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[Pressure] Struggling with pressure optimization, please help
#1
Ohmy 
Struggling with pressure optimization, please help
Hello forum members,

I've been reading a lot of the threads in the forums for a long time now.  I thought I could learn from other people's experiences but experience has taught me that not everyone's experience/solutions with cpap are the same.  I have been struggling with finding optimal therapy for the past year.  I am seeking the wealth of knowledge and wisdom from all you great members.  Here is were I am with my experience.

I was initially prescribed pressures of 
min 6
max 17.6
EPR 3

these min's and max's and EPR have been adjusted many times by my RT.  I wasn't feeling any better and they were not listening to my concerns, I decided to take my own therapy into my own hands and started changing my own pressures.  

I've tested many pressure settings, as high as the sky.  I've attached the screen shot of all my combinations that I have tried and my AHI's are usually low but I have a lot of flow limitations and I just can't figure it out for the life of me.

I am able to sleep throughout the night but when I wake up, I don't feel rested.  My brain feels foggy, and I also experience cognitive dysfunction, I'm finding that I am more forgetful.  I developed depression and an anxiety disorder because I wasn't getting enough restful sleep.  The last year has been my most difficult year of my life.

Please bless me with your help and support, it would be greatly appreciated.

Thank you.


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#2
RE: Struggling with pressure optimization, please help
Hey there!
Wow! That's a lot of changes! You must be feeling pretty tired to be going through all that.

I'll let some of the experts walk through your charts. But you do realize that any AHI up to 4 or 5 is okay? Lower is better, but normal people can have up to 5! (I just wouldn't want you trying to chase an impossible number...)

Your current max and mins look okay to me. Your machine will do it's thing and find the right level as you go through your sleep cycle.

So what is bugging you...? Hmmm... You are feeling crappy, but the data looks okay to me. Is there something else going on that's messing up your sleep? A different mask? A different mattress? A different...something for sleep hygiene? Filters, clean tubes and tub?

I think you will get a lot of suggestions and support from people here. Hang in there!

My personal opinion is to just leave your settings alone for a week or two. Your top is 14 now. Bump it up if you have to, but otherwise...well... you have a good, high end machine. Let it work it's magical algorithms.

Sending good thoughts your way.
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#3
RE: Struggling with pressure optimization, please help
Welcome to the forum

Because of how you are feeling I'd suggest doing what you are trying to do, attack the flow limits and RERAs.
How you feel is very important, so keep that info coming.

I'm interested in seeing your 30 April and your 8 May charts. I want to see how your RERAs and Flow Limits did on those days. These are days with higher pressures.

You are using EPR 3 so that is good. With your AutoSet all we can do is raise pressure from here, but . . . I want to see how you do with higher pressures

So let's try Min 15 Max 20 EPR 3

Then we will step up to min 17 Max 20 EPR 3

I am thinking of a ResMed AirCurve 10 VAuto
EPAP Min 4
IPAP Max 15
PS 4

The plan would be to re-evaluate and slowly work PS a bit higher. PS is the best tool for Flow Limitation and RERAs
Notice I have the pressure, at least initially considerably lower than your current settings.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Struggling with pressure optimization, please help
Trailrider -
Thank you for your insight.
That screen shot of pressure changes was only half of them, there was more.

Yes, I understand that an AHI of under 5 is normal breathing. I've tested pressures of min 6 - 15, and can get an AHI of under 5, but still have unrestful sleep. From what I've read on here, AHI can be low but flow limitations and RERAs are the culprits of bad sleep.

I was on a FFM at first, but had too many air leaks at the bridge of my nose, which created ocular irratation, my eyes got dried out and were constantly red and discolored. I have been on the Resmed Airfit P10 for a while now and that has basically eliminated the leaks. Mattress has been the same one I've slept on for the past 5 years. I stick to a strict sleeping schedule, bed at 10PM and up at 6AM. Auto heat climate tube and auto humidifier is fine. Clean my equipment every week.

Thank you for your support, really appreciated.
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#5
RE: Struggling with pressure optimization, please help
Bonjour -

Thank you for the suggestions.

I have attached the requested daily charts.  I have also been on fixed 14, 15 and 16.  At fixed 16 I felt a lot of aerophagia, it was very painful, which is why I've been afraid to raise the min so high.  

The reason why I started to reduce my min back to 6 was that I do recall that when the min was set high, I would feel light headed for those days and my eyes would burn.

I will try your suggestion tonight and see how it goes.

Thanks


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#6
RE: Struggling with pressure optimization, please help
Bonjour-


Based on April 30 and May 08 charts, flow limitations are reduced, but which one is the better chart?  Is APAP or CPAP better for me?

I've noticed the relation of big pressure spikes with flow limitations, is your recommendation based on flattening the flow rate curve by reducing the range?

The thought of trying min 15 max 20 had crossed my mind but I never did it because my RT initially had me set up at min 6 max 17.6, and I thought that it was such a huge jump.  How could my RT be so off the mark with min setting?  I thought I was crazy to do something like that because they were the "expert".

I've only had my machine for 13 months, and I believe that my insurance will only allow me a new machine every 5 years maybe.  If I was to get the ResMed AirCurve 10 VAuto, it would have to be out of pocket.  We will cross that bridge when we get there.

Thanks
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#7
RE: Struggling with pressure optimization, please help
Your insurance will only replace your machine if.

  1. it is old ( > 5 YO )
  2. it is broken and cannot be fixed or replaced under warranty
  3. if you get a new Rx because your therapy is not working for you.

It is number 3 that may work for you.

I'm not seeing the improvement that I was hoping for in the 2 additional charts,  
The goal is to try increasingly higher pressures that will likely work to prove that no settings on this machine will work to eliminate your RERAs.  We could get lucky.  The VAuto is a better machine for you, at the worst, it will be no worse than your AutoSet.  If you get the VAuto you will have a backup machine.

Here are descriptions from ResMed on the lower level machines.
  • CPAP (continuous positive airway pressure) Fixed pressure delivered with optional expiratory pressure relief (EPR). It Treats OSA
  • AutoSet/APAP (automatic positive airway pressure) Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas. It treats OSA
  • AutoSet for Her/APAP Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas along with an increased sensitivity to each flow-limited breath, providing a more comfortable therapy for women. Increases sensitivity to each flow-limited breath, providing a more comfortable therapy for women (OK for men too). It Treats OSA
  • VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA
Note that the VAuto is for non-compliant OSA or for where your apnea is obstructive and CPAP and APAP are not managing it.  
There is no guarantee that the BiLevel will fix your therapy.  All it does is provide another tool, that being Pressure Support.

The Strategy, Take you slowly up to 20 cmw IPAP, to either prove that 20 cmw will not treat your RERAs or that it will.
If it does and you are comfortable great.
if not, get your settings down low  EPR = 3, Min Press = 7, Max Press = 15 then tweak for comfort.

Work on getting the VAuto, with settings
EPAP Min 4
IPAP Max 15
PS 4
then titrate to eliminate the RERAs (slowly increase the PS)
This requires a lot of contact with your medical team letting them know that you are still having issues, symptoms, and letting them know it frequently.  This is what could get you a new Rx
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#8
RE: Struggling with pressure optimization, please help
The 95% is static on 15 with cpap and the apap 95% is 16.5. If you want to put the cpap on 16.5, you will have something more comparable. The charts show fairly low pressure changes during the night.

If you have apap, bonjour's suggestion on min pressure for 15 is a good choice.
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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#9
RE: Struggling with pressure optimization, please help
Boujour -

Thank you for laying out my options for me.

I will try the min 15, max 20, EPR 3 tonight and see how it is going first and slowly work up.


Thank you
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#10
RE: Struggling with pressure optimization, please help
ajack -

Thank you for your input.
I tried fixed 16 before and had too much aerophagia, I don't know if I could handle 16.4.
I will try Boujour's suggestion.
Thanks
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