Pressure Settings - auto cpap - question/s

Hi All,

I'm 30 days in now and have some questions about pressure settings. My original prescription from my sleep test a couple months ago was 5-15 ramping using a nose mask - 45 minute ramp up time. It turned out that I was a major mouth-open sleeper and I asked for a full mask which is working pretty well. I found the pressure settings way too high - much leakage and gas. Doc reduced it to 5-10 - I was still uncomfortable and he basically said I could go as low as 6 if I wanted. I set it a 8 and changed ramp time to 30 minutes, and I found comfort with great readings for a couple of weeks - but always sluggish during the day. I felt I needed more pressure and increased it to setting of 8.4. Again, good breathing and great stats but again sluggish during day. The last two or three nights have been uncomfortable breathing - the feeling I was not getting enough air. This morning at 5 a.m. I looked at my unit and I was at full 8.4 (it had been usually at 7 something), so on a lark I pumped it up to 15 - the original script. When it ramped up to around 13, I felt like a new person with regard to breathing comfortably; however, there was leakage and lots of gas this a.m. My questions: 1) should I continue to increase pressure but in small dosages? 2) Do auto pap machines first go through a complete cycle - up to the top number - before settling in to the number you need - or is that done from the get-go? I definitely feel I need a higher setting because I really felt like I was breathing fully at the higher numbers. As always, thanks for any info you can give me.

SleepyDeb wrote:Hi All,

I'm 30 days in now and have some questions about pressure settings. My original prescription from my sleep test a couple months ago was 5-15 ramping using a nose mask - 45 minute ramp up time. It turned out that I was a major mouth-open sleeper and I asked for a full mask which is working pretty well. I found the pressure settings way too high - much leakage and gas. Doc reduced it to 5-10 - I was still uncomfortable and he basically said I could go as low as 6 if I wanted. I set it a 8 and changed ramp time to 30 minutes, and I found comfort with great readings for a couple of weeks - but always sluggish during the day. I felt I needed more pressure and increased it to setting of 8.4. Again, good breathing and great stats but again sluggish during day. The last two or three nights have been uncomfortable breathing - the feeling I was not getting enough air. This morning at 5 a.m. I looked at my unit and I was at full 8.4 (it had been usually at 7 something), so on a lark I pumped it up to 15 - the original script. When it ramped up to around 13, I felt like a new person with regard to breathing comfortably; however, there was leakage and lots of gas this a.m. My questions: 1) should I continue to increase pressure but in small dosages? 2) Do auto pap machines first go through a complete cycle - up to the top number - before settling in to the number you need - or is that done from the get-go? I definitely feel I need a higher setting because I really felt like I was breathing fully at the higher numbers. As always, thanks for any info you can give me.

I can't figure out whether you're talking about your minimum or maximum pressures.
It's obvious from your post that you need a higher minimum pressure to feel better, but it's unclear which numbers you're actually referring to.

Your perceptions about APAPs and what they do are not what actually happens.
APAP machines set to a range of pressures don't "KNOW" what pressure you need. They just respond to breathing characteristics.......and especially if you're having Flow Limitations and/or Snores........all night long. If you need more minimum pressure, you need to change your settings so the machine doesn't take so long to respond to increase to the pressure needed to prevent events. In reality, when using an APAP in a range of pressures, the minimum pressure needs to be set to where it eliminates most of the events. If the minimum pressure setting is too low, that is essentially substandard therapy.
And, for some people, ranges of pressure can be very sleep disturbing as the pressures change all night long. Your breathing can change as you enter deeper or REM sleep stages and the machine senses this and may increase pressures. This can bump you our of your needed sleep stages and into lighter ones and leave you feeling unrested.

If you're not using software (like Sleepyhead) to see what's going on during the night......you NEED to. That will make it clearer after you study a number of nights of data.


Den

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After re-reading my post, I can see how it might be confusing. When diagnosed, the prescription was for minimum 5 and maximum 15 - 45 minute ramp time. I was totally uncomfortable with those settings and asked to have it changed. Doc changed it to max of 10 but same minimum of 5...then I learned how to make changes on the machine myself. I found 10 to be also too high. I reported to my doc that it was too high and that I learned how to change the settings. He told me I could go as low as 6 for my maximum (he's not a sleep doc but rather my PCP. I can't get into the sleep doc until January, so he's consulting sleep doc when he hears from me via email - I know, goofy.) I changed my max to 8 and then a few days later to 8.4 and my minimum to 5.6 and decreased ramp time to 30 minutes b/c I thought it was taking too long. During the night I felt good with these settings but somewhat tired during the day and lots of coughing. Two nights ago I started to feel I wasn't getting enough air so I increased the maximum early this a.m. to see what it would be like...all the way up to the prescribed 15. When I fell back to sleep, I awoke when it was at 13.4 because of mask leakage but the air felt great in my lungs...but the downside was eating a lot of air - I'm still gassy at 5 p.m. today...but less coughing. Anyway, I guess I will have to figure out that software...I don't know how to do it, but I'll read up on it. Tonight I will set the max at 9 or 10 (since I seem to be getting used to the higher settings and 8.4 seems to be too low now) and maybe increase the minimum to...?...(all this is so exhausting). Thanks, Den.

SleepyDeb wrote:After re-reading my post, I can see how it might be confusing. When diagnosed, the prescription was for minimum 5 and maximum 15 - 45 minute ramp time. I was totally uncomfortable with those settings and asked to have it changed. Doc changed it to max of 10 but same minimum of 5...then I learned how to make changes on the machine myself. I found 10 to be also too high. I reported to my doc that it was too high and that I learned how to change the settings. He told me I could go as low as 6 for my maximum (he's not a sleep doc but rather my PCP. I can't get into the sleep doc until January, so he's consulting sleep doc when he hears from me via email - I know, goofy.) I changed my max to 8 and then a few days later to 8.4 and my minimum to 5.6 and decreased ramp time to 30 minutes b/c I thought it was taking too long. During the night I felt good with these settings but somewhat tired during the day and lots of coughing. Two nights ago I started to feel I wasn't getting enough air so I increased the maximum early this a.m. to see what it would be like...all the way up to the prescribed 15. When I fell back to sleep, I awoke when it was at 13.4 because of mask leakage but the air felt great in my lungs...but the downside was eating a lot of air - I'm still gassy at 5 p.m. today...but less coughing. Anyway, I guess I will have to figure out that software...I don't know how to do it, but I'll read up on it. Tonight I will set the max at 9 or 10 (since I seem to be getting used to the higher settings and 8.4 seems to be too low now) and maybe increase the minimum to...?...(all this is so exhausting). Thanks, Den.

At some point, you might also try a straight pressure of 9 or 10 to see how that feels, too.
The changing pressures could be messing with your sleep or if you're swallowing/ingesting air ("aerophagia").

How about exhale relief? EPR setting? Sometimes they can make a difference in the therapy.


Den

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EPR is set to off on my machine. I can turn it on, but I don't know much about it. I wouldn't know what to set it to.

EPR is for trouble exhaling against the pressures... if you don't feel the need for help exhaling, ignore the feature, but if you do want to use it, try the low setting (? 1) and then try the #2 and/or 3 and see where you're comfortable. You must do a little research for yourself as we can only make suggestions - you're the one who's going to use it.

I also think you might have misunderstood settings in general - the low one is the one that matters most, and you'd set it first to a lower #, i.e. 6 or 7 (4-5 are so uncomfortable - hard to breathe at) and set the high limit at e.g. 10 or 15, then see if SleepyHead says you spent e.g. 95% of the night at lower pressures (e.g. below 10 somewhere) or higher ones... then set your machine accordingly with the low one just below wherever SleepyHead says you almost never went down to, and the high one a couple above whatever the highest overnight # you reached. For instance, I always spend most of the night around 9 + 10, so my low setting is at 8 (just in case) and my high one's at 12 as I never go above that except maybe for a one-off one night which is not important unless it becomes a habit.
In general, you can put the high setting even at 20, and it won't matter much to anything - the low one is the important variable.

I would also just turn the ramp off - do you realize that until the machine ramps up to your low setting (at least) over whatever time period you set you're not being treated fully until the ramping has reached it? You don't need it (would be unlikely) at such low settings - you're just making life more difficult for yourself as is. A ramp time of e.g. 5-10 mins. might be appropriate for an old person possibly with other respiratory problems whose prescribed low setting was e.g. 15, not someone who's low setting is 6!

I'm sorry but "I would also just turn the ramp off - do you realize that until the machine ramps up to your low setting (at least) over whatever time period you set you're not being treated fully until the ramping has reached it? " this is just not correct.

IF you are using ramp AND the machine detects a flow limit it WILL respond by increasing the pressure, this is what the treatment is. Being at pressure all by itself is not a treatment, it is intended to hopefully prevent an apnea, if an apnea did not happen then no harm no foul.

If you have trouble adjusting to using CPAP because of the pressure by all means turn on ramp, this is what it is there for. If you have a flow limit during the ramp time the machine will respond to it. Personally I used to use ramp and then I got used to the pressure and turned ramp off BECAUSE I no longer needed it and not because I was not being treated during ramp.

PoolQ wrote: IF you are using ramp AND the machine detects a flow limit it WILL respond by increasing the pressure, this is what the treatment is. Being at pressure all by itself is not a treatment, it is intended to hopefully prevent an apnea, if an apnea did not happen then no harm no foul.

Are you sure about that? What is the point of the ramp feature, if the pressure could increase to the max right away? The whole point of the ramp feature is to ease the person up to their minimum pressure while they fall asleep and THEN start responding to flow limitations and snores. There have been many posts from people over the years of how restarting the ramp constantly during the night meant that they never got decent treatment.

Ramp is intended to be a comfort feature, though for many, it makes it hard to breathe. People take the mask off and quit.

While Respironics machines (in apap mode) will respond to any apnea events sensed during ramp time ResMed machines never have. The auto adjusting algorithm doesn't begin until ramp time has ended.

Where did you find documentation that ResMed has changed how they do the ramp?
It's not in the manual..I just looked.

So for Respironics users....if you use the ramp feature the machine will respond during the ramp time if it thinks it needs to but ResMed users I don't think it will or can respond. Everything in the past has said that the machine doesn't/can't do anything until ramp time has ended and I can't find anything at ResMed or in the manual that says otherwise.

PoolQ wrote:IF you are using ramp AND the machine detects a flow limit it WILL respond by increasing the pressure,

sleepdeb wrote:EPR is set to off on my machine. I can turn it on, but I don't know much about it. I wouldn't know what to set it to.

At the low pressures you're using, it might be counterproductive to your therapy.
And, I agree with turning Ramp off if it is now on.


Den

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Thanks to all. I have an update. I took suggestions from a couple of you. My settings now on the Resmed AirSense 10 are: Auto; max at 9; minimum at 7.4; ramp is off; EPR off; Humidity at 3.

Results just for last night - I switched it from a month data to 1 day data: total of 8 hrs. and 15 minutes usage (with a one hour wake up after 4.5 hours of sleep then back to sleep); 0.4 AHI events; Pressure - 9; Leak 1 L/M; AHI 0.4 - total AI -0; Central AI - 0.

How I feel: it was difficult to wake up - felt like I could sleep another 8 hours; my ear on the side I sleep on is clogged but getting better; seems I'm coughing less - I think because I reduced the humidifier so much and it's cooler air now.

Question: Do you think I should increase the max? The increase I made on the minimum seems just right - exhale not bad - but the maximum of 9 was at that point most of the night.

I read up on Sleepytime with Resmed on this site and it says it doesn't work with AirSense 10 - unless that has changed.

Any suggestions?? I so appreciate all of you...

This link is to a site provided by one of our members and is very helpful with Sleepyhead. And yes it works with Airsense 10 now. When you are on the site checkout the other links. He tells you how to organize your charts and also how to post your shots. Hope it helps you. https://sleep.tnet.com/resources/sleepyhead

You probably read an old posting about SleepyHead and the AirSense machines...initially not compatible but was fixed within a couple of weeks or so. SleepyHead works great with the AirSense machines.

You need to understand the numbers off the LCD screen....especially that pressure number.
The pressure number on the LCD is what is called a 95% number which just means that you were at OR BELOW that number for 95% of the night. It doesn't mean you were there all night.
Given the tight range you are now using...you very well could have been up there most of the night and might benefit from a little more maximum pressure. In general the machine won't increase the pressure without what it thinks is a good reason. Now sometimes that reason might not be as critical as the machine thinks it is if the higher pressures cause more problems than it fixes (like aerophagia) and limiting the range can be an acceptable compromise.

Maximum setting when in APAP mode...just means the machine can go there...doesn't mean it necessarily will go there.

"Maximum setting when in APAP mode...just means the machine can go there...doesn't mean it necessarily will go there." - Pugsy

This is what I always thought. You'd be doing yourself a disservice only by setting the maximum too low, correct? you could set it at the highest pressure the machine will go but it will never go beyond what you need? That's how I thought it worked anyway. My maximum is 18 but I've never gone above 12 and that's rare. I usually have a few small bumps in pressure to 6.5 or 7, with one bigger one to maybe 8 or 9 for about 30min-1 hour duration. I don't really see a need to mess with the max. That being said, what's the point of a max setting anyway? I spend most of my night at my minimum. I guess theoretically I could reduce that minimum but I'm very comfortable with it so I see no point. I agree with the post saying the minimum is probably the most critical. As for the ramp, I never used it. Nor the exhale relief. But I'm at a fairly low pressure.

Tdub210 wrote:what's the point of a max setting anyway?

Some people have special needs or maybe they have special pressure needs only under certain circumstances like supine sleeping or REM sleep (or a little of both). It hurts nothing to have the max higher than it ever goes. Doesn't affect the response time because it never is up near the max anyway.
Heck if the machine could go to 50 and we set the max at 50 and it never went beyond 10 cm...it becomes a moot point. That's why I don't jump into the middle of discussions that say use a small range or 2 cm above so and so as max. It's still a moot point if it doesn't go there anyway.

Now sometimes the machine thinks it has a good reason to climb and sometimes the climb is worse than the reason so if that happens then it is a good idea to rein in where it can go.

It also doesn't hurt anything to use more of a minimum pressure than is maybe technically needed per the reports. Lots of people will tell you that according to their reports they only need so and so pressure to keep the AHI down but they feel better (and sleep better) using maybe 2 or 3 cm above what might be technically needed.

The primary goal...get good sleep and feel good during the day. It isn't get the best AHI at the lowest possible pressure.
I tend to try to keep people at the lower end just to limit pressure related issues (aerophagia or exhale problems) but if they feel better with higher minimums I am all for what makes a person feel better and sleep better.