Therapy Questions [high AHI, smoker, drink alcohol]

[Hydrangea]

Welcome, Tosh!

When AHI has been lowered so significantly (to below 5), it's more important to focus on how you're feeling vs what the exact number is. But this forum is a great place to learn how to do both!

[Tosh78]

Thanks everybody for comments and suggestions. I will try to reply to most of you in one reply post.

I agree that feeling better is ultimate goal, but wouldn't mind getting it lower as I can. I have mixed nights which don't have some trend (one day is 3, another day 5, next day 3 again and similar). I think that lowest numbers will be visible after weight loss, less alcohol and quitting smoking (@Sleeprider - unfortunately smoking "ritual" is very common in southeastern Europe and much more that in western EU or USA and hopefully soon I will be quit, but wouldn't mind staying on beer little longer ).

As for pressure I believe it should be more than starting point of 4, but at this moment I would not change it without doctors permission. @OpalRose slightly under 95% (which is same as maximum automated settings of 16), you meant something like configuring 12-16 or 14-16?

I have mostly OA (2.14) and HY (2.07). CA is average of 0.51. Those are all last 30 days average and that is about same period as I started using CPAP machine.

@ClearStonePrez - I don't have oxymeter. Should I need one?

In attachment I posted statistics, and in detail last 4 days.

[Sleeprider]

Tosh, call your doctor's office and tell him your minimum pressure of 4.0 does not work and immediately results in numerous apnea events at the beginning of the night. All indications are that you need a minimum pressure of 10.0, however, even if it was as low as 8.0, your AHI would be greatly improved.

You have pretty substantial flow limitation and hypopnea, and should investigate why CPAP does not seem to relieve the upper airway restriction. In my opinion, you will ultimately be much better treated with BiPAP /VPAP. It is the differential pressure between inhale and exhale that helps to specifically target the flow limitations and hypopnea that make up a lot of your events. In addition, bilevel will relieve the snoring without requiring much higher pressures. In auto bilevel, I would put your minimum EPAP at 8.0 with pressure support of 4.0, and would set maximum IPAP pressure at 20. That may completely clear the events you are seeing with CPAP, however you would still have the option to try higher pressure support if needed. CPAP is not going to offer the flexibility and efficacy of bilevel in your case.

Bilevel therapy is frequently authorized for CPAP users that do not tolerate or obtain the results they should with CPAP. In your case, your AHI shows you are treated, however you feel a need for better treatment (let's call it continuing fatigue or discomfort for insurance approval purposes). Clearly you are at the beginning of therapy, and need to try the higher minimum CPAP pressures. If the FL, H and snores do not clear up with that higher pressure, I think you're a prime candidate for bilevel. I don't say to to many people here, and I don't make that suggestion lightly.

[Tosh78]

Tosh, call your doctor's office and tell him your minimum pressure of 4.0 does not work and immediately results in numerous apnea events at the beginning of the night.  All indications are that you need a minimum pressure of 10.0, however, even if it was as low as 8.0, your AHI would be greatly improved.

You have pretty substantial flow limitation and hypopnea, and should investigate why CPAP does not seem to relieve the upper airway restriction.  In my opinion, you will ultimately be much better treated with BiPAP /VPAP.  It is the differential pressure between inhale and exhale that helps to specifically target the flow limitations and hypopnea that make up a lot of your events. In addition, bilevel will relieve the snoring without requiring much higher pressures.  In auto bilevel, I would put your minimum EPAP at 8.0 with pressure support of 4.0, and would set maximum IPAP pressure at 20.  That may completely clear the events you are seeing with CPAP, however you would still have the option to try higher pressure support if needed.  CPAP is not going to offer the flexibility and efficacy of bilevel in your case.  

Bilevel therapy is frequently authorized for CPAP users that do not tolerate or obtain the results they should with CPAP. In your case, your AHI shows you are treated, however you feel a need for better treatment (let's call it continuing fatigue or discomfort for insurance approval purposes).  Clearly you are at the beginning of therapy, and need to try the higher minimum CPAP pressures.  If the FL, H and snores do not clear up with that higher pressure, I think you're a prime candidate for bilevel.  I don't say to to many people here, and I don't make that suggestion lightly.

Thank you for quick response Sleeprider. I could try talking to doctor, but I risk there if he gets offended or not. I have experience in some other situations with other doctors where I suggest something and doctor thinks I'm a smart-ass as I interfere in their job.

Here below in attachment there is one day in the beginning days of treatment when my machine was configured to recognize automatically starting pressure based on first 30 hours of usage (something like that). When I bought machine medical personel had accidently switch on that option instead of having 4-16 setup all the time. I guess that's a good thing as I saw that starting pressure of 10 could be good. It is hard to say as it is only one day, but results are not bad (this is not my best day but one of better ones - few days are better than this one on 4-16 pressure but not in a row). Maybe if starting pressure could be 8 or 10 I could get some trend to get it under 3 or 4 all the time... I don't know, hard to say from one day.
Do you think it is wise that I set it up for few days to be from 8-16 to see if there is improvement? Can anything bad happen?

Just one more question. When I was in hospital first 3 days of treatment, one of medical personal said that results are good (regarding my starting AHI of 88 at polysomnograph), but the "problem" is that my pressure is 95% of the time on maximum. Of course I believe that it is better to have both - low AHI and low pressure, but if I would have to choose, then better to have lower AHI with higher pressure than other way around. I guess when you get both of things low, then that is the way to cure yourself completely?

[Sleeprider]

Tosh, you should never feel as though you are not welcome to ask your doctor questions or to suggest approaches to your therapy you feel work better. Most doctors will welcome that input, and if this particular doctor is one of the few that can't be bothered by his patient's input, then it's time for a new doctor! Give him a chance, and consider your medical providers as a part of your care team.

Your original setup used a feature on your Dreamstation called Opti-start. The Opti-Start feature will monitor your therapy for a length of time, and will reset the start pressure closer to whatever your previous 90% pressure was. As you can see, Opti-Start and I are on the same page. Since this does not require a change in your pressure settings, you should feel free to use Opti-Start. This quick tutorial will show you how to enable Opti-Start https://www.apneaboard.com/dreamstation-...structions

Please talk to your doctor or fire him. This is not a workable relationship if you put him on some kind of alter that he cannot be bothered with your well-being. Your current settings are the manufacturer default settings. In this scenario, your doctor is not treating you, Philips Respironics is. You deserve better care, and I'm not kidding you about bilevel. You need to talk to your doctor about your results, even with a higher starting pressure. Pressure support is the tool that can treat the flow limits, hypopnea and snores. If you want some technical literature for your hip-pocket so you don't have to say "I heard this on a forum", I can give you some readily available titration protocols and technical literature you can use as a discussion starter. For example, read this article in the Apnea Board Wiki from a respected sleep doctor http://www.apneaboard.com/wiki/index.php..._and_BiPAP

[Walla Walla]

I agree with Sleeprider about needing a BiPAP/VAUTO. Your showing snores at pressures up to 16cm. You may hit the maximum with this machine without resolving the problem.

[Tosh78]

Thanks Sleeprider, I will check these links.

As for doctor, he is the top doctor in country for sleep apnea, and he knows his job. Hopefully he won't interpret my question as attack on his profession.

[Sleeprider]

Okay, I'm not quite done yet.  We need to talk about this chart.  As you can see, with a higher start pressure, your obstructive apnea was a bit lower, but it did nothing for your hypopnea and flow limitation.  In addition, your pressure immediately increases to the maximum setting.  This is due to a chronic flow limitation that you have, and will have until it is treated with pressure support in bilevel.  You can probably be treated at the pressures I posted earlier with EPAP 8.0, PS 4.0 and IPAP max 18, with a reserve judgement higher pressure support may be necessary.  You will not be fully treated until you have a bilevel machine, and until you are treated, your machine will always seek the maximum allowed pressure which will be uncomfortable, and ineffective.  

You need a doctor that is going to listen to you, and you might as well start now to find out if your current doc is going to be that guy, or if you need to start looking around for a compassionate expert, or perhaps transfer your care to your primary care doctor. That is what I do. Since your doctor is a top expert, your problems should be viewed as a challenge. He will know, just as I do, what needs to be done. Use a tactful approach, but let him see the problem here. It is not a failing on his part that you need the next tier of treatment. Nothing is more satisfying to an expert, than to see an undeniably good outcome from a difficult case. Give him a chance.

[Tosh78]

I agree with Sleeprider about needing a BiPAP/VAUTO. Your showing snores at pressures up to 16cm. You may hit the maximum with this machine without resolving the problem.

I saw somewhere that snores are not that much of a problem. Is it possible that machine detects snores when mask is not adjusted tight enough? I mentioned in my initial post that when i initiate snoring on exhale when I am wake, my mask vibrate under nose in a way that it is kind of jumping on snores.

[Tosh78]

Okay, I'm not quite done yet.  We need to talk about this chart.  As you can see, with a higher start pressure, your obstructive apnea was a bit lower, but it did nothing for your hypopnea and flow limitation.  In addition, your pressure immediately increases to the maximum setting.  This is due to a chronic flow limitation that you have, and will have until it is treated with pressure support in bilevel.  You can probably be treated at the pressures I posted earlier with EPAP 8.0, PS 4.0 and IPAP max 18, with a reserve judgement higher pressure support may be necessary.  You will not be fully treated until you have a bilevel machine, and until you are treated, your machine will always seek the maximum allowed pressure which will be uncomfortable, and ineffective.  

You need a doctor that is going to listen to you, and you might as well start now to find out if your current doc is going to be that guy, or if you need to start looking around for a compassionate expert, or perhaps transfer your care to your primary care doctor. That is what I do.  Since your doctor is a top expert, your problems should be viewed as a challenge.  He will know, just as I do, what needs to be done. Use a tactful approach, but let him see the problem here.  It is not a failing on his part that you need the next tier of treatment.  Nothing is more satisfying to an expert, than to see an undeniably good outcome from a difficult case.  Give him a chance.

Thanks for advice Sleep. How about leakage from all these print screens? Are they ok? And how can I fix when I am sleeping on the side. I noticed when I turn to side that more air is leaking out (there aren't large leaks but it is annoying to hear the "whistling" sound of air). Maybe tighten the mask more? And with that also eliminating "mask jumps"?