Let's look at that daily data:
On this night, you're maxing out your pressures and there's significant flow limitations going on. Unlike the earlier data, the clusters of OAs are not as long and persistent. So these OAs appear to my patient's eyes to be much less likely to be mis-scored CAs than what I was seeing in the earlier data. Indeed most of the OAs and Hs are "isolated" from each other by at least 2 minutes. And that means most of the pressure increases are due to the flow limitations: There's a lot of activity in that flow limitation graph.
Your data also indicates the machine is spending a significant amount of time maxed out at 20cm, and that the flow limitations being scored at 20cm are still significant. And that raises the question of whether you might meet the criteria for being switched to a bilevel machine that can deliver up to 25cm of pressure.
You asked what to do:
(07-31-2014 11:31 AM)readyforsleep Wrote: I am ready to think about my next step. I could be feeling better. My current pressure is set at 13-20. Here are my options, I think.
1. Do nothing. I am averaging an ahi of 5. Give it more time.
2. Keep slowly raising my lower pressure.
3. Try straight cpap. If so, what pressure do I try?
4. Send my data to my doctor and see what she says.
My advice is a combination of these:
If this were my data, I would send the data to the doc and ask her for her opinion. She may just say "do nothing" or she may make a suggestion of either raising the min pressure setting or if she notices how much time you are spending at 20cm, she may recommend a switch to bilevel. If she recommends a pressure change or a switch to bilevel, I'd follow her instructions.
If the doc says "Do nothing and give it more time", I would give some serious thought about continuing to slowly raise the minimum pressure setting. I'd raise it 0.5 to 1.0 cm at a time and I'd leave it at the new setting for 5-7 days before doing another pressure increase. You may very well find your sweet spot with some patience and careful monitoring of your data. But I'd stop the pressure increases if any of the following happens:
- A significant increase in aerophagia that leads to discomfort and/or pain
- A significant increase in bothersome leaks or in leaks that are above the 24 L/min threshold for Large Leak on the Resmed S9 AutoSet.
- A significant increase in mouth breathing issues. Obviously mouth breathing can lead to increased leaks when you are using a nasal interface. But mouth breathing can lalso ead to an increase in problems with dry mouth regardless of whether you're using a FFM or a nasal mask. And mouth breathing with dry mouth symptoms can be an issues even when the leaks remain below the 24 L/min RedLine when you are using a nasal interface.
- An increase in the CAI that persists for several days.
- An increase in the OAI or HI that persists for several days, particularly if the clusters start to lengthen to where they are lasting 30+ minutes at a time
- A noticeable decrease in sleep quality that persists for several days at the new setting.
I'd stop increasing the pressure if any of these things started to become a problem because they are all more likely to be issues when the pressure is higher than you can comfortably tolerate. And trying to obtain a super low AHI by making it impossible to sleep comfortably with the machine is counterproductive.
I don't think I'd be inclined to try straight CPAP at this point: It looks as though your 95% pressure level is pretty close to 20cm, and that would normally indicate that the "starting guess" for straight CPAP would be 20cm. And changing from APAP with a range of 10-20 to straight CPAP = 20 seems like too big of a change to make.