First data download and need advice

[OpalRose]

Since EPR is not even on in your current mode, it won't help.

Look on Statistics chart: Pressure is set at 15 cpap mode, and
EPAP is reading 12. That is a pressure drop of 3cm, which suggests
EPR is set at 3.

[Sleeprider]

Yep, and I see it in the chart...must have been thinking of something else. Still in CPAP mode, and the pressure is well above requirements.

[shylock31]

Thank you all for so much helpful information! I will start with seeing how lowering the EPR does, and then will follow up with changing to APAP mode, if I'm still having a lot of CAs after several days. My DME is not making changes remotely, but I think the difference in pressure is related to not taking the mask off as much now as I did the first week. Since I had a 45 minute ramp, with just a few days' data, they averaged out to only 13 for the pressure. I have decreased the ramp time to 20 minutes, and I generally only take the mask off once during the night, if nature calls. That leads to a higher average pressure, as shown on my machine. Since I didn't have an SD card for the first 3 weeks of treatment, I don't have any better details than what I read off the machine for those early days.

I was also able to go online and get my sleep study results. I had a home study for diagnosis and an in-lab titration study, so both notes are included below. Unfortunately, they only provide me with this written report, and no graphs or tables to make it easier to read.

Home Sleep Test performed on 10/13/2016 moderate sleep apnea, with AHI 16.3/hr, desaturation index 17.6/hr.

METHODS:
This unattended home sleep test was performed using the Level III MediByte Junior Home Sleep System. Variables monitored included respiratory effort, airflow, oxygen saturation, heart rate, snoring, and body position. Patient noted time to bed and time out of bed. No EEG recording was obtained. The monitoring sensors were applied at home by the patient.
REPORT:
This ambulatory sleep test had a total recording time of 495.5 minutes. The overall AHI was 16.3/hr. The overall desaturation index was 17.6/hr. Snoring was noted. The patient’s average heart rate was 93 bpm, minimum heart rate was 64 bpm, and maximum heart rate was 112 bpm. The mean O2 saturation was 94.3% and the lowest was 87.0%. The patient was in the supine position for 46.2% of the night, and the remainder was spent in the non-supine position.

INTERPRETATION:
This overnight polysomnogram demonstrates that the patient has:
1) Mild to moderate obstructive sleep apnea.

CLINICAL CORRELATION:
This degree of sleep apnea may contribute to daytime sleepiness and long-term cardiovascular morbidity.
1) A repeat PSG with CPAP titration is recommended.


Titration Study performed on 11/5/2016 recommended a pressure of 15 cwp, residual AHI: 1.3/hr.

HISTORY: This is an overnight polysomnogram with tritration of positive airway pressure (PAP) on this 38 year old patient with complaints of excessive daytime sleepiness.
A previous home sleep study done on 10/13/2016 revealed moderate sleep apnea with an apnea hypopnea index (AHI) of 16/hr, and desaturation index of 17.6%/hr.

METHODS:
This overnight polysomnogram was performed using the Nihon Khoden Polysmith Digital system. A total of sixteen channels were recorded. Six EEG channels were recorded using Grass disc electrodes placed according to the standard 10/20 electrode placement system to assess sleep stages (C4-M1, F4-M1, 02-M1, Fp1-O2, T3-Cz, Cz-T4). Airflow was measured using an oronasal thermal sensor and a nasal air pressure transducer, microphone for snoring. Hypopnea is defined as a >50% drop in the baseline nasal pressure signal, lasting a period of at least 10 seconds and accompanied by either a 3% drop in oxygen saturation or an arousal. Thoracic and abdominal respiratory effort was measured using inductance plethysmography. Axial EMG activity was recorded from the mentalis muscle. Leg movements were recorded using standard Grass disc electrodes placed over the tibialis anterior muscles of both legs. Electro-oculogram and electrocardiogram tracings were recorded. The oxygen saturation was recorded using a finger probe connected to the Nihon Khoden Polysmith digital system. Positive airway pressure (PAP) was provided using a Respironics Inc. BI-PAP airway management system. A humidifier was used. CPAP was started at a pressure of 4cm of water and was titrated to eliminate apneas, oxygen desaturations, snoring and arousals. Transition to bi-level PAP or adaptive servoventilation (ASV) was carried out as clinically indicated.
RESULTS: See attached scoring sheets. (MY NOTE - No scoring sheet was accessible online, so I'll have to request it from the physician)
REPORT: During titration, CPAP pressures between 4 cwp and 15 cwp were used. The TRT was 430 min and the TST was 339 min resulting in a sleep efficiency of 78.7 %. The sleep latency was 41 min and the REM latency was 285 min. The overall central apnea count was 12. At CPAP pressure of 15 cm water, the best sleep was noted and the AHI was 1.3/hr with a TST of 89.5 min at this pressure. The desaturation index was 3 /hr and the arousal index was 9/hr. Supine sleep accounted for 34% of sleep at the recommended pressure. REM sleep was recorded at the recommended pressure. The overall periodic leg movement index (PLMS) was 10/hr with a movement associated arousal index of 1/hr. The single-lead EKG showed no significant arrhythmia.
INTERPRETATION:
This PAP titration polysomnogram demonstrates that CPAP at 15 cwp with heated humidification had significant benefit in improvement of the patient's quality of sleep.
CLINICAL CORRELATION:
CPAP titration demonstrated improvement in the patient's sleep quality.
CPAP pressure of 15 cwp with heated humidification is recommended for initial home PAP therapy.
During this study, the patient utilized a Small, Respironics Nuance Gel, Nasal Pillow Mask.

[shylock31]

So I downloaded last night's data with the EPR set to 1. I it was a better AHI, but I'm not sure that one night is enough to know if that "solved" the problem. I still had a lot of CAs. I'm posting the whole night for review, and a zoom in of an area with several events in a short period of time.

Based on advice from several of you, I have changed my setting to APAP. I am not sure if I need to change the max pressure, or just leave it and set the min pressure higher (because 4 would definitely be too low for me).

Jan 12 - whole night (earlier nap omitted)

Zoom in of some CAs

I'm especially curious about whatever's going on at 6:48:30. Is this also an apnea-event, but too short to register? I've noticed several "blips" that look like the same pattern as the marked OAs and CAs, but aren't registered as any kind of event. Is this normal? Thanks in advance for any guidance you can give!

[Beej]

If 4.0 cm pressure is too low, definitely set the minimum where you know you can breathe comfortably.

The definition of an apnea includes that the duration is a minimum of 10 seconds. For more info on how scoring is done, go to this article in the Journal of Clinical Sleep Medicine.

[shylock31]

Thanks for the article. Very helpful!

[holden4th]

Forget EPR for the moment, just leave it where it is. Instead, you have to go into Auto mode to get anything meaningful from your charts and to optimise your therapy. Also, don't worry about the maximum setting set it at maximum if you like but 15 sounds good. I like Opal Rose's idea of a minimum setting of 9. With the EPR already set at 1 this means it will only drop to 8. You can then see what maximum pressure is reached when you sleep. I suspect that it won't be anywhere near 15. Try this for a week and then come back to us with your Sleepyhead results.

Do you know how to switch for CPAP to APAP and how to change the settings? If so then let's see how you go. If not we can help you with that as well.

[shylock31]

So it's been a couple of weeks and I've collected more data about how the switch to APAP is going.  I am thoroughly confused , as my average AHI for the time period since the switch has been a little better, but I have had several higher than usual nights and not sure what to do next.  I wouldn't be so concerned, as the average is technically "treated," but I still feel so tired all the time, and I felt I was beginning to be more alert before making the changes.  So I'm sharing a few links to see if the group can help me figure out the next steps.  

The first link is to the overview of the time since I switched to APAP mode, using the suggestions given by all of you. Overview

Since I've had some high nights, I thought that data might be helpful, but I wasn't sure what would be most useful to zoom in on.  Here are the full nights - just let me know if there are time periods that would help to review. Jan 28  Jan 29

To compare, I had two low nights, which I thought might also give helpful information.  Again, these are the whole night, but I can zoom in and post additional views as needed. 
Jan 19  Jan 20

I am so grateful to have this group as a resource and support!

[Sleeprider]

There is no obvious pattern that separated good nights from higher events. If you felt more rested with fixed pressure, it looks like 13 cm is what works best. You might set minimum and maximum to 13 and try a night of steady pressure and see if that sorts it out. On your best nights, you rarely exceeded 13 cm, and on some of the nights with more events pressure varied, but was often much lower. We don't have a lot of options for reducing CA events, and holding pressure steady sometimes works better.

[shylock31]

Thanks, Sleeprider,
I'm glad to hear that I wasn't missing some life-altering pattern between the two types of nights.    I will try a steady pressure of 13 and see how that goes.  It is very frustrating to have these CAs, because I had none reported on my titration study, unless they just didn't tell me and didn't note it.  I see my provider in two weeks and can ask about the CAs.  Thanks for the suggestion!