should I narrow the pressure range further?

I've been trying to be an advocate for my mom, who's AHI tends to always be in the upper teens, and even over 20 on some days. Before I insisted on a new sleep study, the sleep doctor considered this to be good. ( At least this is half of what her AHI was before APAP).

Her pressure min is set at a ramp of 8 for 15 min, then goes to a range of 12-20. Her EPR is off. She uses a Resmed 9 autoset and a full face mask with a liner (which I shamed the sleep Dr into supplying for her. The DME does not have them.)

I live an hour away from her, so I don't have access to her sleepyhead data to get screen shots. I did visit her today and downloaded an almost 4 week span of data to her computer, so I could see what has been going on. She actually had 2 days (Whoopie!!) where her AHI was below 5, but the majority of days, her AHI was in the mid to high teens. She does not have any major leaks at home, although leaks were major during her titration. Mom says the tech had to come in at least 5 times and wake her up to adjust the mask.

She is very compliant using her APAP. Her pressure on any given day is a 95% value of 19, and while it occasionally does go lower, for the most part the graph is a straight line at 20, once the 15 min ramp completes.

Should I try narrowing the pressure range even more? We are waiting results of her titration study, done as over-night in the sleep center, two weeks ago. The tech did try BIPAP for the first half of the study, then APAP the second half. Mom was aware of the difference between the two, and felt BIBAP was better, but had major leak issues that never got better. The tech did not try more than the leaky mask. Mom was even sent home with that mask as her first new mask since June of 2013. One night of trying it at home resulted in a blistered sore across the bridge of her nose. Thankfully the mask liner has fixed the leaks, and she's trying a gel pad designed for the bridge of the nose tonight.

I really suspect BIPAP is what she needs, to be able to get a higher pressure. I should also note, she still snores, even on APAP, and told me she was aware of her snoring during the titration study. Because of all the major leaks during the titration, so I don't know how accurate or reliable the data is going to be. So frustrating that this has been a year of therapy with an AHI allowed to be so high.

If it is at 20 most of the time, she really does need a bipap machine as it will be a lot more comfortable with the higher pressures as well as being able to go higher than 20, which she may need.

If they don't prescribe a bipap from t he titration study, I would recommend printing the summary report showing the last month with the high pressures and continued high ahi. Then some nightly graphs showing what the pressure is doing. Be pushy and demand that they move forward with a machine that will actually provide successful treatment for her.

What happens sometimes is that when AHI looks high, people scramble to raise their pressure, but if they also have large mask leaks, the leaks become worse the higher the pressure goes, so AHI looks a lot worse (all the therapy air is going out instead of down) and so they raise pressures again (and start thinking about bipaps being needed)! Maybe all that's needed is a slight rise in pressure to 9 or 10 (which seems to be effective for so many), but better leak control so she actually gets treated?

The thing to try is a full face mask (or, less effective, taping and/or chinstraps). Once leaks are controlled, pressure can come down.

Your mother being on a 15 min. ramp time to a relatively low pressure of 8 may be counterproductive as she's spending all that time at less-than-therapeutic and likely less-than-comfortable (in terms of ease of inhalation) pressures. What are the chances you could lessen the ramp time (considerably) so she gets 'treated' sooner?

Julie wrote:What happens sometimes is that when AHI looks high, people scramble to raise their pressure, but if they also have large mask leaks, the leaks become worse the higher the pressure goes, so AHI looks a lot worse (all the therapy air is going out instead of down) and so they raise pressures again (and start thinking about bipaps being needed)! Maybe all that's needed is a slight rise in pressure to 9 or 10 (which seems to be effective for so many), but better leak control so she actually gets treated?

The thing to try is a full face mask (or, less effective, taping and/or chinstraps). Once leaks are controlled, pressure can come down.

Your mother being on a 15 min. ramp time to a relatively low pressure of 8 may be counterproductive as she's spending all that time at less-than-therapeutic and likely less-than-comfortable (in terms of ease of inhalation) pressures. What are the chances you could lessen the ramp time (considerably) so she gets 'treated' sooner?

She is using a FF mask with a liner and she is compliant

To answer the original question...should I narrow the pressure range??? It's a good idea to know how were you thinking of narrowing it? Increase the minimum? Decrease the maximum?
Also need to know the event category breakdown in that AHI that is a bit higher than we would like to see.
I forget exactly which machine she is using but assuming one of the newer models that flags centrals...how much of the AHI is central in nature? That would be clear airway events if looking at a SleepyHead or Encore software report.

If the bulk of the AHI is obstructive in nature (OAs and hyponeas) then a little increase in the minimum pressure might be a good choice to think about trying. Let the machine hold the airway open a little better to help prevent the collapse of the airway tissues and when it can't prevent the collapse a little more baseline pressure gives the machine a better head start getting to where it needs to be and thus better chance of warding off further collapse.

If the bulk of the AHI is central....we don't treat those with increased pressure with this type of machine and you get to have a different discussion about what to do.

Push for the BiPap since she is more comfortable using it. Comfort is important. It makes for better compliance in general and also helps for simply feeling better overall.

Thank you everyone. I will try to coach her by phone on how to change her settings. I'm thinking of raising the ramp to a 9, and the minimum pressure after that to 12.5, so the minimum won't be a drastic change. The ramp is currently 8 and the min is 12. The max is already at 20, and she needs that. I'd turn off the ramp altogether, except she likes having that 15 min, and is asleep that fast. If sleep results take longer than a week, then I'll recheck her data again and if necessary, go to a ramp of 10 and min of 12.5 so that any changes are not drastic ones, and hopefully are still comfortable for her.

She doesn't have a problem with central apneas, and she doesn't have a leak problem. She is sensitive to any level of leaks, and if her mask leaks, she wakes up and adjusts it, then goes back to sleep. Most of the time, she doesn't shut off the machine to do that, so she doesn't go back to ramp mode. She is using a resmed s9 autoset with humidifier, but not a heated hose. (yet).

Hopefully we hear something soon from the sleep doctor, and that something is BIPAP. Nobody could be more compliant or trying harder to use her CPAP than my 86 year old mom. No aerophagia, claustrophopia, and shakes off mask blisters on her nose. Thank heavens the mask liner is preventing the mask irritation problems. She is making everythink work- except it's not effective therapy for her because her AHI is still way too high.

Tonight she is trying my almost brand new (tried 3 nights) Quattro air with a liner. She tried it once before and could not get a seal, but that was an issue with any mask she has tried before using a mask liner because of the high pressure.