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Sircadian-

You stated in the OP that she failed a sleep test.

Did they also do a titration study, or is that what is being done at home with the loaner?

If as to the former the answer is 'yes', they would come up with an 'optimum' fixed pressure at the sleep lab.

So, somewhere 2 or 3cm below that optimum pressure might work minimum APAP, assuming adequate Sao2 and that she tries to sleep on her side.

As an example. my optimum pressure is 12cm, and by definition, that is while supine. I am now finding that at a setting of 10-14cm I may have hit the mother lode. Felt great this morning (with adequate sats/minimum desats- overnight pulse oximeter used throughout), and this is after extensive testing at fixed optimum pressure of 12 (which I find difficult to sleep with and when awake feel like there is 'too much air' in my body) and lower, as well as variable APAP pressures.

And I agree that one can not always go by the numbers as to how one feels. I've felt very good or even great at various APAP settings. But 02 saturation and desaturation is a factor with my chosen APAP pressure because it IS an issue FOR ME. If it's not an issue for your wife, then perhaps she should just go with a minimum baseline pressure where she consistently feels good. I agree the minimum pressure is more important than the maximum pressure but if to err, it is better to err on the high side of that minimum pressure scale.

Sircadian wrote:

Jay Aitchsee wrote:So, the worst AHI I've seen in what you've posted (I may of overlooked some) is 3.89. Not exactly horrible. The AHI's that have been posted include a significant number of CA's, which could be caused by not being used to and being disturbed by the therapy. These events could easily be reduced as your wife becomes accustomed to the machine. I don't think you are doing her any favors by your constant "fiddling". As I think was stated earlier, one night does not constitute a trend.

No, not horrible but after ~6-7 days of an AHI that averaged ~1.75 the 3.89 is more than double the wide open 4-20 cm setting.

To address you and Palerider's comments on the 'fiddling'. Keep in mind the clinician that called, after remotely reviewing her first week of open therapy, seemed surprised I hadn't fiddled and suggested an 8 cm setting to my wife as a starting point. Admittedly, I was itching to see what a straight pressure would do. I'm doing this on a green light from the sleep clinic. I am starting to question my belief that CPAP works just as well or better than APAP. My CPAP brought my numbers down, not so in this case. Make any assumptions you wish but the experimenting interests me.

So long as AHI is <5, I would be less concerned with the 'numbers' and more concerned with how she feels at given settings, such settings to be tested for at least 3 days- as suggested by another poster. In spite of the foregoing, if the wife is 'stuck' with a straight CPAP, then I agree it is best to get her off APAP now.

tedburnsIII wrote:So long as AHI is <5

No.

tedburnsIII wrote:it is best to get her off APAP now.

No.

Sircadian,

I'm kind of late to this discussion, but I want to put in my two cents.

First, I understand the constraint that your wife will soon be switched over to the S9 Elite, which is a very nice machine even if it doesn't have the APAP mode. Nothing wrong with that machine---as you well know. And because the Elite records full efficacy data, you'll still have plenty of data for making decisions on how to tweak the pressure setting once she's using the permanent machine.

Next, I understand why you're wanting to do the fiddling with the pressures NOW, but at the same time, it's important to understand that one night's worth of data is often not enough to base a decision on. In particular, the nights that you have posted where your wife was using fixed pressure at 8cm and 7.4cm as compared to the APAP nights show nothing more than the normal variation in the number of OAs/Hs that most of us see night to night. The number of CAs while using fixed pressure at 7.4cm and 8cm is not yet enough to get overly worried about, but they are enough to warrant prudent watching. Some people do have a bit of a problem with CAs when they first start out on CPAP at a high enough pressure to prevent most of their obstructive events, but in most cases, the problem with CAs is self-limiting. In other words, the number of CAs goes down with time---as in within a month or two of PAPing at the necessary pressure, the number of CAs is close to 0 and no longer makes up a significant portion of the events on a nightly basis. So chances are when your wife starts using the Elite at something around 7 or 8 cm of pressure, the number of CAs will start to decline over the first month of usage. If it doesn't decline or if it goes up, then of course, it's back to talking to the doc.

As for which mode (APAP or CPAP) and what pressure range to use right now: I'd recommend talking with the wife to see if she has been able to tell a difference in how she actually feels when she wakes up and during the daytime. If she feels better after a night of fixed pressure, then go with that and just keep an eye on the CAs for now. If she feels better after a night of APAP, then go with that and worry about transitioning to the fixed pressure machine when she gets the Elite.

I don't get the whole sneaking the changes thing. I'd be pretty mad if someone kept making changes without telling me. But that's just me I guess.

ChicagoGranny wrote:

tedburnsIII wrote:So long as AHI is <5

No.

tedburnsIII wrote:it is best to get her off APAP now.

No.

I don't get your disagreement, and you haven't stated reasons therefor.

<5 RDI is the standard for optimum pressure.

If the patient is on APAP when she is going to need to switch to CPAP, seems to make sense at this time to titrate at different fixed pressures, just like they do it at the lab. Seems she has had considerable experience with APAP, and now it is time to switch. It will only be a greater transition if she presently remains APAP.

HanzT wrote:I don't get the whole sneaking the changes thing. I'd be pretty mad if someone kept making changes without telling me. But that's just me I guess.

I'm not presently married, but if I were, it would tick me off. Changing pressures frequently and behind one's back is not a good thing for patient comfort. But maybe under the dynamic of this particular relationship it doesn't matter. To each his own.

Granny doesn't seem to be here this afternoon, so let me take a stab at it.

tedburnsIII wrote:<5 RDI/AHI is the standard.

I typically run 0.8 - 1.8 AHI. Anything above 3.0 and I don't feel as well the next day.

If you think about an AHI of 4.9, over seven hours of sleep that is about 35 events. Would you want to be awoken by a bell ringing 35 times every night? Would you want to be awoken by someone choking you 35 times every night.

You are going to go to the trouble and inconvenience to use CPAP, why not get the best out of it? It usually doesn't take much extra effort.

tedburnsIII wrote:titrate at different fixed pressures, just like they do it at the lab.

Titrating at home is hardly like titration by a technician in a sleep lab. The technician can fiddle with the pressure as he sees things happening and could easily make a dozen adjustments during the night. At home, you usually only change the pressure once (or less) per day after you have seen the last night's results.

I don't know that labs exclusively titrate at fixed pressures. My doctor prescribed an APAP with a pressure range.

I would let the APAP do some of the titration work during the limited time you have it.

But, do what you want.

tedburnsIII wrote:<5 RDI/AHI is the standard.

DeadlySleep wrote:I typically run 0.8 - 1.8 AHI. Anything above 3.0 and I don't feel as well the next day.

If you think about an AHI of 4.9, over seven hours of sleep that is about 35 events. Would you want to be awoken by a bell ringing 35 times every night? Would you want to be awoken by someone choking you 35 times every night.

You are going to go to the trouble and inconvenience to use CPAP, why not get the best out of it? It usually doesn't take much extra effort.

tedburnsIII wrote:titrate at different fixed pressures, just like they do it at the lab.

DeadlySleep wrote:Titrating at home is hardly like titration by a technician in a sleep lab. The technician can fiddle with the pressure as he sees things happening. At home, you usually only change the pressure once (or less) per day after you have seen the last night's results.

I don't know that labs exclusively titrate at fixed pressures. My doctor prescribed an APAP with a pressure range.

But, do what you want.

According to the JCSM/AASM Clincial Guidelines, sleep labs appear mandated or at the least it is recommended to titrate at fixed pressures.

http://www.aasmnet.org/Resources/clinic ... 040210.pdf







My optimum pressure was 12cm at lab. But my doc originally chose to prescribe APAP 6-15cm. I would speculate that part of the reason for doing so would have been a better chance of Medicare compliance.

tedburnsIII wrote:According to the AASM Clincial Guidelines, sleep labs appear mandated to titrate at fixed pressures.

I'll let one of the AASM wonks respond to that.

But if indeed the bureaucracy has a mandate to do it that way, maybe that is a reason for a free man to do it a different way?

I treat myself, not a bureaucracy.

But, do what you want.

tedburnsIII wrote: <5 RDI is the standard for optimum pressure.

That is the minimal Compliance Standard and Insurance thing. Compliance is NOT the same a Therapy. You can be 100% compliant at 4.99 and just over 4 hours of sleep 70% of the time and you will most likely be a complete wreak.

...seems to make sense at this time to titrate at different fixed pressures, just like they do it at the lab.

Not really. In the LAB the tech has feedback on your LIVE data, access to brain waves to tell what stage you are in and they make adjustments while you are sleeping to find the best combination that is right for the patient.

Doing it at home, the best you can do is look at the report after the fact and make changes based on that WITHOUT the sleep stage info and other inputs. Talk about hunt and peck.

Why do you think they provided the APAP for the trial instead of just a plain CPAP?

Krelvin wrote:Why do you think they provided the APAP for the trial instead of just a plain CPAP?

It's like refusing an automatic transmission rental for a road trip, because you know you are stuck with your old manual transmission clunker when you get home.

robysue wrote:the wife

If I would say that around my womenfolk, I would get a thrashing.

DeadlySleep wrote:

Krelvin wrote:Why do you think they provided the APAP for the trial instead of just a plain CPAP?

It's like refusing an automatic transmission rental for a road trip, because you know you are stuck with your old manual transmission clunker when you get home.

Some of us prefer our sweet manual transmissions. I and hubby have two Mazda3s, both with manuals. They're much more fun to drive than an automatic.

A normal person has an RDI of <5. So I don't get all caught up with the numbers now, so long as I am under 5.

My AHI was 0.0 last night- 5 hours 45 minutes on machine.

I felt better the day before where my AHI was 0.9.

Bottom line is how one feels, and how one feels may not necessarily and solely be linked to AHI. I say this because there are so many other factors that contribute to quality of sleep/sleep efficiency.