Decent - but we all deserve better than that! Suggestions please.

[CPAPveteran]

First, not obsessing here, but you know when your therapy aint right, as in you dont ever feel rested after 10 years of CPAP therapy.
I'm posting some thoughts and questions below? First, is there a better way to attach/export/etc Oscar data into post here? Thanks.

So here is last nights data. Many will say this looks OK, AHI is great, etc. But this is what I’ve learned so far in my CPAP journey:

1. Way too much emphasis on AHI, even when patients still don’t feel rested.
   
2. Not enough scrutiny on the actual flowrate shapes and spikes and their associated micro-arousals.
   

So if you will please, I have a couple questions about last nights data:

1. There are a lot of breathing disturbances that you can see from looking at the whole night at once. You dont even have to zoom in. The flowrate graph should be smooth, like 3:40 to 4:10 am, save for 2-3 REM sessions. If you dont agree with this mindset, please let me know, this is the cornerstone of my CPAP therapy understanding.
   
2. What adjustments might be needed? My 4-20 and 7-11 APAP tests both show my 95%-tile pressure to be 10-11 range. Hence I set pressure to 11, EPR of 1, to net EPAP of 10. Any thoughts on EPR helping or hurting my desire to decrease all of those pesky spikes in my flowrate graph?
   

Thanks all and Merry Christmas and Happy Holidays!

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[Gideon]

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U
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I do assume you know that EPR or PS is your best tool to manage hypopneas, flow limits, RERAS and UARS.

[CPAPveteran]

To add an attachment 
1. Click the reply button, not quick reply
2. Below the message box in the attachment section
Choose file
3. Then click Add Attachment to the right of where you chose the file
4. Add document to post
U
You cannot directly add a image to a post.

I do assume you know that EPR or PS is your best tool to manage hypopneas, flow limits, RERAS and UARS.

I attached a screenshot. Is there better way to capture Oscar images to share here?
On the EPR, I did not know it was a foregone conclusion is the best tool. I'm still learning . Let me ask your opinion this way...of the total therapy received by a CPAP device, what % is having the right P, and what % is using the right level of EPR?

[SarcasticDave94]

I would say, even though the areas are a small portion of the whole night, your few Obstructive Apnea and Flow Limits both would be better served with a bit higher pressure AND EPR.

I would offer the best answer is to run the CPAP in AutoSet, setting a pressure range from maybe 9-14 and EPR full time 3. At least try that, however it's not set in stone that would be your only or final edit. Basically this is a self titration over several nights to dial the settings to become best for you.

I'm not certain at all what you're asking pertaining to percentages. With both pressure and EPR are available, both can be tried to obtain best for you settings.

[Gideon]

nearly 100% of the exhale pressure on treating OA events
nearly 100% of the EPR for treating hypopneas, flow limits, RERAS, and UARS

Titration Guidelines
Increase EPAP/Exhale Pressure until OA events are managed
Increase the difference between inhale and exhale to manage hypopneas, flow limitations and as the following are flow limit based, RERAS and UARS
Do note that on a CPAP/APAP increasing EPR may require a corresponding increase in pressure to maintain the same exhale pressure. That said many individuals are at a higher pressure than they need so that adjustment may not be needed. If pressure is not adjusted the results should be reviewed for an increase in OA events and then an appropriate correction applied.

Looking at APAP data you want your min pressure to be approximately by ROT 2cmw below the median (not 95%). Max pressure shouldn't matter too much when properly tuned because the correct treatment should keep the pressure down vs artificially holding it down because of pressure increases resulting from poorly managed events. Yes there are individuals who do need the max limited.

ROT says that most adults find 5-6cmw to be not enough. Many here go for 7-8 Min. 7 Min allows EPR to fully function.

[CPAPfriend]

heyCPAPveteran

Your complaints resonate with the hearts of many, and for what consolation it can provide, they are trying very hard to better measure sleep disturbance / sleep-disordered breathing. I expect substantial progress in the next half decade as the collective conscience begins to wake up to the importance of sleep and the epidemic of sleep-disordered breathing. The current, best statistical analyses suggest around 950 million people suffer from an AHI of 5 or greater, so you can imagine the financial incentives structure that is in place to correct the airway.

Yes, AHI is a crude metric that ceremoniously fails to capture the true cohort of patients with sleep-disordered breathing. Two areas of interest that I'm trying to follow are pulse spikes and just natural flowrate breathing. There is a lot of emphasis on eliminating obstructive and central events, and that seems to be where the arbitrary line is drawn, as you mention, but why would we not aim for normal flowrate? That is, flowrate that is representative of a cohort of normal sleepers. Although only lightly supported by the available scientific literature, this is why I gently suggest to patients they aim to near fully eliminate their flow limitation, as it is, in end effect, still upper airway resistance and, therefore, logically would contribute to the same physiological outcomes as resistance greater than it.

Some advice is contingent upon the sleep study that elicits it. I believe it can prove helpful trialing other PAP modes, such as bilevel or ASV, even when it's not always clear from the PAP data. Of course, should one explore those avenues, do so under the guidance of a healthcare professional, make sure you don't have any contraindications, etc.

[CPAPveteran]

nearly 100% of the exhale pressure on treating OA events
nearly 100% of the EPR for treating hypopneas, flow limits, RERAS, and UARS

Titration Guidelines
Increase EPAP/Exhale Pressure until OA events are managed
Increase the difference between inhale and exhale to manage hypopneas, flow limitations and as the following are flow limit based, RERAS and UARS
Do note that on a CPAP/APAP increasing EPR may require a corresponding increase in pressure to maintain the same exhale pressure.  That said many individuals are at a higher pressure than they need so that adjustment may not be needed.  If pressure is not adjusted the results should be reviewed for an increase in OA events and then an appropriate correction applied.

Looking at APAP data you want your min pressure to be approximately by ROT 2cmw below the median (not 95%). Max pressure shouldn't matter too much when properly tuned because the correct treatment should keep the pressure down vs artificially holding it down because of pressure increases resulting from poorly managed events.  Yes there are individuals who do need the max limited.

ROT says that most adults find 5-6cmw to be not enough. Many here go for 7-8 Min. 7 Min allows EPR to fully function.

So let me make sure I understand you:

Q: When you say OA, I assume you just mean apneas, for you list hypopneas, flow limits, RERAS, and UARS separately?

Comment: I do not use APAP, for when I do, events happen and then the machine ups the P and then lowers it again, and then events happen again, over and over. I guess I'm more proactive and like CPAP for that reason.
Q: Do you find the Resmeds may slightly underestimate required P? For instance, if my 95% P with trial of APAP suggests 10.3, then perhaps I should have CPAP of 11?
Q: EPR seems to help with my flow limitations, etc. So I assume most people get the most benefit from the max EPR setting of 3? Or is it that people are split evenly among all 3 EPR levels?
Q: I attached last night screenshot, Pressure 13, EPR 3, net EPAP 10. Looks decent, but flow rate bar graph still looks fuzzy as if it needs a shave . Per Q above, my CPAP/EPAP might need to be 11, so I might try 14 with EPR 3. Does anything in the chart look like need for Bi-level like you have? Say more PS, say 4, 5?
Thank you Gideon so much!

[CPAPveteran]

Thanks for the reply! Agree 100 with everything you say. From my experiences so far:

1. The DME is not in the game at all with respect to sleep quality. They are lucky to get you the right equipment and deal with the insurance challenges.
2. Even your sleep Dr, if lucky enough to have one that wants to work with you after your AHI of <5 is confirmed, don't want to look at detailed info (flow rates, breath curve quality, etc).
3. Even if they do, they are limited to the data from the machine, and per your notes above, wont have the sleep test level data to go out on a limb to suggest trials of other therapy/machines.

Let me know what you think! Thanks again!

PS: Here is my last night's chats, your thoughts?

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OOOps, see attachment now...

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OOOps, here is attachment...

[CPAPveteran]

Thanks for the reply!

On the percentages...it seems to me the only real tools with a PAP machine is APAP/CPAP, Pressure, and EPR. And if you want CPAP, then that just leaves two, pressure and EPR. I guess I was trying to ask what part of someones total therapy is finding the right pressure, and then using/finding the right level of EPR.

My guess is the right pressure is 60%, and use/level of EPR is 40%.

[Gideon]

Yes OA is Obstructive Apnea.
My philosophy is that when events are driving pressure up, it is better to treat and manage the events then to manage it otherwise.

On EPR the most common value here is 3 mostly because we use it to manage events. New people often have it set to ramp only and at 3 because it may cause central Apneas, and IMHO a lack of understanding of what it is. It is marketed as a comfort feature.

On your comment, I would have you lower your pressure a bit, slowly, and run in APAP mode. Keep the band narrow to maintain your comfort The pressure increases are an indication that you are not optimally managing the OA, H, and/or Flow Limits that drive pressure. Identity what is causing the pressure increases and target those. It is possible that you are an individual that needs a single constant pressure. It is also possible you would be better treated with a BiLevel. This process would also look at that.

I really don't look at 95%pressure other than to see where it is in relation to the machines max. I focus on events and preventing them. .
I do pay attention to the clustering of events as the method of fixing that is different.