PS [Pressure Support]

[LarryRapp]

Slight improvement but AHI was 11.90 with hypopneas at 53, CA's at 32, an OA's at 21.  I called the doc.  He said to go to sleep 1 hour later (10:00 instead of 9:00) and add another pound to CPAP (8 instead of 7).

[Sleeprider]

So, once he figures out this is a dead end, what's next? We already know how this story ends with pressures near 14 cm and the same events.

[LarryRapp]

I think you're right but you and others have said that I have to follow the doc.  Frankly, the good news is that I can call him so stuff gets changed every day.  I am hoping we get to ASV and whatever is necessary.  His emphasis is how I sleep and how I feel.  I would like to change CPAP to S as CPAP is not as comfortable.

[Sleeprider]

I would encourage you to share with your doctor that your previous best results were with VPAP-S mode, setup as a CPAP with 1-cm of pressure support for comfort. He will probably agree, and just continue increasing pressure to find the best treatment point. Previously it was anywhere from 10/9 to 14/13, but never satisfactory for long-term therapy. I'm sure his conclusion will be the same; and yes, do continue working with the doctor and ignore my occasional acerbic comment.

[LarryRapp]

Thank you - I'll do it.  Can you explain the difference between CPAP and S?  I feel that S was better but I don't know why!

[Sleeprider]

The S is bilevel with fixed inhale (IPAP) and exhale (EPAP) pressures. CPAP is fixed single pressure, however it can use EPR (exhale pressure relief) which will drop the exhale pressure by a set amount. I think your VPAP-S has EPR available in CPAP mode, and that may be what you want.

[LarryRapp]

As I recall, the doc said NOT to use EPR so I haven't.  I don't understand what the difference is between S and CPAP with EPR.  And, if my machine has S with EPR, why?  I.e. if S means bi-level what is the point of having EPR?  Thank you.

[Sleeprider]

EPR and bilevel work much the same, at low pressure differences between IPAP and EPAP. Let's say we want you to be treated at a CPAP pressure of 9.0, but have 1-cm of pressure relief. With the VPAP-S, the settings are VPAP-S mode, EPAP 8.0, IPAP 9.0. In CPAP mode it is CPAP mode pressure 9.0 with EPR at 1.0.

Those settings would be indistinguishable.

[Shin Ryoku]

I would stay in CPAP mode with EPR off and work with the doc. It's true that the doc is trying things you've already tried, but sometimes that has to be done when you're working with someone new.

Personally, I'd also wait for at least 3-4 days of data after any settings change before calling the doc to review unless he recommended otherwise, reason being that we know your day to day results vary some when staying at the same settings.

[zzzZorro]

EPR and bilevel work much the same, at low pressure differences between IPAP and EPAP. Let's say we want you to be treated at a CPAP pressure of 9.0, but have 1-cm of pressure relief.  With the VPAP-S, the settings are VPAP-S mode, EPAP 8.0, IPAP 9.0.  In CPAP mode it is CPAP mode pressure 9.0 with EPR at 1.0.  

Those settings would be indistinguishable.

Have been sorta following Larry along with his feedback.  If what I say is hairbrained PLEASE correct me.  I am only an observer.

I have found S-mode kicks me in the head (heavy AHI and much longer O/As) where straight CPAP-mode reduces both substantially. 
It appears (to me) that the CPAP locks out the 'algorythm fiddling' that the S-mode allows?  And in CPAP NO EPR helps to splint the airway where using EPR does not?  This is an observation made by a guy who reacts in a non-conventional way but it has seemed to bear itself out.  Like the two last nights on VAUTO; S-mode [IPAP-14cm EPAP-14cm] was AHI->30 with up to a 52 sec O/A and CPAP-mode [Fixed-14cm] was AHI-< 9 with up to a 21 sec O/A.  Those theoretically should produce the same results at 14cm pressures.

I doubt using the example, even though the settings are indistinguishable, would produce a similar outcome for everyone?