Optimizing therapy

Note: We the authors of the Wiki and contributors to the forum are not medical Doctors, nor do we have registered medical backgrounds. All that we mention here has been gathered from what we believe are reliable sources or is our personal experience.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM OR ON THE WIKI SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.

First and foremost, help is readily available at our forums. Please feel free to ask any questions about your apnea there. Please keep your posts in one thread to maintain history. http://www.apneaboard.com/forums/ http://www.apneaboard.com/forums/Forum-Main-Apnea-Board-Forum It is impossible to advise on a cause or a correction without knowing the types of events and what your Autoset machine is doing in terms of pressure. This is a long and drawn out way of saying We Need To See The Data.

APAP Optimization

Step 1: Review your sleep Studies Review your original (or recent) Sleep Study, this is the one done without a xPAP machine. In this study you are wired to measure your sleep stage (EEG) and cardiac function EKG, Are you mouth or nose breathing, and your O2 Saturation levels thru the night. This study determines non-obstructive apneas which are more complex to treat. For us here it determines the presence or absence of Central and / or Complex Apneas. Review your (typically) second study, your titration study. This is where a pressure recommendation is made. This recommendation is a good starting point but it is 1 point in time where you are sleeping in an unfamiliar bed in an unfamiliar location with a bunch of wires stuck to your head and various other straps and monitors. A Caution flag. If you have or CA (Central Apnea) make only small changes and see how they impact your data. Obstructive Apnea is generally treated by increasing a pressure. Central Apnea often increases with an increase of pressure. These two treatments (decreasing pressure for Central Apnea and increasing pressure for Obstructive Apnea) often contradict each other. It’s possible one or other of the sleep studies (ie diagnostic and titration) may be skipped. In this case carefully monitor your results to see if you have central apneas. Some machines and software refer to these as “clear airway” apneas – a subtle but important distinction.

Step2: Your Machine OK, now we can get down to the nitty gritty, your machine. While there are excellent used and new older model machines out there, we will concentrate on the new current machines here. If cost and payment indicate otherwise please enquire on the forum for choices. The best machine to get is the current Auto Machine, currently Philips Respironics DreamStation Auto or the ResMed AirSense 10 (A10) AutoSet There are other specialized PAP machines, BiPAP, BiLevel, ASV etc. that this article is not intending to discuss. Please visit our forums for questions involving these machines. A recent recommendation on the forum was “Get the auto, request the Resmed Airsense 10 Autoset as the machine you want, and you will be on your way in no time.” If you do not have an Auto machine as above optimization can be achieved if you have a full data capable machine. For access to the widest range of on-line assistance, your machine should be compatible with SleepyHead software, but having full data capability and access to the Vendors software will also work. If your machine only offers AHI data, while certainly not optimal, treatment can be somewhat optimized by the trial and error method sometimes called educated guesses. Please request help on our forums for this.

Step 3: Download and install Sleepyhead software http://www.sleepfiles.com/SH2/ Once SleepyHead is installed on your computer, insert the SD card from your machine into the computer and allow SleepyHead to import the data and display your results. There is a very comprehensive tutorial on SleepyHead below

Step 4: Initial Pressure Setting If your doctor or DME has not already set the pressure, or you do NOT have a prescribed pressure, then set the APAP machine for 6-20 cmH2O in Auto mode. – This is to get the first look at what the machine will use. If you have data because you have been using CPAP evaluate the chart data, The pressure should only go up as high as needed to resolve events and flow limits. Some people do need a maximum pressure to prevent the machine from going excessively high. This value, the maximum pressure, will be set on night 2 if desired.

Step 5: Upload the Data Create a screenshot of your SleepyHead output and upload it to the forum and ask for an evaluation. Please keep all of your posts in a single thread to maintain history. Guidance on downloading, organizing / formatting the SleepyHead output, and linking it via the photo-sharing site Imgur can be found below: Download SleepyHead Organize your Sleepyhead charts Post from Imgur What are we looking for? First we look for anything that may present issues with managing your therapy, This includes any sign of CA, Central Apnea or Complex Apnea. If there are any signs we will proceed cautiously. What is the relationship between your assigned pressure range and your running range? Are you hitting the high number and staying there? Are you sitting on the bottom or low number. The low number, the EPAP provides the support for OA, Obstructive Apnea and Hypopnea. We are also looking for relationships between Events and the various charts that SleepyHead presents.

Step 6: Analyze the Data 6.1 Maximum pressure If the machine reaches the maximum set pressure and stays there for a period of time, this indicates that it is trying to go higher to treat obstructive events. (This applies if your maximum pressure is less than 20. If it is set to 20 and the machine is stuck there, a more detailed analysis is necessary, and a different type of machine may be required). 6.2 Minimum pressure If your pressure is too low you are likely to see obstructive apneas and hypopneas. If you notice your average auto pressure is higher than your minimum setting, the hypopnea are likely from the minimum pressure being too low. A good rule of thumb is to keep your minimum pressure setting about 2-cm below your 90% pressure (PR) or Med Pressure (ResMed) or near the average if they are close. The Dreamstation tends to be conservative with raising pressure, and the algorithm favors returning to the minimum setting. This can often adequately treat OA, but leave you with excessive H events. The remedy is an increase in the minimum pressure setting. PR machine: If your 90% setting is 12 cmH2O Min is set to 10 cmH2O and Max Remains at 20 cmH2O ResMed machine: Use the Med value for pressure. If your Med setting is 11 cmH2O, set the minimum to 9 cmH2O and Max remains at 20 cmH2O. Note: there is no need to reduce the max unless there is concern over CA events or to minimize the max for comfort at this time. Note that once your titration is complete a good practice is to set the max pressure for just above the max that you normally see, just to prevent “run-away” pressures and leave enough room that you can see your pressure ran higher than you expected.

Step 7: Repeat Conditions change. Perhaps you have gained some weight, (I KNOW that has NEVER happened to any of us (sarcastic switch off)), or you are now sleeping on your right side instead of your left, or you have a new pillow. It doesn’t matter what, but things change. And when they change your apnea may or may not be impacted. When your treatment effectiveness may be impacted, when your AHI is higher than expected over a period of time, it is time to re-evaluate your therapy. What do you need to do to positively impact your therapy?

To Titrate a fixed Pressure CPAP you

1. Set your initial pressure, protocols call for values from 4 to 6 or 2-3 cmH2O below your current settings then
2. Increase CPAP ≥1 cm H2O every ≥5 mins for obstructive apneas, hypopneas, RERAs and at least 3 min of loud or unambiguous snoring
3. Is the patient having obstructive events? If yes, repeat step 2

Obviously we cannot make an evaluation every 5 minutes while we are sleeping so we perform our evaluations in nightly cycles.

Obstructive Apnea (OA)

A good rule of thumb is to keep your minimum pressure setting about 2-cm below your 90% pressure or near the average if they are close. The goal is to raise support (Min Pressure / IPAP) to reduce/minimize/if we are lucky, eliminate Obstructive events. These include Hyponeas, Flow Limits, and Snores. The Max Pressure / EPAP is lowered to minimize other issues (Aerophagia http://www.apneaboard.com/wiki/index.php?title=Aerophagia, swallow too much air, too much pressure causes wakeups) if needed. Typically it is set at either MAX pressure (20 cmH2O) or just above the max pressure to prevent wild running high.

Complex or Mixed Apnea (OA / CA)

The best CPAP therapy tends to be a low fixed pressure with no exhale pressure relief. Complex or Mixed Apnea is typically a mix between Obstructive and Central Apneas. For high levels of events Machine of choice is an ASV machine. These are among the most expensive of all PAP machines. Please post on the forums if you see this in your data. If an Auto band is used it is typically a very tight band.

Central Apnea (CA)

http://www.apneaboard.com/wiki/index.php?title=Central_sleep_apnea_(CSA) Central sleep apnea (CSA)  Central sleep apnea is a disorder in which your breathing repeatedly stops and starts during sleep. Central sleep apnea occurs because your brain doesn't send proper signals to the muscles that control your breathing.

Central Apnea is best treated with an ASV machine. These are among the most expensive of all PAP machines. On an xPAP the best we can do is to minimize the Max pressure and utilize EPR or other relief (PS on BiLevel / BiPAP)if available, at the same time as raising the EPAP (min Pressure) to support obstructive events. These two treatments “fight” each other and it is a real balancing act. If an Auto band is used it is typically a very tight band.

EPR

EPR is exhale pressure relief. EPR acts a lot like bilevel (BiPAP/VPAP). To really understand its impact on therapy, you need to understand bilevel titration, where EPAP is used to resolve obstructive apnea, and pressure support (IPAP) can be used to manage flow limitation, hypopnea and RERA. A concern with EPR is that for patients with a CPAP titration based on fixed pressure, it actually can undermine the prescription, unless the CPAP pressure (IPAP) is increased.

For example, let's say you are titrated at 8 cm H2O pressure for CPAP. You get your new Resmed machine and dial in EPR at 3, and now instead of fixed pressure at 8.0, you now have bilevel pressure at 8/5. Well 5.0 cm EPAP pressure allows obstructive apnea to occur, so you find out you need a pressure of 11/8 and so you wonder why the clinic got it wrong. Happens all the time.

Compared to CFlex and AFlex used by Respironics, EPR is a true bilevel variable that is allowed as a "comfort feature". Flex is only a temporary pressure reduction at the beginning of exhale or inhale and is actually a comfort feature, and pressure returns to the CPAP level before exhale begins; but EPR is bilevel, and keep the pressure low until inhale begins, unless the airway collapses and then the pressure stays low until the apnea ends.

This is all more than you wanted to know, but the point is bilevel therapy is much more comfortable than CPAP, and if you use EPR, it helps to understand how it might affect therapy.

'Other Software'

MyAir (ResMed) Two values have more importance than the others, The AHI and the leak. The AHI is measure of the overall effectiveness of the treatment. The Leak as an indication that you need to look at more detailed information (SleepyHead) to see if leak is really a problem.

• Usage Hours – Compliance Hours 10 points per hour, max of 70 points
• Mask Seal – 20 points for minimal mask leak, 10 to 15 points for moderate leak, and 0 to 10 points for higher leak. Mask type dependent.
• AHI / Events per hour –minimal events, you get 4 to 5 points
• Mask on/off –Every mask removal > 1 loses a point. If you get up to relieve yourself ihat is a point down.
• 14 day snapshot

The overall scoring is good for encouraging compliance. For me non-compliance is a night without any sleep or with minimal sleep. I ALWAYS use my xPAP, there is no question of compliance with me.

DreamMapper (Philips)

• Usage
• AHI
• Mask Fit
• Up to 90 day views

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