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Adjusting my pressure down, advice - sumzzzs - 01-16-2015

I want to play with my pressure to see if I can lower my CA index. My OA is averaging 1.5 or so, however it's my CA that is high. Last night 40 events. I've been on CPAP for 40 days, should I lower both IPAP and EPAP pressures? If so by how much?

RE: Adjusting my pressure down, advice - quiescence at last - 02-01-2015

did you ever get any help for this? usually I have seen in the forum advice was to reduce EPAP to reduce CAI. But, also if your CA are persistent, it may mean you actually need an ASV (ventilator) type machine. do you have your CAs all in a row? What is happening when these occur? Pressure, respiration, tidal volume. maybe if it is all in a 30 minute clump you could post a screenshot of the 30 minutes for review.

QAL



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RE: Adjusting my pressure down, advice - vsheline - 02-01-2015

(01-16-2015, 04:18 PM)sumzzzs Wrote: I want to play with my pressure to see if I can lower my CA index. My OA is averaging 1.5 or so, however it's my CA that is high. Last night 40 events. I've been on CPAP for 40 days, should I lower both IPAP and EPAP pressures? If so by how much?

Hi sumzzzs,

Lowering EPAP is probably not advisable, because lowering EPAP (when IPAP is higher) will usually worsen obstructive events without decreasing the number of Centrals.

Quite a few patients who use ResMed EPR or Philips Respironics A-Flex have found that lowering EPR or turning off A-Flex will lower the number of centrals they get. Lowering EPR or turning off A-Flex has the effect of keeping IPAP unchanged and raising EPAP, which lowers the pressure difference between EPAP and IPAP.

In bilevel therapy, either lowering IPAP itself and/or lowering the difference between IPAP and EPAP often lowers the number of centrals we get.

Your profile presently says "CPAP Pressure: 8 EPAP 14 IPAP" as if you are using basic manually-adjusted "S" bilevel therapy mode rather than Auto BiPAP therapy mode. If your machine is using S therapy mode, this means IPAP is fixed at 14 and EPAP is fixed at 8 all night, and the pressure difference between EPAP and IPAP (which is often called Pressure Support) is a fixed amount of 6 all night. A Pressure Support of 6 is fairly high and could be causing most of your central apneas.

If your machine is in S therapy mode, I suggest leaving EPAP unchanged (8) and lowering IPAP gradually, by 1 cmH2O per week (13 first week, 12 second week, etc), and watching the effect this has on your AHI and RERA events. This may decrease your central apneas but may increase your RERAs and hypopneas.

If your machine is in Auto BiPAP therapy node, I suggest looking at the data using SleepyHead to see what pressures the machine has been using. But in any case, the approach would be similar, meaning that you would gradually lower the Max Pressure Support setting and watch what effect this has on your Central Apnea Index and RERA Index and Hypopnea Index.

If your machine is in Auto BiPAP therapy node and the Max PS setting is already low (such as 1 or 2) then perhaps you nay need to reduce the Max Pressure setting, especially if most of your central apneas are occurring when your pressures are raised higher than your median or average pressures.

I also suggest avoiding any sleeping flat on your back, because sleeping on our back is usually the worst position for obstructive sleep apnea, requiring higher pressures, and in some patients the higher pressures sometimes produce an excessive amount of central apneas.

Take care,
--- Vaughn



RE: Adjusting my pressure down, advice - sumzzzs - 02-02-2015

(02-01-2015, 04:19 PM)quiescence at last Wrote: did you ever get any help for this? usually I have seen in the forum advice was to reduce EPAP to reduce CAI. But, also if your CA are persistent, it may mean you actually need an ASV (ventilator) type machine. do you have your CAs all in a row? What is happening when these occur? Pressure, respiration, tidal volume. maybe if it is all in a 30 minute clump you could post a screenshot of the 30 minutes for review.

QAL



_
Here is a sreenshot of Fri night, also concerned about my leak rate. Hope to get some advise from any of you.[Image: MneMGBP.png]


RE: Adjusting my pressure down, advice - sumzzzs - 02-02-2015

(02-01-2015, 09:40 PM)vsheline Wrote:
(01-16-2015, 04:18 PM)sumzzzs Wrote: I want to play with my pressure to see if I can lower my CA index. My OA is averaging 1.5 or so, however it's my CA that is high. Last night 40 events. I've been on CPAP for 40 days, should I lower both IPAP and EPAP pressures? If so by how much?

Hi sumzzzs,

Lowering EPAP is probably not advisable, because lowering EPAP (when IPAP is higher) will usually worsen obstructive events without decreasing the number of Centrals.

Quite a few patients who use ResMed EPR or Philips Respironics A-Flex have found that lowering EPR or turning off A-Flex will lower the number of centrals they get. Lowering EPR or turning off A-Flex has the effect of keeping IPAP unchanged and raising EPAP, which lowers the pressure difference between EPAP and IPAP.

In bilevel therapy, either lowering IPAP itself and/or lowering the difference between IPAP and EPAP usually have greater effect on the number of centrals we get.

Your profile presently says "CPAP Pressure: 8 EPAP 14 IPAP" as if you are using basic manually-adjusted "S" bilevel therapy mode rather than Auto BiPAP therapy mode. If your machine is using S therapy mode, this means IPAP is fixed at 14 and EPAP is fixed at 8 all night, and the pressure difference between EPAP and IPAP (which is often called Pressure Support) is a fixed amount of 6 all night. A Pressure Support of 6 is fairly high and could be causing most of your central apneas.

If your machine is in S therapy mode, I suggest leaving EPAP unchanged (8) and lowering IPAP gradually, by 1 cmH2O per week (13 first week, 12 second week, etc), and watching the effect this has on your AHI and RERA events. This may decrease your central apneas but may increase your RERAs and hypopneas.

If your machine is in Auto BiPAP therapy node, I suggest looking at the data using SleepyHead to see what pressures the machine has been using. But in any case, the approach would be similar, meaning that you would gradually lower the Max Pressure Support setting and watch what effect this has on your Central Apnea Index and RERA Index and Hypopnea Index.

If your machine is in Auto BiPAP therapy node and the Max PS setting is already low (such as 1 or 2) then perhaps you nay need to reduce the Max Pressure setting, especially if most of your central apneas are occurring when your pressures are raised higher than your median or average pressures.

I also suggest avoiding any sleeping flat on your back, because sleeping on our back is usually the worst position for obstructive sleep apnea, requiring higher pressures, and in some patients the higher pressures sometimes produce an excessive amount of central apneas.

Take care,
--- Vaughn

Just had my titration done last week, but my Dr isn't going to see me till end of Feb. My machine is in Auto BiPap that much I know, it pushes 14 IPAP a good portion of the night. I'm trying real hard to stay off my back, I'm about to try the "backpack" method. I defeat the tennis ball in my shorts method. Thanks for your input Vaughn


RE: Adjusting my pressure down, advice - quiescence at last - 02-02-2015

if the chart provided is characteristic of most nights, and not just an odd one, your overall outlook is wonderful. meaning, you'll be able to quiet this down some with a few adjustments.

I defer to #vsheline for more exact suggestions for range, but just note that (1) you have a lot of stop starts and RERA, (2) IPAP starting at 7 and 10, even though median is 13.9, suggesting ramp start higher and min IPAP higher, (3) as you note your upper limit is pegged often, suggesting increasing the max IPAP some, (4) not too worried about the leaks, as your stats for leak rate (the bottom trace) is treated as acceptable to the machine - it says large leaks 0.00%.

When your IPAP started lower (at 7) the rate of climb seems to be faster than when you started at 10, suggesting you will get a lower rate of climb if adjusting min IPAP higher.

I am a FFM fan, too.

QAL



RE: Adjusting my pressure down, advice - vsheline - 02-02-2015

Hi sumzzzs,

As QAL said, your Leak is fine. Top trace is Total Leak, which includes the intentional vent rate of the mask.

In the data you posted, Central Apneas are the least of your problems.

The machine spent half the night pegged at Max IPAP. RERAs and Ostructive Apneas and Hypopneas dominate your events, indicating higher Max IPAP was needed.

Either Max IPAP would need to be raised, or perhaps it may be sufficient to improve sleep position by ensuring you will always stay off your back.

I suggest turning the Ramp off, or raising the ramp start pressure to 8 or higher.

Take care,
--- Vaughn




RE: Adjusting my pressure down, advice - quiescence at last - 02-02-2015

yes and it looks like on Friday night, you pressed the ramp button 4 times. when you did that, do you remember what you were feeling - was there a reason you pressed the button? examples: just uncomfortable, angry at device trying to force my breathing, out of sync, dry mouth, noisy machine?

thanks,

QAL

RE: Adjusting my pressure down, advice - sumzzzs - 02-02-2015

(02-02-2015, 09:30 AM)vsheline Wrote: Hi sumzzzs,

As QAL said, your Leak is fine. Top trace is Total Leak, which includes the intentional vent rate of the mask.

In the data you posted, Central Apneas are the least of your problems.

The machine spent half the night pegged at Max IPAP. RERAs and Ostructive Apneas and Hypopneas dominate your events, indicating higher Max IPAP was needed.

Either Max IPAP would need to be raised, or perhaps it may be sufficient to improve sleep position by ensuring you will always stay off your back.

I suggest turning the Ramp off, or raising the ramp start pressure to 8 or higher.

Take care,
--- Vaughn
Thanks Vaughn, I'm going to take your advise and Raise my max IPAP by 1, usually the Centrals dominate my sleep. I haven't been using ramp. I think those are times when I wake up and go to use bathroom and machine starts again.


RE: Adjusting my pressure down, advice - sumzzzs - 02-02-2015

Question, if I raise my max IPAP and my PS is at 2 does that automatically raise the Max EPAP to follow?