Just diagnosed but headed back for 2nd study. Advice?

[shylock31]

I just wanted to say how exciting it is, as a fairly new member, myself, to see the group "in action" and a fellow newbie getting good results! It makes my heart sing LOL. I am so excited for Piggles!

[Piggles]

Things have been going pretty well but I'd like to dial in further if possible. My AHI is always below 2 but I feel like there is still room to dial it in.

I had a cold and had some trouble dealing with the machine. I was averaging about 5 hours of sleep but I've now gotten to the point where I can use the machine for a full 8 hours. Here are my last 2 days charts + cpap statistics.

I'm thinking of bringing MAX IPAP down to 16 and bringing MIN EPAP up to 9. Any thoughts or recommendations?

[Sleeprider]

Truth is, I think you are trying to perfect, near perfection, but I don't see any harm at all in trying the pressures you suggested. Narrowing your range has been a positive so far, and I think we've eliminated any doubt that the sleep titration got it wrong.

I would suggest the IPAP decrease and EPAP increase be done in .5 cm increments.

[vsheline]

Hi Piggles,

Congrats on your excellent results.

Congrats as well on keeping the settings unchanged for three weeks, since making adjustments too often can lead to faulty conclusions.

With RDI (RDI = AHI + RERA) less than 2.5 you have no obvious need for changing settings, other than very slowly as part of fine tuning. Paying attention now to how you are feeling and your general energy levels are important, but keep in mind that with no changes in settings new CPAPers may imperceptibly heal and gain in energy and stamina gradually over the first 6 months.

Regarding increasing EPAP to 9, your data shows that EPAP has been varying between 8 to 11. No need to change this but I suspect 9 may prove to be better, especially since PR machines tend to be a little slow to raise EPAP.

Not sure why you are thinking of lowering Max IPAP. Conventional thinking is the machine's algorithm won't take IPAP higher than necessary, but having excessive (painful) amount of air swallowing (aerophagia) or excessive (bothersome) mask leaks might be good reason to lower the Max IPAP a little, as a trade off.

I think the likely difference in your self-titrated results versus professional titration may be differences in sleep position. At home you are probably mostly avoiding sleeping on your back.

Professionals want to provide for the possibility we will at least occasionally sleep on our back. For example, what if injury or hospitalization in future requires us to sleep on our backs? Your autotitrating machine would be able to adapt to the changed sleep position only if the Max IPAP is not unnecessary set too low.

Take care,
--- Vaughn

[tuckman]

Well dang!  It's going to be hard to keep up with that!  How are you ever going to explain this to the people that titrated you at 24/20.

time to update your profile.

Not really. He is avoiding sleeping supine at home. The lab he went to has a poor policy of mandating patients sleep supine.

Those high numbers could have been avoided with a lower pressure and positional therapy like he is currently doing.

[vsheline]

Well dang!  It's going to be hard to keep up with that!  How are you ever going to explain this to the people that titrated you at 24/20.

Not really. He is avoiding sleeping supine at home. The lab he went to has a poor policy of mandating patients sleep supine.

Hi tuckman,

Actually, I wouldn't call it a poor policy.  In this the lab is following industry-wide sleep medicine standards.  I think it is a good rule of thumb, so that cases of sleep apnea are not missed (mistakenly ruled out).

I think it is just that the rule's outcome not always optimal, which is why followup is very important.

Take care,
--- Vaughn

[tuckman]

Well dang!  It's going to be hard to keep up with that!  How are you ever going to explain this to the people that titrated you at 24/20.

Not really. He is avoiding sleeping supine at home. The lab he went to has a poor policy of mandating patients sleep supine.

Hi tuckman,

Actually, I wouldn't call it a poor policy.  In this the lab is following industry-wide sleep medicine standards.  I think it is a good rule of thumb, so that cases of sleep apnea are not missed (mistakenly ruled out).  I think it is just that the rule's outcome not always optimal.

Take care,
--- Vaughn

I would rather have a study with supine and non-supine sleep rather than just supine. 

I think its poor policy, but maybe that's just me.

[logansandres]

I was in a similar position to you in 2003.

If you don't have the pressure don't worry about it.
Set your machine for auto mode with low at 4cmH20 and high at 20 cmH2O.

The machine is smart enough to figure out what pressure you need.  Over time post your sleepyhead data and get adjustment advice.  Many will boost the low pressure up to where you are getting many of your events and will feel better doing that.

Fred

Thanks! I was haveing the same issue some time ago! good advice

[Sleeprider]

Well dang!  It's going to be hard to keep up with that!  How are you ever going to explain this to the people that titrated you at 24/20.

time to update your profile.

Not really. He is avoiding sleeping supine at home. The lab he went to has a poor policy of mandating patients sleep supine.

Those high numbers could have been avoided with a lower pressure and positional therapy like he is currently doing.

Tuckman, I think your interpretation is interesting, but if go back to post #24 in this thread, Piggles provided his sleep study for review.  There was a clear error by the technician conducting the study because the best results were at bilevel 17/13.  The technician continued to increase pressures to the 24/20 level and got barely passable results.  Piggles was unable to tolerate the high pressures long enough to even determine if those pressures would work.  Since he was issued an Auto Bilevel, we simply restarted the process using the Philips Respironics recommended titration protocol, and observed the results.  We were all surprised and pleased that this led to excellent results at much lower pressures; however positional therapy was not really part of the strategy. 

In any event, the sleep study tech almost found the right pressure at 17/13, he just didn't stick with that successful result long enough.  There are a couple lessons here.  First sleep studies may yield incorrect results.  We see it all the time.  With the right coaching an individual can more successfully titrate with an auto titrating machine.  I think there might be more here, but why second-guess success?

[tuckman]

Well dang!  It's going to be hard to keep up with that!  How are you ever going to explain this to the people that titrated you at 24/20.

time to update your profile.

Not really. He is avoiding sleeping supine at home. The lab he went to has a poor policy of mandating patients sleep supine.

Those high numbers could have been avoided with a lower pressure and positional therapy like he is currently doing.

Tuckman, I think your interpretation is interesting, but if go back to post #24 in this thread, Piggles provided his sleep study for review.  There was a clear error by the technician conducting the study because the best results were at bilevel 17/13.  The technician continued to increase pressures to the 24/20 level and got barely passable results.  Piggles was unable to tolerate the high pressures long enough to even determine if those pressures would work.  Since he was issued an Auto Bilevel, we simply restarted the process using the Philips Respironics recommended titration protocol, and observed the results.  We were all surprised and pleased that this led to excellent results at much lower pressures; however positional therapy was not really part of the strategy. 

In any event, the sleep study tech almost found the right pressure at 17/13, he just didn't stick with that successful result long enough.  There are a couple lessons here.  First sleep studies may yield incorrect results.  We see it all the time.  With the right coaching an individual can more successfully titrate with an auto titrating machine.  I think there might be more here, but why second-guess success?

The sleep study did not yield incorrect results. If he decides to sleep fully supine for several nights then his auto would have him at a very high pressure because his apnea is significantly worse in the supine position. It is also worse in supine rem sleep.

17/13 was not the right pressure because he hadn't even had a rem period yet. When he finally hit rem, he went in the gutter. It would be a clear error to leave him at a pressure in rem having continued events. 

The only error by the tech is having no non-supine sleep. Which would be easier to tolerate for a new user...9 cm with positional therapy or 24/20 cm without? I've already seen the answer from his last few posts.