Thoughts on setting minimum and maximum pressures

[zonk]

Oh, I forgot to mention I do get Mr Green smiley face ever morning.. don't know how that is determined and/or if it means much.

Mr Green smiley face in the morning indicate "good mask fit" 70th percentile leak is less than 24 L/m

Personally I don,t see a problem with leak as far as leak does not come near the eyes or disturb my sleep

Those spikes you,re talking about might indicate some mouth leaks during those periods (spikes). Its essential to keep mouth closed as you,re using nasal pillows mask, chinstrap helps keep mouth closed and minimize mouth leaks, some people might prefer full face mask so they can breathe thru nose or mouth

Edit: see case study 1 - suggested solution (page 57)
ResScan interpretation guide http://www.apneaboard.com/ResScan_Interp...-Guide.pdf

[PaytonA]

robysue, I've read many of your posts and always find them thoughtful. I am concerned about my leaks, however it appears to be mostly short term events. Let me give you some data from last night, which was not a great night but fairly typical. According to sleephead my average leak was 7.43 and 95% was 37.2. Looking at the graph I see about a dozen instances where it spikes from 0 up to the 15-25 range most of these are a duration of under 15 seconds, however 3 of them were in the 2 minute range. More worrisome is that I had about 9 events going up to the 30-45 range these typically were in the 5 minute range. I'm not sure what to make of this. As I said I don't think I'm mouth breathing, I am aware that I jar the mask from time to time and have to reset it. Any thoughts for how to monitor this? What to look for?
Thanks

First, I do not think that I need to say this but I am not robysue. Second, I wish I had your leakage numbers. Mine from last night were Median=13.2, 95th percentile=61.2. My graph, however, shows the same type of spikiness that you describe only with a lot more and higher spikes.

I use a nasal mask and I do not believe it leaks appreciably. I seldom detect a leak once I get it seated. I also never wake up with air rushing out of my mouth as I have heard described by some. I do, on occasion, wake up with some lip farts but not that often, especially since I corrected the Ti max and Ti min settings that my DME messed up when they originally set up the machine.

I have convinced myself that my leakage problem is mouth leakage. I am currently working with a chin strap to try to contain this. The first couple of tries were very encouraging but not conclusive. The third night was only slightly better than without the chin strap but the strap came off my chin during the night. The subsequent 2 nights are showing what looks like it might be a downward trend. All nights with the chinstrap have been at least somewhat better than without.

The chinstrap holding the mouth closed is only part of the equation. The other part is blocking off the back of your mouth with your tongue. Of course having your mouth wide open makes it more difficult. My problem is made a little more difficult by the fact that my therapeutic pressure is 20 cmH2O.

If I had your numbers, I would be pretty happy.

Best Regards,

PaytonA

[Lukie]

"The chinstrap holding the mouth closed is only part of the equation. The other part is blocking off the back of your mouth with your tongue. Of course having your mouth wide open makes it more difficult. My problem is made a little more difficult by the fact that my therapeutic pressure is 20 cmH2O."

I sleep on my side with a Ruby Red chin strap around my head and a small square pillow shoved under my chin. It seems to keep my chin in place along with the chin strap. I use a nasal mask. My AHI last night was 0.3.
If I use a different chin strap or forget to use the pillow, it goes up higher and if I use a full face mask it is up around 1 or 2.

[PaytonA]

I sleep on my side with a Ruby Red chin strap around my head and a small square pillow shoved under my chin. It seems to keep my chin in place along with the chin strap. I use a nasal mask. My AHI last night was 0.3.
If I use a different chin strap or forget to use the pillow, it goes up higher and if I use a full face mask it is up around 1 or 2.

My AHI is actually pretty good but my leakage rates suck. I am told and it makes sense to me, that high leakage rates tend to obscure apneas. It does not look to me like tahoemark's leakage rates are in that area. As I said, I would be very happy with his leakage rates.

Best Regards,

PaytonA

[mjbearit]

Tahoemark,
If I am reading this properly, it really sounds like you are only having real issues while you are awake and wearing your mask. It took me awhile to learn my machine that I currently have because my old one was just a one pressure CPAP, blowing away no matter what! One of the things I had to learn was how to breathe while I was awake. Your machine does not know you are awake. All it knows is that your breathing pattern has changed, and it is trying to get you back on track to avoid an event. When you are awake, breathe long, slow and gentle. don't fight the machine, breath with it, not against it. As long as you are wearing that mask and have that machine in the ON mode, you have given over control of your breathing patterns to the machines discretion. When you fight it by not breathing the way it expects, it is going to fight you back by raising the pressure, sending pulses and other lovely little tricks it has up it's mechanical sleeve! Once you get used to working with the machine, you will find that this does not happen anymore. If you can find the time, just lay down for a half hour to an hour a day with the intent of getting used to the machine. Put on some soft music, or whatever and just get used to each other. If you fall asleep, well, bonus, but just concentrate on letting the machine pace your breathing and learn what it wants you to do. You'd also be surprised how refreshed you feel after an hour of this!
I'm not that familiar with the S9 as I use a Respironics machine, but on my machine there are different "comfort" features. A-Flex, vs CFlex, levels of each and it could be that you need to explore the equivalent on your machine. I found my sweet spot on mine, but it took me a good few months of working at it. You have to set it to something and leave it for at least a week, then move on. You try them all, taking notes, then narrow it down, and go head-to-head with the top ones and then set it. Once you get that set, it can make a big difference in your perception of how the machine functions, it sure did with me. One of the ResMED folks can tell you about the equivalent settings on your machine if you have questions.
Good luck!
Mike

[tahoemark]

mjbearit brings up a good point that I've been wondering about. For all you RESMED S9 users is there a trick to how you breath when you are on the machine and awake? I will try MJ's ideas but I suspect that his machine works differently than the S9.

[herbm]

I am very conscious of my breathing while awake.

Part of this is annoying but much of it is due to being an former commercial diver (breathing correctly is very important) and also to doing Systema (Russian Martial Arts) -- Systema takes breathing properly to an almost religious level. (Also Tai Chi.)

Breathing is also a wonderful way to encourage your body to relax which aids in falling asleep.

Yes, I do breath a certain way, but it's never like the nasal pillow mask (or oral mask) is "Fighting me".

For me it is more like it is RESTRICTING me (a little.) I turned my pressure up immediately, day one, first nap, from 6 to 8, then that day to 10.

When I use the "small nasal pillows" the flow restriction is more obvious.

In any case, I try to breath slow and regular, moderate to deep -- not REAL deep either.

I don't want the machine to see me go from big deep breaths to more shallow sleep breathing.

If it bugs you, try looking at your sleep breath data magnified in SleepyHead (select a region) and count the lenghth of inhale and exhale and then use that count to match you awake breath at bedtime or when aroused and trying to return to sleep.

(Counting breath times is about as effective as counting sheep in any case.)

You can also note you "depth" of breath after you settle down in bed and then look the next day to see how much MORE (or less) you volume appears to be -- like your awake breath will be much larger, less regular.

[yogigupta]

I started at 4-20 on pressure...

I am NOT a physician. I also use ResMed S9 Autoset. I was precribed a CPAP machine set at 13.
To achieve that one has to do following:
Start Pressure = 4, it is automatic for the ResMed S9. You can not change it
Min Pressure = 13
Max Pressure =13
EPR Off
Ramp time = 5 minutes
You machine will start at 4 cm and reach 13 cm in 5 minutes.

But thats really not the end of the story.
You should Turn on the EPR that makes breathing easier, reduce the Min Pressure by about 3. New setting will look like as follows
Starting Pressure = 4
Minimum Pressure = 10
Maximum pressure =13
EPR = On Full time.
EPR Level = 3.
Now watch your AHI levels. Lowering EPR level will effectively increase the pressure.. You have to play with it.
After it is all balanced out, you may try to increase or decrease pressure by no more than 0.6 per night to get the optimum pressure.

[me50]

I started at 4-20 on pressure...

I am NOT a physician. I also use ResMed S9 Autoset. I was precribed a CPAP machine set at 13.
To achieve that one has to do following:
Start Pressure = 4, it is automatic for the ResMed S9. You can not change it
Min Pressure = 13
Max Pressure =13
EPR Off
Ramp time = 5 minutes
You machine will start at 4 cm and reach 13 cm in 5 minutes.

But thats really not the end of the story.
You should Turn on the EPR that makes breathing easier, reduce the Min Pressure by about 3. New setting will look like as follows
Starting Pressure = 4
Minimum Pressure = 10
Maximum pressure =13
EPR = On Full time.
EPR Level = 3.
Now watch your AHI levels. Lowering EPR level will effectively increase the pressure.. You have to play with it.
After it is all balanced out, you may try to increase or decrease pressure by no more than 0.6 per night to get the optimum pressure.

EPR is only for exhale and it ends upon inhale. Your example is for using a set CPAP pressure and not using the autoset feature.

[robysue]

Although everyone is different, you should have a difference of about 10 and your high should be at least 2 or 3 more than your 95th percentile. There is no use limiting your pressures too much or you may as well use a straight CPAP? For example mine is 5-15 with my 95th around 12.

While this very wide range seems to work for Tez62, it's worth pointing out that many people do not tolerate really wide APAP ranges. Some people find that if the min pressure setting is 6-8 cm below their 95% pressure setting, too many events get through before the machine manages to raise the pressure up enough to be effective. Others find that when they seal the mask at the beginning pressure, the mask is very prone to springing leaks once the pressure is up close to the max setting.

Many experienced PAPers will tell APAP newbies to set the min pressure 2-3 cm below the long term 95% pressure level and the max pressure 2-3 cm above the 95% pressure level. If you have had a titration study, you can start out by setting the min 2-3 cm below the titrated pressure and the max 2-3 cm above the titrated pressure.

As for why one might want to use a very narrow auto range: I use an Auto BiPAP with an exceptionally tight range. My pressures are limited to the following ranges: 4 <= EPAP <= 6 and 6 <= IPAP <=8. Why do I use such a tight range? Here's why: I definitely need a pressure combination of 8/6 at times, but my stomach cannot tolerate 8/6 full time. Using the tight range allows the machine to increase pressure up to 8/6 when needed, but much of the night my pressures (particularly my EPAP) are less than the max. By capping the max pressures at 8/6, I keep the machine from overreacting to snoring or minor flow limitations and increasing the pressure above what my stomach can tolerate. Would I recommend such a tight cap for most people? Not really. But it works for me.

You also need to let it settle for a few weeks at a time. With the sleeping and energy it normally takes most people 3-6 months for people to start to feel the real effects of CPAP.

I agree with this 100%