questions about lowering AHI

[Beth T.]

I started CPAP therapy on 2/2/12. I have an S9 autoset and my inital pressures were set at 5 and 8 by the titration study. My sleep clinic was great during the studies and setting up and explaining the machine - horrible at supprot and follow up that they said they would do. RT told me he would call after 4 days to see how it was going and then again at 2 weeks. Neither happened. I emailed him after a few days and he called and answered a couple of questions. I told him that I was not seeing an AHI on my machine. He said if I wasn't it was because it was 0. Of course that was not true. I figured out how to turn on the sleep report and was able to monitor it. Always under 5 but often in the 4s. Then I went back on 3/6 and saw the doctor. I told him that my 95th percentile was always at 8 so he agreed that the pressure should be raised and said he would raise it to 6 and 9. I also told him I wanted to try a full face mask as I was having some congestion problems and mouth breathing even with a chin strap. They measured me and said they would have to order one and would contact me when it came in. 3 weeks and 2 emails later and still haven't heard anything. Checked the next morning and my 95th percentile was still 8. So I figured out with the help of this board and the apnea board how to get into the clinician's settings. Sure enough the pressure had not been changed. I changed it to 6 and 9. AHI still hovering in the high 3s and 4s. Better certainly than what it was before CPAP but I want to get the most bang for my buck! However I kept it that way for 20 days to get used to it. I then changed it to 10 leaving the lower range at 6. Ramp is only 10 minutes but it is an easy way to get started every night. So for two nights I have had it at 10. THe 95th percentile pressure on both nights is 10. AHI of 2.5 and 3.1. Better certainly but - really - I want it to get as low as I can. However I will leave it at this to get used to it and see what happens. I want to post some of my data but am unsure of how to do it. I have both Sleepyhead and the Res Scan software.
I am so frustrated with thie after care and support that I am receiving. I did talk to the doctor about it when I saw him as I was having some problems with his billing person not returning calls too and he seemed really concerned and then - DIDN'T CHANGE THE PRESSURE WHEN HE SAID HE WOULD. I see him again on 5/8. Prepared to listen to crap about chaniging my own pressure and prepared to reply to that crap as well. Aetna has me paying for the machine for 10 months after which I own it - wonder if I can change doctors during that time...
So I have rambled but my questions are - how can I post some data? SHould I raise the lower pressure as well so it is in a 3 point range? How long should I wait before I raise it again if my 95th percentile keeps reaching the upper limits? Thoughts on staying with this practice or changing. They blah blah when you are on hold about how important you are to them and how they know the most important thing is their patient's satisfaction and the best compliment is a referral - and yet they really do not offer good support when that is what is most crucial.

[zimlich]

Beth, unfortunately the aftercare you have (not) received is all too common. This is where apneaboard fills in the gaps. Your present AHI is very good. You may be able to get it a bit lower by raising your upper and lower numbers- you know the drill by now about how much to change and to take time to acclimate to changes- a week to 10 days if you're impatient. I think a month is a better trial. At some point you may find that raising your upper number becomes counter productive and your AHI does not go down anymore. Stop here or back down a cm or 2 You can certainly change doctors any time you want and it should not change your relationship with your Medical Equipment Provider. Does your doc have techs in his office who read the data and make the prescription changes? Is he connected with the Equipment provider? My doctor works for a system that has it's own health care program, but I don't have to use them. In fact I just changed to them with the latest machine change and I'm sorry I changed from a great DME to a lousy one. I'm sorry I don't know how to post data.
Something else I have learned is that when you're having trouble with the doctors office or the equipment provider- talk to the office manager. Good luck.

[JudgeMental]

Above poster has given very good advice. Lack of followup from MD and DME's is indeed very common. You have to be your own best health advocate. Put a good timeframe in between pressure changes.

If you are having leaking problems w/ the nasal mask, then when you try out the new full face mask, it just might be the answer to lowering you AHI a bit..You are in a good range now and I'm glad the therapy is working for you.

There should not be any trouble with changing DME's and/or sleep specialists if you care to do so. It's your call.

[JumpStart]

So I have rambled but my questions are - how can I post some data?

Beth T, can you tell us what form of data you wish to post? For example, am image of a graph, a statistics page, a document, all of the above, ??? And what operating system are you using - Win 7, XP, Mac? I had the same issue not long ago when I wanted to post an image of a graph. Can you create a .jpg or .jpeg of whatever it is you want to post? Or a .txt file? If either a .jpg or .txt or Word file, posting is easy and I will tell you what I learned about it. I may be less help if you cannot already create an image (if that is what you wish to post), but there are others on this forum who can post ANYTHING, and will no doubt be willing to help.

[RWRPSGT]

I use an S9 Autoset which after several nights of averaging my highest pressure set it to CPAP at 18cm H2O. It is my understanding after speaking with several of my colleagues that the adjustment up and down, more common between NREM and REM actually can cause more fragmented sleep over the night. My AHI is now around 1.2 on a nightly basis.

I DO know that the algorithm in an S9 does not increase for a specific number of events as we would in the lab. It measures the airflow waveform and increases to the correct pressure or drops the pressure if it appears too much. I am not sure if this gives a higher than average AHI, as in the lab we would actually count the number of events scored and divide by the number of hours total sleep time (TST). The fact that it factors in snoring as well would suggest this. If you unlock your settings and scroll the information it will tell you how many Apneas it believes you had, how many centrals, and an AHI. I have been able to fool this machine by holding my breath, so I do not think it can distinguish between when you are awake or asleep.

I also know from speaking to the ResMed rep at a staff meeting recently that all the ResMed models autpmatically adjust for acceptable leaks, but the higher ones over the maximum will generate the sad face. My problem is that if I don't wear a chinstrap my mouth falls open in REM, causing the air to rush out of my mouth. I still wake up refreshed.

I would try looking at your average nightly and closing the gap to about two below your highest pressure as a minimum. My original was 10-20 and I gradually changed it to 16-19 and then again to 16-18. This has given me positive results. If you use the EPR function on it you get a BiPAP type feel as well.

Hope that helps.


Robb Webb, RPSGT
Registered Polysomnography Technologist and CPAP user

[PaulaO2]

Find out from others who use the software of what piece of data would be best. You can upload a graph or other data via the 'attachment' option.

In a nutshell:

Down below where you write a post (the full screen, not the quick reply) you'll see a section that starts with "New Attachment".

Click the 'browse' button.

Find the data you want to upload. Click on it and select 'open'.

The path to that document/image should now be in that box. To the right, click the 'Add Attachment' button. This uploads it to the server. (if it is too large, you'll get a notification)

It does NOT add it to your post, however.

Click inside your post where you want the document/image to appear.

Click the 'Insert Into Post' button'.

For most items, you'll see an 'attachment=##' with the number being your upload.

Click 'Post Reply'. Check to make sure the upload worked. This is one of the things that 'Preview Post' won't let you check.

[SuperSleeper]

Robb Webb, RPSGT
Registered Polysomnography Technologist and CPAP user

Hey Robb - welcome to the "real" Apnea Board Forum! Glad you made it over from Linkedin.

For those not familiar with our group on Linkedin, Robb has made some very helpful posts over there and I'm sure has some "battle scars" from a recent conversation to prove it.

Good to see you here, Robb!

[zonk]

Hi Beth T
Sorry you,re having a rough time with your doctor.
As Robb mentioned the S9 can not tell whether the patient is awake or asleep.
ResMed say the S9 can compensate for leak up to 24L/min
and if stay over this figure than the therapy would be compromised and affect data measurement.
I would try to turn ramp and EPR off see if makes a difference as it,s only a comfort feature some prefer to use and others don,t.
AHI below 5 is good and imo the most important sign of the effectiveness of the therapy is getting a decent night sleep and how you feel is better sign than having a lower AHI.
Sleep hygiene is important too.

[RWRPSGT]

From a clinical standpoint, 0-5 AHI is normal for most people. Anything over 5.0 is significant for Obstructive Sleep Apnea (OSA).

Your treatment is effective as long as your AHI remains below 5.0.

[Netskier]

AHI still hovering in the high 3s and 4s. Better certainly than what it was before CPAP but I want to get the most bang for my buck!

...

AHI of 2.5 and 3.1. Better certainly but - really - I want it to get as low as I can.

Since, AHI below five is considered clinically to not be apnea, to get the most bang for your buck I currently recommend managing your Apnea Symptoms profile to minimize Obstructive Apnea first, followed by minimizing Hypnoneas next, instead of minimizing the total AHI. I don't think you can go wrong with this, provided that your total AHI is five or lower.

To do this, use Sleepyhead, Daily, Events, click on Obstructive Apneas, and then click on the individual events listed, to inspect them in the Events Flags Graph, and then note the mask pressure at which each event occurred.

Consider raising your minimum pressure to prevent Obstructive events from starting at all.

Consider raising your maximum pressure if your Autoset can not stop your Obstructive events after they have started.

We discussed this in greater detail in "Shouldn't the goal of PAP treatment be to minimize Obstructive Apnea?" on 2012-03-23.

Please let me know if this helps, or is not clear.