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Advice on APAP settings
The DME currently has my machine set to CPAP at 11. While all my numbers are looking pretty good with this setup, I have trouble sleeping at this constant level. I was thinking about switching it to APAP mode with a setting of maybe 6-11. Any advice from the group?
.....Have a blessed day!.....

Mike S
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If 11.0 is working to keep the number of events low, then use that as a baseline to try alternate pressures. Your idea of 6-11 is fine to try out. If you notice a significant increase in Hypopnea or OA then increase the minimum pressure until that goes away.

Some users find a lot of relief in APAP lower pressures, while others incur sleep disruption or higher apnea. Finding what works well and is comfortable is just part of the journey. I encourage you to give it a try with the understanding, it takes time for new settings to be fully tolerated. Don't make assumptions based on the first night after the change.
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My advice depends somewhat on how long you have been using CPAP. First off, APAP hs its own set of issues and may not be the right way to go for you. There is a reason your doctor decided to put you on CPAP even though scripting an APAP machine for you. If you are still in the trial period, by all means consult with your doctor about changing the pressure setting.

With all that out of the way, my take on this is as follows. You may want to bounce this off your doctor as well. If you have been using CPAP for a month or more and the pressure level is causing you problems, by all means lower it. You may temporarily lose the full benefit of therapy but you will gain two other important things. First it may allow you to get some much needed rest. Second, if the new pressure level is tolerable, you will find that in a month or so you can increase the pressure back to your titrated level and you won't be able to tell the difference. It's amazing how the body can adjust if given time.

Best regards, Dude
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If you have been using the CPAP for a while, like Dude said, my suggestion is to go for 6 to 12. This lets you see if you need more than the 11 without it going too far too quick. Unless your data is just absolutely crazy and you cannot tolerate it, let it sit there at that setting for AT LEAST ten days. You are looking for trends, not duplication night after night. Then after that, you can decide if that setting is working or should be changed.
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I decided to leave the settings as they are. I did try the ramp feature and I really didn't like it. On another note, I slept like garbage last night. I woke up around 10;30 and thought I was having a nightmare. Then I realized I just couldn't breath. This has happened a few times before both with the P10 and the Nuance. They weren't leaking much but when I roll onto my side the pillows get crushed and I can't get enough air. I talked with my DME and she suggested that I try a nasal mask because that's what gave me the best results during my sleep study. She gave me a Wisp and said to try it for awhile. So, the saga continues. Thanks for the advice though....
.....Have a blessed day!.....

Mike S
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(03-11-2015, 02:46 PM)H2Daddy Wrote: This has happened a few times before both with the P10 and the Nuance. They weren't leaking much but when I roll onto my side the pillows get crushed and I can't get enough air.
You might want to try this trick. When you roll on your side, place one of your hands (open) under your cheek that is against the pillow. This will raise or tilt your face a little higher than the pillow's surface.
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I found that I was better with the bottom number just under what my fixed pressure would be so that it doesn't change so much. It can still go up if it needs to -- and does most nights for a little while. But i have fewer events than when my bottom number was lower.

I've also lowered my upper number as reports suggested it was mostly going up to adjust for leaks -- and by going up, it made the leaks worse. Since lowering that upper number, that hasn't been an issue and my numbers and sleep patterns are better.
Lovin' my CPAP since day 1! (January 2015)
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(05-09-2015, 03:06 PM)ClarkK Wrote: I've also lowered my upper number as reports suggested it was mostly going up to adjust for leaks -- and by going up, it made the leaks worse. Since lowering that upper number, that hasn't been an issue and my numbers and sleep patterns are better.

Hi ClarkK,

Thanks for sharing your experience, that a lower pressure limit has been beneficial in your case.

I suggest, though, that your machine might not have been mostly going up to adjust for leaks. It might, instead, have been adjusting the pressure higher in response to obstructive events, which the leaking was allowing to happen more often.

The machine's algorithm for adjusting pressure tries to avoid changing pressure in response to leaks.

Instead, the machine tries to increase or decrease the amount of air the machine is delivering in order to compensate for leaks and to maintain a desired or target therapeutic pressure.

Some members have found that as soon as unintentional Leak is better under control their AHI also improves markedly. I suspect this is because the higher the unintentional Leak, the less well regulated and more variable the pressure will tend to be, and a varying pressure would make it more likely that occasionally the pressure may momentarily drop loo low at the end of our exhalation or beginning of inhalation, which is when obstructive apneas are most likely to form/start. And once formed it may take an arousal to achieve the increase in effort needed to re-open the collapsed airway and end the obstructive apnea.
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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(03-10-2015, 08:05 AM)H2Daddy Wrote: The DME currently has my machine set to CPAP at 11. While all my numbers are looking pretty good with this setup, I have trouble sleeping at this constant level. I was thinking about switching it to APAP mode with a setting of maybe 6-11. Any advice from the group?

There is one other option:

It sort of depends on when you are next going to see your sleep doc. if that is months away, you may want to tinker, and if it is a couple weeks away, you probably don't.

You have SH, so you know what the system is doing. You have the power to closely monitor a dynamic situation, and your doc does not have that power.

Instead of a gross change to 6-11, try 10-11 for a few days, and see if your pressure stays at ~10, or if it climbs. If it does not climb, go to 9-11 for another few. Keep an eye on your AHI, and if it does not climb significantly (a day or two is not a trend, as Paula says), you can keep doing these small adjustments as long as things stay normal. You may even want to raise the top limit to ~13 just to see if the machine feels the need to take you there regularly. Its a form of titration.

Think of it this way: if the DME made an educated guess that 11 is "your pressure", they are either right or they are wrong. Opening up the range will allow the APAP to either validate that guess, or blow it out of the water. The APAP has the power to be the absolute authority regarding how good a guess the DME has made, but only if you let it.

Just look for raises from the baseline pressure of less than ~2, and AHI to stay relatively the same (if not better). If your pressure seems to stay nearer to the top of a new range, you may have gone a bit too far and may want to come back the other direction.

It's a bit of an adventure, and hard to predict, but there is not much you can do by doing this this carefully, that can hurt you. You already have good numbers, and if you can gradually lower the baseline without it causing AHI to go up or pressure to cruise near the top of a new range, you are probably not hurting your therapy while at the same time achieving better comfort.

Your APAP is intelligent, and is designed to know what the best pressure is to give you at any given moment, as long as you carefully titrate and calibrate the range. It is so benign that sleep docs often start a patient with the range fully wide open. But your APAP can't use that intelligence to help you find your optimal range if it is bricked at a fixed pressure.

This approach is a way of dipping your toe, instead of plunging in head-first. You trade the luxury of a quick magic fix for a lower risk, by making these changes slowly and gradually.

EPR might also be something to try. Just watch your numbers carefully.

You state "the DME has my pressure set at 11". Was this a choice by the DME or the sleep doc? You are closer to the numbers, so you probably have better data than either of them.

I do not want to discount professional knowledge or technique, and will never insult sleep docs by not having respect for that knowledge and training. A sleep doc can make a better-informed decision, all else held equal, but there is an argument that you can make a better-informed decision simply because you have more and better and newer data, right in front of you on your SD card. It's 2015, and APAP is a major paradigm shift to the old-school mindset of PSG. It is another valuable tool to complement the initial PSG. The PSG is really valuable for ruling out all other causes of your symptoms, and helping make the diagnosis of SA and what the parameters of your particular SA are, while the APAP is valuable at automatically giving you the best pressure at any given moment, once you are diagnosed with SA. PSG is purely diagnostic; APAP is both diagnostic and therapeutic. Both are important tools. Use both.

There is also a tendency for a sleep doc to have a home-team preference for his limited data done in a foreign environment for 3 hours in an uncomfortable bed over the large aggregate of data that you may have from weeks of sleeping in your own bed. If you are a hammer, everything looks like a nail, and there is a mindset that the limited data of a one-time PSG done for a few hours, weeks ago, is better than the very large data sample done by your APAP just recently. And if a sleep doc doesn't make a slight change now and then, how can he validate his own position? It is human nature to support making a decision, right or wrong. If he doesn't weigh in, whether right or wrong, in his mind, the patient will start to think "what do I even need that guy for?" Making a decision, regardless of what it is, helps insulate him from becoming irrelevant to this partnership. So they think they have to weigh in, even if they don't have an informed decision.

The sleep doc thinks his decision based on a limited PSG must be all-important, because he charges either you or insurance ~$3700 for it, and wants to keep doing that, and does not want to be usurped by the disrupter to his business model that the modern APAP has become, and is now a threat to that. In his mind, his data just has to be better. It had better be, or his business model is in trouble. So the informed decision a sleep doc makes may often be easily skewed by fear, old-line thinking, and just pure arrogance and desperate need for control. But your decision is pure, based on a large sample of pertinent data that you have, and what is best for you.

You are the patient, and your health, and not his business model, is what is of paramount importance. You are not in his ballpark; he is the visiting team in yours. Take control of the situation, rightfully so.
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A portion of the Clinical Guidelines:

[Image: TITRATION%20OPTIMAL%20STANDARD_zps5jlxvyxj.png]

Here's my titration part of the split-night study, which apparently conforms to the Guidelines (optimal pressure as 12cm):

[Image: 8932ffad-1373-4835-8e9e-005ab489b133_zpscula7hy8.jpg]

There is no need for 'educated' guesses as to optimal pressure if a titration study was performed. It tells one what one 'needs' optimally while supine the night of the study.

Assuming that a person does not have 02 issues, one can tinker. But my titration schedule indicates inadequate 02 below 12cm though RDI was fine way below that pressure.

Straight 12cm has been a bit much for me to handle, so I have been titrating up using Auto. I've done my own oximetry studies and can get by at a minimum pressure of ~9.5 or 10cm with adequate 02 saturation.

I am currently at 11-14cm Auto. I want to maximize O2 so titrating up.

Interesting to note that many times I felt good, very good or even great at pressure ranges 6-15, 9-15, but in light of the titration table more than my ox studies I am convinced that I need higher.

Original Rx was for 6-15cm. Cardio would be first to admit he didn't know much. At that setting it would average around 6 or 7cm- too low 02 for this patient. Do note that RDI was only 3.3 at 7 but 02 sat was bad-minimum 02 of 83%!

Sometimes I believe that doctors may choose to prescribe Auto to better assure Compliance requisites. And I'd have to admit that my chances of successful compliance at straight 12cm would have been considerably less if doc had prescribed fixed pressure of 12cm.

Had to learn a lot on my own from sleep lab, DME, and various forums and literature.

As an aside: I did experience some shortness of breath walking dog while at orginial Rx of 6-15cm. Emergency inhaler worked immediately, but incident prompted a visit to a pulmonologist
who told me that he would've prescribed straight CPAP. He did not mention o2 and seemed to be more interested in REM occurring at pressures of 9 and above, and upped the Rx to 9-15cm.

Do whatever works best for your comfort level. Some people prefer Auto, others straight CPAP. But keep in mind 02 and other issues that may apply.
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