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does ramp impact reported AHI ?
#1
Please advise why I appear to go into higher AHI territory for a brief time at the end of my auto-ramp session from 4 to 11 (my fixed pressure). I looked back through sleepytime reports for my first month and this pattern seems present on many other days too. When I turn off auto-ramp and start cpap immediately at my fixed 11 setting, I seem to avoid the high AHI cluster of events at this time of night when I fall asleep. Any thoughts or experiences? Should I experiment with tuning the ramp from starting at 4 to starting at a higher setting, such as 8 to get to 11? Thinking-about

Also, I found conflicting information from the forum on whether AHI events that occur during ramp-up time are counted towards the total night's session - in my case, last night, is 7.70 (see attachment).
Thank you in advance. Dan


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#2
(12-22-2014, 08:11 PM)BlueHorseshoe Wrote: Please advise why I appear to go into higher AHI territory for a brief time at the end of my auto-ramp session from 4 to 11 (my fixed pressure). I looked back through sleepytime reports for my first month and this pattern seems present on many other days too. When I turn off auto-ramp and start cpap immediately at my fixed 11 setting, I seem to avoid the high AHI cluster of events at this time of night when I fall asleep. Any thoughts or experiences? Should I experiment with tuning the ramp from starting at 4 to starting at a higher setting, such as 8 to get to 11? Thinking-about

Also, I found conflicting information from the forum on whether AHI events that occur during ramp-up time are counted towards the total night's session - in my case, last night, is 7.70 (see attachment).
Thank you in advance. Dan


Hi BlueHorseshoe, welcome to the forum!

Looks like your pressure was not high enough for your initial sleep position.

Looking at the Pressure waveform and the "Flow" waveform, it appears that you were having obstructive apneas all throughout your Ramp period, but these did not start being scored as Obstructive Apneas until after the Ramp period ended.

Perhaps you fell asleep on your back and then rolled onto your side in your sleep, ending the cluster of obstructive events? (Obstructive apneas are typically much worse when we are sleeping flat on our back.)

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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#3
Adding to Vaughn's very insightful answer, I would suggest

1) Try eliminating the ramp. If you can't handle going straight to 11 then go from 8 to 11 for a few days, then 9 to 11, then 10 to 11 and then eliminate the ramp. Also, you can try shortening the ramp time.

2) Try sleeping off your back otherwise these clusters will keep coming as the 11 set pressure is probably not enough to ward off these events in supine position.

3) Best would be to get your hands on an Auto PAP machine, set it a range of possibly 9 - 20cm h2o and go from there. You may need to convince your sleep doctor that your titration was inaccurate and APAP is a cheaper answer to this than a new sleep lab titration. You may want to look at your sleep study report and see if you spent any time in supine position while getting titrated.

Started APAP 4-20, Closed range to 7.5-14, then straight 8.0 w/ Aflex 3
RDI always below 1. But sleep much much better at straight pressure.
Started on F10, Tried Quattro Air successfully. Finally settled on P10.
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#4
wow, your ramp is for 7 minutes. nice. I wonder if shifting that fast causes any frustration to your body trying to get settled down. I'd try ramp from 7 or 8, or setting the ramp to a more gentle pace, 15 to 20 minutes.

I ramp, if you call it that, since mine is a gentle ramp of 2 cm in 15 minutes.
Dedicated to QALity sleep.
You'll note I am listed as an Advisory Member. I am honored to be listed as such. See the fine print - Advisory Members as a group provide advice and suggestions to Apnea Board administrators and staff concerning Apnea Board operation and administrative policies. 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.
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#5
Another possibility - It appears to me that you were awake during that early cluster period. I'm guessing you actually went to sleep around 23:07. Anything prior to that time looks like might be anxiety patterned breathing. If so, I would tend to throw those events out of the total count. That type of anxiety action will likely diminish as you become more comfortable with the initial pressure as therapy begins. From the later graph it appears that you are doing pretty well but eventually will need a tad more pressure. I wouldn't increase it now however but wait until you get more comfortable with your present setting of 11 cm H²O.

BTW, I don't think your 7 minute ramp time is doing you any good whatsoever. Increasing it to a higher setting that will allow you to get to sleep before getting the higher pressure could help you get over the early anxiety events. That's the normal way that the ramp is used. Eventually most users quit using the ramp once they get more comfortable with CPAP and manage to fall asleep with the pressure right from the start.

The above are just my own opinions. I will add that if you have any doubt about which course to follow, I'd suggest you stick with vsheline since he has much more insight into this therapy whereas I'm practically a newbie in comparison.
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#6
Uneducated post. Verbiage deleted by author.

Best Regards,

PaytonA

Got to have a sign off. Do not want to get Galactus in a tizzy.
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#7
Don't tell my nephew my CPAP has a ramp... He'll want to skateboard on it.
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
(12-23-2014, 10:42 AM)surferdude2 Wrote: Another possibility - It appears to me that you were awake during that early cluster period. I'm guessing you actually went to sleep around 23:07. Anything prior to that time looks like might be anxiety patterned breathing. If so, I would tend to throw those events out of the total count. That type of anxiety action will likely diminish as you become more comfortable with the initial pressure as therapy begins. From the later graph it appears that you are doing pretty well but eventually will need a tad more pressure. I wouldn't increase it now however but wait until you get more comfortable with your present setting of 11 cm H²O.

Hi BlueHorseshoe,

It looks like you are using the A10's new automatic Ramp mode, which stays at the Ramp Start Pressure setting until the machine decides you have fallen asleep, and then starts ramping up to your full therapy Pressure setting. So, I am assuming you were asleep by the time the pressure started increasing.

From the A10 set-up manual (Clinician Guide):
Ramp Time can be set to Off, 5 to 45 minutes or Auto. When Ramp Time is set to Auto, the device
will detect sleep onset and then gradually increase from the start pressure to the minimum
treatment pressure at a rate of 1 cm H2O per minute. However, if sleep onset is not detected, the
device will reach the target pressure within 30 minutes.

Hi surferdude2,

Notice that the zoomed-in period (the highlighted period) doesn't start until 6 or 7 minutes after the session had started, and the pressure does not start increasing until after an additional 7 minutes into the highlighted period. So, the pressure did not start increasing until 13 or 14 minutes into the session.

I am not familiar with anxiety patterned breathing. Would anxiety cause clear airway apneas or hypopneas, rather than the scored obstructive apneas?

A swallow will cause a complete obstruction for about 2 to 4 seconds, I think, but scored apneas last longer than 10 seconds and would have been verified by ResMed's Forced Oscillation Technique (FOT) as being obstructive in type. Many of the times with no Flow while the pressure is ramping up last longer than 10 seconds, so I think these are obstructive apneas which were not scored only because events are not scored until after ramping has completed. (Each minor division is one tenth of 120 seconds, or 12 seconds.)

The apneas shown (but not scored) in the Flow waveform while the pressure is actively ramping up look like obstructive apneas, which typically end with sudden hard breathing which gradually lowers to apnea again, like an arrowhead. For obstructive apneas, the amplitude envelope of the Flow is typically like an arrowhead or like a cosine, which starts at full amplitude and gradually decreases again to zero amplitude.


ADDED LATE:
The above excerpt from the A10 set-up manual has now been added.
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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#9
Vaughn,

I was not aware of a ramp change for the A10 (I am saying that I just did not know about it). Learn something every day. In light of my newly learned information, ignore what my previous post said, Blue Horseshoe.

Best Regards,

PaytonA
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#10
(12-23-2014, 01:03 AM)vsheline Wrote:
(12-22-2014, 08:11 PM)BlueHorseshoe Wrote: Please advise why I appear to go into higher AHI territory for a brief time at the end of my auto-ramp session from 4 to 11 (my fixed pressure). I looked back through sleepytime reports for my first month and this pattern seems present on many other days too. When I turn off auto-ramp and start cpap immediately at my fixed 11 setting, I seem to avoid the high AHI cluster of events at this time of night when I fall asleep. Any thoughts or experiences? Should I experiment with tuning the ramp from starting at 4 to starting at a higher setting, such as 8 to get to 11? Thinking-about

Also, I found conflicting information from the forum on whether AHI events that occur during ramp-up time are counted towards the total night's session - in my case, last night, is 7.70 (see attachment).
Thank you in advance. Dan


Hi BlueHorseshoe, welcome to the forum!

Looks like your pressure was not high enough for your initial sleep position.

Looking at the Pressure waveform and the "Flow" waveform, it appears that you were having obstructive apneas all throughout your Ramp period, but these did not start being scored as Obstructive Apneas until after the Ramp period ended.

Perhaps you fell asleep on your back and then rolled onto your side in your sleep, ending the cluster of obstructive events? (Obstructive apneas are typically much worse when we are sleeping flat on our back.)

Take care,
--- Vaughn

Vaughn - I do start to sleep on my back and then roll over to my side usually and always fall asleep on my side, so this is part of the puzzle I'm sure. Thank you.
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