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[Treatment] Cant seem to adjust pressures
#11

What are all your pressure settings?
Min EPAP = 7?
Max IPAP = 11?
Min PS (Min Pressure Support) = 1.5?
Max PS = 4?

Yes my machine is set to auto and I think you might have just given me a golden nugget of information. My min PS was set to 0.

My settings are Auto Bipap
Min EPAP = 7
Max IPAP = 11
Min PS was 0 for tonight it is set to 2.0
Max PS was 3 and is now 4.0

I am hoping for a good night and good results.
Thank you
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#12
I'll start by saying I am really new to this CPAP thing but was curious after reading your post. My sleep lab results were only verbally told to me-highlights only and sound very similar to your last results.

My sleep doc said I have 7 apneas per hour average but during REM is significant at 25. O2 sat's then drop around 85% if I remember correctly. Yet after my sleep titration test at the lab I was told I was on CPAP pressure of 6.

You mention you were set on a CPAP pressure of 12. But with similar-almost the same numbers I was set to 6. Now I can't say that all my symptoms have disappeared yet, but I'm only just into my 3rd week of this.

I guess I don't understand enough about all this. Maybe there are other factors that influence this?
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#13
(09-26-2015, 06:29 PM)Cookie Wrote: My settings are Auto Bipap
Min EPAP = 7
Max IPAP = 11
Min PS was 0 for tonight it is set to 2.0
Max PS was 3 and is now 4.0

Hi Cookie,

In my view your changes are reasonably small and prudent.

With these settings EPAP will initially be 7 and IPAP will initially be 9.

With these settings the EPAP and PS will be automatically raised, if needed, in response to obstructive conditions.

With these settings, PS will be automatically raised up to 4 when needed, unless the machine raises EPAP first. For example, if the machine has already sensed FL or snoring or hypopneas or apneas and has raised EPAP to 8 or 8.5 then PS cannot be raised higher than 3 or 2.5, because PS can never be raised higher than Max IPAP minus EPAP.

With these settings EPAP will be automatically raised up to 9 when needed, unless the machine raises the PS first. For example, if the machine has already sensed FL and has raised PS to 3 or 3.5, then EPAP cannot go higher than 8 or 7.5, because EPAP can never be raised higher than Max IPAP minus PS.

With these settings the IPAP will likely hit its max (11) occasionally during the night, which might be optimal or might be suboptimal; only time (and weekly or less frequent fine-tuning changes) will be able to tell us. If you see the pressure maxing out at Max IPAP, this does not necessarily mean that you should raise Max IPAP.

Especially with patients who are already having occasional CA events while asleep, increasing the Max IPAP setting may increase the number and severity of the CA events. For example, your doctor has already tried raising the pressure to 12 and the number of CA events increased (although remaining still fairly low). And when the pressure was reduced to 10 the number of CA events reduced to zero (at least for the days listed in your post).

Also, an increase in PS can cause an increase in the number of central apnea events during your sleep. A few CA are already showing up in your data, and tonight the increase in Min PS may increase how many CA events you will get.

But I think CA events, especially if fairly short like 20 seconds, may be less disturbing to sleep than obstructive events. Also, I think many patients, perhaps most patients, have a few CA events while falling asleep and this is considered normal.

If you zoom in on the Flow waveform (Flow is the estimated rate at which we are inhaling or exhaling air into or out of our lungs) with the full horizontal scale filled with just a minute or two around a CA event (and with the vertical scale adjusted to perhaps +/- 60 mL/second so you can see fine detail) I think you are likely to see the apnea end with a gradual and smooth increase in Flow and with no signs of distress or jump in heart rate. But if you zoom in around the end of an obstructve event like an obstructve apnea or an obstructve hypopnea or a RERA, I think you'll usually see a sudden gasping for air and (if you're wearing a pulse oximeter) a matching spike in the pulse rate also.

I think it is reasonable to watch the data for a week or two or longer and then make another change.

Some of us write down all changes in a daily diary of how we feel upon waking, to help us keep track of the results of each change.

Take care,
--- Vaughn
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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#14
Cate1898, it's often the case that people with the same AHI on test will titrate to quite different pressures. This is most likely because of physical differences from person to person - some have wider or narrower airways, better or worse muscle tone in the throat, thicker or thinner neck, more or less fat, different shaped tongue and so on etcetera. Sleeping posture also plays a big part, which is why the labs like you to sleep on your back, which is usually the worst case situation.

So you might find somebody with quite severe apnea (in terms of events per hour) will respond to a low pressure while somebody who has a much lower AHI still needs a high pressure.
DeepBreathing
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www.ApneaBoard.com


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#15
Not sure what to say about last night with the new settings.

min EPAP - 6
max IPAP - 11
min PS - 2
max PS - 4

As Vaughn suspected my my pressure hit the 11 max for significant periods.

AHI - 2.26
CA -5
FL - 20
HY - 13
OB - 4
EPAP 95% - 7.3
IPAP 95% - 11

I am not sure that I should make another change without letting things run for a few days to a week to make sure last night wasn't out of the normal. Most events are less than 20 seconds hypopnea's being the exception where about 1/2 exceed the 20 second threshold.
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#16
(09-27-2015, 04:56 PM)Cookie Wrote: Not sure what to say about last night with the new settings.

min EPAP - 6
max IPAP - 11
min PS - 2
max PS - 4

As Vaughn suspected my my pressure hit the 11 max for significant periods.

AHI - 2.26
CA -5
FL - 20
HY - 13
OB - 4
EPAP 95% - 7.3
IPAP 95% - 11

I am not sure that I should make another change without letting things run for a few days to a week to make sure last night wasn't out of the normal. Most events are less than 20 seconds hypopnea's being the exception where about 1/2 exceed the 20 second threshold.

Hi Cookie,

Your 95 percentile IPAP pressure was 11. This means the pressure was 11 or lower at least 95% of the time. It also means the pressure was 11 or higher at least 5% of the time. For example, if the pressure had been 11 for 20% of the time the 95% pressure would still have been 11.

What was your median pressure (the pressure you were at or lower, for at least 50% of the time)?

The AHI of 2.2 is the average per hour of the total of CA + HY + OB, which totaled 22 events, so the machine was delivering therapy for nearly 10 hrs, right? If you were asleep more than half of that time and if none of the CAs occurred while you were awake, the average number of CA per hour of sleep would have been 1.0 or less, which I think doctors would consider negligible.

Did your machine report any Respiratory Effort Related Arousal (RERA) events?

How did you feel this morning? If you awoke feeling fatigued, was leaking keeping you from sleeping? I think SleepyHead can report both Total Leak and Unintentional Leak for your machine. When the Unintentional Leak is larger than 24 Liter/minute this can start to degrade the efficacy of your therapy.

If results remain similar to last night, then as the next adjustment I would probably suggest raising both EPAP and Max IPAP by 1 each, with a view toward decreasing obstructive events within out increasing CA events to more than 1 or 2 per hour of sleep, if the CA events remain fairly short.

--- Vaughn
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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#17
Hi Vaughn,

What was your median pressure (the pressure you were at or lower, for at least 50% of the time)?

Did your machine report any Respiratory Effort Related Arousal (RERA) events?

Median EPAP 6.2
Median IPAP 9.8

I scored 7 RERA and I was sleeping for very near the 10 hours.

Thank you!
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#18
Hi Cookie,

So it looks like your PS typically adjusted itself to be around 3.5 (in order to reduce FL), so when obstructve conditions came along (typically because REM sleep stage starts or we roll onto our back, or both) the EPAP was only able to raise itself up to around 7 or 7.5, which was not high enough to prevent the 24 obstructve events.

The way your bilevel machine works is, if an obstructve apnea starts at the end of exhalation and prevents the start of inhalation, PS will not start and raise the pressure until the apnea has run its course and an arousal has caused inhalation to start. The machine musts sits there and measures how long the apnea lasts (how long until an arousal occurs and ends the apnea).

So the EPAP pressure must be high enough to prevent the start of obstructve apneas. That was why I suggested the next adjustment can be raising both EPAP and Max IPAP by one each, which would allow EPAP to raise itself up to around 8 or 8.5 when needed, while PS would still be able to raise itself up to 4 or 3.5 in order to treat Flow Limitation.

But, again, if you can maintain the present settings for a few days longer, this would allow you to begin to see how repeatable the results are at the present settings.

Take care,
--- Vaughn

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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#19
Last nights numbers

AHI 2.47
CA 8
FL 17
HY 9
OB 3
RERA 4

Med EPAP 6.5
95% EPAP 7.0

Med IPAP 9.9
95% IPAP 11.00

So although my AHI continues to climb the majority of events are FL and all are less than 12 seconds in duration. CA range from 6-22 seconds my hypopneas however range from 13 - 41 seconds. Obstructive are all less than 10.

Should my next adjustment be to increase my pressures by one each or just my pressure support? I do seem to max out my pressure at 11 several times for significant periods of time. My current pressures are min EPAP 6, Max IPAP 11 with ps from 2-4. So if I am understanding this correctly my pressure cant exceed 11 even if the machine thinks it should?

Thanks to all for help I am looking forward to mastering this!
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#20
First attempt to post an attachment of sh data

[attachment=1762]

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