Making Progress – Welcome Input

[RWhipkey]

I’ve taken the advice on this forum to not change settings too quickly; that is, to give each new setting at least a week to gather data for review.  I increased the minimum pressure on my Dreamstation to 7.0 and set the maximum pressure to 11.0 on February 5.  In addition, I lowered  AFlex to 1. I started to see gains over the prior settings so, I left it this way for 11 days.  I then moved the minimum to 7.5 and the maximum to 11.5 for the next 7 days, again leaving AFlex at 1.  The results again improved:
1.      Average AHI fell from 2.51 to 1.66
2.      Usage per night increased 1 hour on average
3.      Leaks did not increase and remain a non-issue
4.      PB decreased
However, both FL and RERA increased and awakenings remained about the same.
 
I have posted the data for the two periods in the attached PDF.  I’m pleased with the AHI, but do not know what to make of the FL and RERA.  Are they high?  In addition, as you can see from the PDF, when one of either FL or RERA falls significantly, the other often increases substantially.
 
I have also posted Sleepyhead screenshots for the last two days in each period.  I do so because, being a novice, I could easily miss something important that you may spot.
 
I’m ready to move further.  I’m torn between beginning a period of an 8 to 12 pressure range, or trying a “fixed” range, setting both the minimum and maximum pressures to, say, 8.  What would you suggest?  Also, should I eliminate AFlex altogether?  I appreciate all of the help you've given me on this forum and would deeply appreciate your input.

February 24:


February 23:



February 17:


 
February 16:

[Sleeprider]

Residual events and flow limitations still show there may be a benefit to increased pressure. I would not hesitate to try 12/8 for a while and see if further progress occurs. You have a good baseline at 7.5 and it's certainly worth a look...Good work, and good luck!

Just a side note, I'm impressed how persistent the Dreamstation is at keeping at its minimum pressure, even in the presence of flow limitation, snore and hypopnea. The only thing that would keep me from increasing pressure would be if CA increases unacceptably.

[RWhipkey]

OK, thanks Sleeprider; 8-12 it is.  I'll post results after at least a week.

[RWhipkey]

As planned, I increased the minimum pressure on my Dreamstation to 8.0 and set the maximum pressure to 12.0 (max 11.5 the 1st two nights) on February 25.  After seven days at these settings my observations are as follows:


1.      Average AHI fell again from 1.66 to 1.35. The first 2 days had AHI’s of 2+ and the last 5 days averaged 0.92.
2.      Leak rates were up (but still good) the first few nights.  I switched to mouth taping and they fell to almost nothing again.
3.      Usage per night decreased for two reasons; (1) the night of 3/1 had a 3+ hour power interruption and (2) awakenings per night increased.  I believe the awakenings may be related to pressure increases as I wake up feeling considerable pressure against the mouth tape, and, perhaps the charts substantiate this.  I also have experienced some aerophobia increasing over the night.  As a result of awakenings and some aerophobia perceptive sleep quality has declined.
4.      FL has not decreased and RERA has gone up.  I thought that pressure increases would, instead, improve both.

Earlier in this thread, Sleeprider suggested that I might try single pressure therapy and AshSF sent me a link to a study that found perhaps up to 18% of users of APAP variable pressure can be thrown out of a deeper sleep stage by pressure changes.  He had great success with quality sleep by using a single pressure.  At this point, would it be worthwhile for me to consider a trial of single pressure?

The way I see it, I have several next step options:
1.      Continue as is for another set period.
2.      Keep minimum and maximum pressures at 8.0 and 12.0, but eliminate AFlex altogether.
3.      Raise minimum pressure to 8.5 and maximum to 12.5, leaving AFlex at 1.
4.      Try single pressure at 8.0 or 8.5 for a set period.
5.      Another idea not listed above.
 
I have posted the data for the two periods prior and for this past week in the attached PDF.  I have also posted Sleepyhead screenshots for 2/28 and 3/3 as representative of the week.
I would appreciate your input.

2/28:
   

3/3:
[/url][url=http://imgur.com/Q1e48uZ.png]

[Sleeprider]

With your last five days averaging 0.92, that's pretty good. Are you comfortable and rested? Is there something different you want from your therapy?

What I'm seeing is a machine that stays at the minimum pressure setting except for the auto algorithm tests. Zero OA, and a low level of hypopnea, with data showing some FL and RERA. I see no need to change, but you know where you stand, so if you want to chase these minor events, at least you know where to go home to. Try whatever you want, but this may be where you return. Congrats on your progress. I have better and worse days, but rarely perfect. JMHO, you may have arrived.

[AshSF]

I had a similar pressure waveform at 8cm minimum. The respironics algorithm does its hunt-n-peck pattern by raising pressure by 1.5cm over 2 minutes, evaluate if the breathing pattern improves further. And drops it back to baseline if it didn't.

Looking at your feb 28 chart, you may want to try going on a straight pressure of 8cm or maybe 8.5cm for a week and see if any qualitative changes occur in how you feel in the morning.

This will also help with leak rates.

[RWhipkey]

Sleeprider and AshSF

To answer your question, Sleeprider, I'm really not feeling rested all that often.  Nonetheless, I agree that I'm where I need to be with an automatic pressure range.  AshSF raises a good point that you raised earlier to me.  I think I owe it to myself to try a fixed setting to make sure that I'm not one whose sleep pattern is affected by pressure changes.  If a fixed pressure does not improve the frequent awakenings, then, as Sleeprider points out, I have a very good point to return to. I would return to 8 - 12 setting and only further adjust comfort settings.  I feel I've come a long way and I know I could not have done so without the help of this fine community.  But, I am especially indebted to the two of you for your guidance and patience.  I can't thank you enough.  I will keep you posted.

[RWhipkey]

Since my last post, I did try a fixed pressure of 8.0 (minimum = 8.0, maximum =8.0) for only three nights.  The results are posted in my attachment.  Basically, the AHI and RDI numbers were fairly equal to the previous 8 nights with minimum = 8.0 and maximum = 12.0.  However, sessions (corresponding with awakenings) went up and subjective sleep quality did not improve.  I know 3 days is a short sample, but I sensed from the data that, for me, awakenings or sleep stage interruptions were not necessarily caused by pressure changes.  So, I returned to a pressure range.  I chose 8.0 to 11.5 and tried AFlex of 2 and 1.  The results are posted below.  I’ve returned to the AHI and RDI averages I had for the last period that I posted (range 8.0 to 12.0) and asked for comments.  But, sessions were minimal (2, several nights with only one awakening), which is a big improvement over my pre – APAP experience and over my APAP experience to date.  Comfort level has improved and I logged an average use of over 8 hours.  Some aerophagia persists, but it is controlled by a chin strap and mouth tape (center of lips).  Virtually no leaks with either setting.

Results:

Fixed Pressure at 8.0
Date   Hours   Sessions   CA    OA     H    AHI    RERA   RDI    FL     PB      PP    MIN    MED    AVG   90%   95%   Max   Flex
3/5     7:14          2        .41   .14   .97   1.52    1.11   2.63  1.52  .00%  2.63  8.00    8.00   8.00   8.00   8.00    8.00   A3
3/6     7:38          3        .00   .13   .66   0.79    0.00   0.79  0.92  .00%  0.13  8.00    8.00   8.00   8.00   8.00    8.00   A2
3/7     6:48          5        .59   .15  1.17  1.91    0.00   1.91  1.17  .00%  0.88  8.00    8.00   8.00   8.00   8.00    8.00   A1
AVG    7.13         3.3      .33   .14    .93  1.41    0.37   1.78  1.20  .00%  1.21  8.00    8.00   8.00   8.00   8.00    8.00

Pressure Range: 8.0 - 11.5
Date   Hours   Sessions   CA    OA     H     AHI    RERA    RDI     FL     PB      PP    MIN    MED    AVG     90%   95%    Max    Flex
3/8     7:11          3        .56   .00  1.25   1.81    0.00   1.81  0.14  .97%  0.56  8.00    8.00   8.19   9.10     9.50    10.90   A2
3/9     8:02          2        .12   .00   .50    0.62    0.12   0.74  1.00  .00%  0.37  8.00    8.00   8.25   9.30     9.50    10.80   A2
3/10   8:38          2        .23   .00  1.04   1.27    0.46   1.73  1.04  .00%  0.46  8.00    8.00   8.56   10.10  11.40   11.50   A2
3/11   8:41          2        .23   .23  0.69   1.15    0.00   1.15  0.81  .00%  0.58  8.00    8.00   8.29   9.50     9.50    11.20   A2
3/12   8:25          2        .00   .00  0.71   0.71    0.48   1.19  0.83  .00%  0.48  8.00    8.00   8.34   9.50    10.50   11.50   A2
3/13   7:18          2        .00   .14  2.33   2.47    1.37   3.84  0.55  .78%  0.14  8.00    8.00   8.69   11.00  11.50   11.50   A1
3/14   8:53          2        .11   .11  1.01   1.23    0.56   1.79  0.68  .00%  0.68  8.00    8.00   8.43   9.70     9.80    11.30   A1,A2
AVG    8.09         2.1      .18   .07  1.08   1.32    0.43   1.75  0.47 .25%  0.47  8.00    8.00   8.39   9.74    10.24   11.24
                      
My inclination is to go with a pressure range, 8.0 to 12.0 (because I hit the max at 11.5 a few nights).  I might only experiment with AFlex and humidification, but will stick with this range for now.

I also posted my best night statistically (March 9) and worst night statistically (March 13) for review.  Subjectively, March 9 was a very good night and March 13 was OK.  March 13 had a cluster of events that I slept through in the first session and I’m not sure why.  I would appreciate your comments and any observations or conclusions I missed  And again, a special thank you to Sleeprider and AshSF.

March 9:



March 13:

[Fedman]

Rwhipkey,

I also use an auto DreamStation and have a similar pressure range.  I was averaging an AHI of 1.5 for the past few months with more hypopnea's than CA or OA.  Approx 15 days ago, I increased my lower pressure from 8 to 8.5.  That small change virtually got rid of my hypopnea's and my average AHI is now 0.5.  Not saying it will work for you but it doesn't hurt to try.  A simple pressure increase of 0.5 or one might help reduce your hypopnea's.

[Cranberry Ray]

RW, kudos to you for trying to get the best out of your Dreamstation. I have been experimenting lately myself and found that changing my range by just .5 cm had a negative impact on my AHI numbers. Going back to the original settings but it never hurts to try and improve. One suggestion I might offer is switching from Aflex to Cflex. Aflex offers pressure relief on both inhalation and exhalation where Cflex only relieves exhalation pressure which is really all you should need. I found it to help with overall AHI results and comfort. Other than that, great job!