiment to find your sweet spot. If you were receiving good therapy at 10 in cpap mode, why did you change over to auto? You don't say why you made the change.... just wondering.

THANK YOU so much for the encouraging replies. To answer a couple of your questions, 10 is my recently (Dec. 2010) titrated pressure, which was an increase over the previous several years at 7. My doctor prescribed an auto machine because I was experiencing more fatigue during the day, and having the steady 10 cm blasting at me all night, even when lying on my side, made it harder to sleep. I do have some pain from a hip that needs replacing soon.

My provider said that both cpap and apap machines were the same insurance code for Medicare, and insurance would not pay for the auto machine since my Remstar Pro 450 was only a year and a half old. So I decided to swallow hard and pay for a new machine out of pocket - and Devilbiss prices were lower and user reviews very positive.

My AHI for the last whole year with the Remstar constant cpap on 10, was 4.4 so I guess a first night at 5.0 was not too bad.

I will certainly increase the minimum from 4 to 6 tonight and see what happens. I can also adjust the Smartflex settings as needed. It was a much more comfortable night with the new auto adjusting machine.

Thanks again for your input!

If you're snoring, your pressure is way too low. The settings you initially quoted were from running the machine wide open. That's not a good way to begin with an auto machine because they are designed to change pressure slowly in order to keep from waking you. While the machine is slowly ramping the pressure up, you're not getting effective pressure and you're not going to sleep well.

If you were on fixed pressure of 10 cm, the recommendation you'll get from most of the folks around here is to set the pressures - 2 cm and + 2 cm from your titrated pressure. In your case, set the minimum to 8 and the maximum to 12. The upper pressure really isn't important unless the machine runs away with you. I've never had that happen.

Hit the sack and collect data for a week or so. One or two nights won't tell you much. You might be able to reduce the minimum pressure further, but if the pressure goes too low, you'll start snoring again and you won't sleep so well. I'm not comfortable below 6 cm.

My titrated pressure was 11 cm. I set my Intellipap for 9 to 14 initially and found that worked for me.



The data above is from my S9 Autoset. See how the pressure occasionally just touches the lower limit? It's important to not set the lower limit too far below your titrated pressure, or your machine will ramp down to a very low pressure during periods of quiet breathing between REM episodes. Then, when more pressure is needed it will take too long for the pressure to climb again to an effective level. Hence the +/- 2 cm recommendation.

Different machines figure the AHI differently. You can't reliably compare them across models or manufacturers. My own sleep doc refuses to even look at the machine's scoring. Instead, he relies on how the pressure has changed during the night, and what my recording oximeter shows (a CMS50E).

Play around with the I rounding and E rounding, too. If you leave them at their factory settings you'll feel a sharp change in pressure from inspiration to expiration. Sort of like Darth Vader's ventilator. I set both of my roundings to their maximum (5) and my Intellipap breathes just like my S9 Autoset.

Best of luck with the new machine. You chose a good one.

drdavedmin wrote:I will certainly increase the minimum from 4 to 6 tonight and see what happens.

I think that is a good plan. Based on your 90% you don't need much more than that (if any) and the lower pressures are bit easier to get more comfortable with and hopefully let you sleep better. And sleeping better is always the number one goal.

I followed advice and here is what happened with a lower setting of 7 (up from 4) and a high setting of 12 (titrated at 10 in sleep study).

Snoring disappeared! Spouse happy about that!

AHI went down from 5.0 to 4.0
95th % went to 10.0
90th % went to 8.0
NRI - 1.75
EPI - 1

At least the AHI dropped some and the %s went up. I have no idea the meaning of the NRI or EPI - anybody tell me where I can read up on this stuff, or just tell me what they are?

NRI....Non Responsive Index
EPI....Exhale Puff Index (I think)

When Emilia gets online she can explain things in much greater detail as to how these indexes factor in to your therapy but both indexes in the low numbers, like yours, are quite acceptable and they can and will vary from night to night.

If you search Emilia's posts here at the forum she has explained these values in more detail to others.

Pugsy got it right on the NRI and EPI definitions. Your numbers on those are fine. Glad to see your AHI dropped, but I still think your range should be adjusted a bit. With the 95th%tile at 10 (your titrated pressure), you might want to nudge up the lower number to 7.5 tonight and then, if necessary to 8 in a few more days. That would put you where your auto range would have been based on your titrated study pressure with +/- 2 (8-12).

Check your PM for some docs to better understand your machine and its algorithm.

Emilia wrote:[snip] With the 95th%tile at 10 (your titrated pressure), you might want to nudge up the lower number to 7.5 tonight and then, if necessary to 8 in a few more days. That would put you where your auto range would have been based on your titrated study pressure with +/- 2 (8-12).

I won't say "I told you so." Oh darn, I just did.

You might want to take a gander at this one, too. It explains pretty well how the machine works:

http://www.devilbisshealthcare.com/file ... T-2089.pdf

Slartybartfast wrote:

Play around with the I rounding and E rounding, too. If you leave them at their factory settings you'll feel a sharp change in pressure from inspiration to expiration. Sort of like Darth Vader's ventilator. I set both of my roundings to their maximum (5) and my Intellipap breathes just like my S9 Autoset.

I changed mine 2 nights ago to those settings. I like it! Thanks! Feel more natural then it did.

Well, raising the lower level to 7.5 apparently did help, as my AHI went down to 3.5 ! At least we are inching downward (5 to 4 to 3.5)!

My 95th % went down a bit to 9.5, and my 90th % went up slightly to 8.5

However my NRI (non-responding index) went up substantially to 8.73, and my EPI to 3. Should I be concerned? Or just wait for a longer term average? What triggers an NRI? Would it be triggered when I am lying there awake, trying to get back to sleep?

Glad you are slowly getting there! This is from the DeVilbiss publication:

Non-Responding Event Index (NRI)
NRI is provided as a number and as a graph. The NRI includes all the non-responding events considered by the AutoAdjust PAP: leaks, non-obstructive apneas, and exhale puffs. The NRI is the average number of non-responding events per hour. If the number is higher than 10, the patient may be exhibiting primary central apneas and need clinical intervention.
NOTE: If non-responding events are present, the algorithm prevents a further increase in pressure because increasing the pressure in the presence of these events is thought to produce central apneas which could be detrimental to a patient with obstructive sleep apnea.3

Exhale Puff Index (EPI)
EPI, unique to DeVilbiss AutoAdjust devices, is provided as a number and as a graph. Exhale puffs are a breathing pattern described as ‘in through the nose and out through the lips’. EPI is the number of exhale puff events detected per hour. If exhale puffs are present in significant numbers, the AutoAdjust algorithm will prevent the pressure from increasing because an increase in the pressure will create more exhale puffs in a patient with obstructive sleep apnea.

Emilia wrote:Pugsy got it right on the NRI and EPI definitions. Your numbers on those are fine. Glad to see your AHI dropped, but I still think your range should be adjusted a bit. With the 95th%tile at 10 (your titrated pressure), you might want to nudge up the lower number to 7.5 tonight and then, if necessary to 8 in a few more days. That would put you where your auto range would have been based on your titrated study pressure with +/- 2 (8-12).

Check your PM for some docs to better understand your machine and its algorithm.

Agreed. I am a 10 and I've set my PR S1 to 8-14 and my AHI dropped. I'm planning on trying 8-12 tonight...don't know if the lower top number will make much of a difference.

Actually I am already at a lower pressure of 7.5, so perhaps I should adjust it to 8?