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the doctor was right
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readyforsleep Offline

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Machine: Resmed S9 AutoSet for her
Mask Type: Nasal pillows
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CPAP Pressure: 14.6-17.4
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Sex: Female
Location: Lawrenceburg, Indiana

Post: #1
the doctor was right
I have reset my pressure to 11-20. My leaks are under contro and my AHI is under
3. I just had to be patient and not monkey around with the low pressure. The higher
I made the low pressure, the higher my pressure needs became. No bipap
needed, I could probably even sleep on my back. I wish I understood why 11 is the magic number....

People like me are the reason doctors prescribe bricks.

2010 sleep study 63 AHI, 2014 3.0
06-17-2014 06:17 AM
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retired_guy Offline

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Sex: Male
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Post: #2
RE: the doctor was right
Good job Ready,

Just roll with this for a little while and see what your numbers do. Then you can make very slight and very slow modifications if you need to. I'm glad you don't have a brick. You're better than that because you care enough to get involved in your own health care.

By the way, try sleeping on your back. That is still one of the great joys for me that has resulted because of the therapy.
06-17-2014 11:29 AM
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readyforsleep Offline

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Posts: 233
Joined: Mar 2014

Machine: Resmed S9 AutoSet for her
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CPAP Pressure: 14.6-17.4
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Sex: Female
Location: Lawrenceburg, Indiana

Post: #3
RE: the doctor was right
Retired Guy,
you always know what to say to keep my spirits up!

2010 sleep study 63 AHI, 2014 3.0
06-17-2014 01:06 PM
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robysue Online
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Machine: PR Dreamstation BiPAP Auto
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Other Comments: Papping since September 2010

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Location: Buffalo, NY

Post: #4
RE: the doctor was right
(06-17-2014 06:17 AM)readyforsleep Wrote:  I have reset my pressure to 11-20. My leaks are under contro and my AHI is under
3. I just had to be patient and not monkey around with the low pressure. The higher
I made the low pressure, the higher my pressure needs became. No bipap
needed, I could probably even sleep on my back. I wish I understood why 11 is the magic number....
First to explain something: No matter what pressure you start out with, it's not uncommon that an event or two is going to sneak through the defenses. And if you're using an APAP, the machine is going to respond. It's just that not all of an APAP's increases in pressure are genuinely warranted.

It may help to understand what goes on during a titration study. In a titration study in the lab, there are strict guidelines for when the tech is supposed to increase the pressure. Each time the pressure is increased, the increase is pretty minor: Most of the time the tech will only increase the pressure by 1 cm (2 cm at most). And after a pressure increase the tech will wait for five full minutes before increasing the pressure again. The reason for that waiting period is that it can take the breathing a while to stabilize after a pressure increase. So the five minute waiting period is to determine whether the current pressure seems fine or whether another 1cm increase in pressure is really warranted because the obstructive events keep coming.

And another reason for waiting before increasing the pressure is to give the tech a chance to see if the increased pressure creates additional breathing instability, most often caused by the PAP pressure causing the patient to blow off too much CO2, which can trigger central apneas in some unlucky PAPers.

And then some people are also super sensitive to pressure increases, and the higher pressure can simply trigger more spontaneous arousals.

If certain kinds of breathing instability are noted by the tech after a pressure increase OR if there's a substantial uptick in the number of spontaneous arousals, the tech will lower the pressure by 1cm to see if the breathing stabilizes and/or the number of spontaneous arousals goes down.

Now consider what can happen on a bad night when you are using a Resmed S9 AutoSet. The AutoSet responds pretty aggressively to clusters of events that the FOT algorithm scores as OAs. As long as the OAs continue to be scored, the machine continues to increase the pressure. And the S9 can increase the pressure pretty rapidly: I've seen posts by users where the pressure goes up by 8-10 cm in as little as 8-10 minutes. When this happens, the S9 is NOT allowing any time for the breathing to stabilize. And under some circumstances, that rapid increase in pressure leads to further breathing instability and more "restlessness" or arousals. The restlessness/arousals can lead to some sleep/wake/junk (SWJ) patterns of breathing that can easily be mis-scored by the S9's FOT algorithm as hyponeas and OAs, and so the S9 continues to increase pressure (if there's still room to increase the pressure) or the S9 continues to keep the pressure at the maximum pressure setting.

The net result is that the overall AHI goes up (sometimes substantially), the events may look like clusters of OAs, and both the median and 95% pressure levels go up.

And, unfortunately, there is a tendency of people on forums like this to look at that kind of data and say: "Whoa---there's a whole bunch of clusters of OAs in your data. That means you need more pressure. Try increasing the pressure up to within 1-2 cm of the 95% pressure and see if that helps." When the pressure increase does not help (because the problem is NOT real OAs, but SWJ breathing and/or some mis-scored centrals sneaking in), the person decides to increase the pressure some more ....

And add to this: A lot of people who are in the active dial winging mode have a tendency to change the pressure settings every couple of days: Every time they have a bad night, they respond by increasing the pressure. But we're all going to have a few bad nights now and then. And there really is some truth to the adage that sleep docs keep telling us: It takes time for the body to fully adjust to PAP therapy. And a lot of the time AHI's that are a bit too high at the start of PAP will come down without any dial winging as the person's body really and truly learns the ins and outs of sleeping with a PAP.

All that said: I don't think all dial winging is bad. I do think knowledgeable PAPers can indeed optimize their PAP therapy over time with little or no help from their sleep docs. But for that to happen, the PAPer really does need to understand what the problem they're trying to fix is and why pressure changes might actually do some good. And successful dial winging also takes patience: You really do need to give each new increase in pressure a reasonable amount of time before deciding that more pressure is indeed needed.

Quote:People like me are the reason doctors prescribe bricks.
In my opinion, your take is NOT a valid reason for prescribing a brick. After all, when a patient has a brick, the doc is flying blind if/when the patient does NOT respond as expected to PAP therapy.
06-17-2014 01:29 PM
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zonk Offline

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Location: Australia

Post: #5
RE: the doctor was right
(06-17-2014 06:17 AM)readyforsleep Wrote:  I have reset my pressure to 11-20. My leaks are under contro and my AHI is under
3.

People like me are the reason doctors prescribe bricks.
whats the median, 95% percentile and maximum pressures?
I've always found minimum pressure around 9 most comfortable for me with no ramp or epr
I set the maximum pressure at 14 but might as well be 20 as most nights never goes above 12
AHI below 0.5 most nights

As for doctors prescribing bricks .... there is no valid reason in the world justify such thing
Nothing wrong in making mistakes, actually by saying I've made a mistake is like saying ... a solution is found
Nothing ventured, nothing gained
(This post was last modified: 06-17-2014 04:33 PM by zonk.)
06-17-2014 04:22 PM
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readyforsleep Offline

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Posts: 233
Joined: Mar 2014

Machine: Resmed S9 AutoSet for her
Mask Type: Nasal pillows
Mask Make & Model: Swift FX for her
Humidifier: attached
CPAP Pressure: 14.6-17.4
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Lawrenceburg, Indiana

Post: #6
RE: the doctor was right
RobySue, thank-you for the detailed explanation. I wish my doctor had explained
this to me when I asked to raise my pressure.

zonk,
From sleepyhead summary statistics :
Average pressure 16.32
95% pressure 19.94
max pressure 20

this data is for the last 2 months

2010 sleep study 63 AHI, 2014 3.0
06-17-2014 07:18 PM
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Sleepster Offline
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Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #7
RE: the doctor was right
During the first few weeks I monitored my data and got my doctor to prescribe a machine change and a couple of pressure changes for me. Once I had my AHI below 5 and my aerophagia tamed, I started making my own pressure changes.

What RobySue calls dial winging. Wink

I would adjust the pressure by 0.5 cm H2O. Keep it there for 30 days. Change my filter, look at my data, and then make another pressure change of 0.5 cm H2O.

It's been about a year now since I've made any changes.

Sleepster
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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.
06-17-2014 09:11 PM
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zonk Offline

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Post: #8
RE: the doctor was right
(06-17-2014 07:18 PM)readyforsleep Wrote:  zonk,
From sleepyhead summary statistics :
Average pressure 16.32
95% pressure 19.94
max pressure 20

this data is for the last 2 months
What was the data for the night when you reset pressure 11-20
06-18-2014 04:40 AM
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readyforsleep Offline

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Posts: 233
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Machine: Resmed S9 AutoSet for her
Mask Type: Nasal pillows
Mask Make & Model: Swift FX for her
Humidifier: attached
CPAP Pressure: 14.6-17.4
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Lawrenceburg, Indiana

Post: #9
RE: the doctor was right
(06-17-2014 09:11 PM)Sleepster Wrote:  I would adjust the pressure by 0.5 cm H2O. Keep it there for 30 days. Change my filter, look at my data, and then make another pressure change of 0.5 cm H2O.

It's been about a year now since I've made any changes.

Sleepster, that is great info on how to tweak. THANK YOU,

Zonk,

11, 18.42,19.96 ahi 2.32

11,18.86,20 ahi 2.12

Not looking much different, does it? When I look at the graph
it appears that the pressure is not always trying to go over the
20 mark now...

11,17.50,19.94 ahi 3.08 (had leak issues)

when I went down to starting pressure of 11 I turned epr off.

2010 sleep study 63 AHI, 2014 3.0
(This post was last modified: 06-18-2014 06:51 PM by readyforsleep.)
06-18-2014 06:07 AM
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