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CPAP setting problem.

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palashmohane +0 points · about 2 years ago Original Poster

At pressure 15 my AHI was 1. my doctor said you should set the pressure according to your comfort at first it was set at max 20 and machine reached 18 but that was uncomfortable I could not sleep, now when I am setting max at 15 it's comfortable and my AHI for that day was 1 so what should I do. As 14 -15 is much comfortable than 18. should I experiment with my settings.

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snuzyQ +0 points · about 2 years ago Sleep Commentator

How is it that you are setting your own treatment pressures? That's usually done by a respiratory therapist via a physician's prescription. If you're using auto CPAP, then there's usually a doctor-prescribed range, along with a ramp pressure and ramp time. If your doctor has not done that for you, then it would be best for you to request it, go from there and communicate your comfort level with your doctor and ask what he/she recommends that you should do.

If you fiddle with your pressure settings on your own, you should at least let the doctor know what you have done so that it can be recorded in your medical record. This becomes very important when you're passed around between different providers of healthcare. So, in answer to your question, if you're now comfortable with your current settings, why not keep things as they are and communicate what you've done to your doctor. Leave yourself open to your doctor's input. Let him/her guide your care. That's what he/she went to medical school for.

There're a lot of valuable suggestions that forum contributers have for guests of this forum, but prescribing pressure settings is not one of them.

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Sierra +0 points · about 2 years ago Sleep Patron

Actually many people adjust their own settings, including most users of SleepyHead. In Canada many people get essentially shut out of using a sleep therapy technician because they end up buying their own machine and when you do that then they will not help you. My impression is that times have changed in the CPAP business. In the old days it was normal to have the sleep test done in an overnight clinic and you came out of that with an apnea diagnosis (or not), and severity. The next step was to do an overnight titration test to determine what your magic pressure setting is. Then they would give you a fixed pressure CPAP set at that pressure and would adjust from time to time if they were diligent with the follow up. Now the cost of an auto machine is virtually the same as a fixed pressure machine. And the machine essentially does a titration test every night. For those that are engaged and monitor their results with SleepyHead, it is a small step to use those results to fine tune their machine settings.

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WarmheartedLazyHummingBird +0 points · about 2 years ago

My sleep doctor here in the US and her NP both encouraged me to find my best pressure settings. Anymore, most insurance only pay for 1 night in a sleep lab and then turn you over to the DME. My DME is worthless, gave me no choice of masks or machines. When I specifically asked for a mask that was newly on the market, I was told I couldn't have it because they couldn't return it once it was open. I had done some research before I met with them, as well as read many of my sleep doctor's published research on women with sleep apnea. I continued doing research and discovered the ResMed AirSense 10 for Her. Demanded the DME get one for me. They had no idea it actually operated on a different algorithm. All the DME wants is the largest profit margin. My settings were 4 cm - 20cm, often hitting 14 during the night. THAT much of a pressure change woke me up as well as blew my mouth open even after trying several chim straps and tape. I adjusted the minimum pressure to 10 since 95% was at 12 and placed the maximum at 16. Also changed over to the DreamWear FFM. Awesome not having anything over the bridge of my nose of tube in front, either.

My husband decided he wanted the AirSense 10 for Her, also. But even with a RX from his doctor, the DME wouldn't fill it. They wanted him to have another sleep study. Ridiculous and a huge waste of resources. Just as well...found an online supplier that was perfectly happy with the RX as written, and gave us a much better price. Also provided much better support for any issues or questions we had, than the local DME.

I'm an RN with a Master's in Nursing Education. Adjusting your insulin or BP pills without guideance or real knowledge could be dangerous or even deadly. This is air holding your airway open. It's the DME's wanting to keep you from adjusting your setting yourself. Your doctor or NP wants you to to take ownership of your OSA and learn to manage it effectively.

And when I go see my sleep group, my SD card records every change Ive ever made. The doctor writes a broad range (4-20) which covers the entire range for the machine.

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Sierra +0 points · about 2 years ago Sleep Patron

I am diabetic and do a minimum of 5 injections of long and short acting insulin per day. Yes, it can be dangerous if you mess up, and it is definitely far more complicated than adjusting your own CPAP.

I think the most harmful issue with how CPAPs are set up is the minimum pressure settings. Quite often the machine is left at default settings which are 4 to 20. The 20 is not really a big problem at least initially. The machine will only go as high as it thinks you need. The minimum is an issue. 4 cm is too low for real comfort, both during the going to sleep period and after you are asleep. This leaves many people feeling short of air, or with that suffocating feeling. A more realistic initial setup would be an Auto Ramp, with a start pressure of 7 cm, a minimum pressure of 7 cm, and an EPR of 3 set for Ramp Only. Then as you gain experience with what pressures you really need, the minimum should be bumped up so at least about 25% of the night you are at minimum. That prevents the machine from letting the pressure slip too low and cause apnea events. Last some final comfort can usually be obtained by bringing the maximum pressure down so it limits the maximum pressure 5-10% of the time. This can improve comfort, and if you watch when events occur, may not even increase the AHI.

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Sierra +0 points · about 2 years ago Sleep Patron

This is the response I gave you in your other post on your issue.

Is your machine an auto CPAP like the AirSense 10 AutoSet? If so, you should be able to set a minimum and a maximum pressure. Unless you use software like SleepyHead which you can download for free, you will be flying somewhat blind. With SleepyHead I like to watch what the pressure does during the night and observe when the apnea events are occurring. If the majority are not happening when the machine is limited to the maximum pressure, then you don't really gain much by increasing the maximum pressure. In fact you will likely gain more by increasing the minimum pressure. I find after a lot of monitoring I end up setting the minimum pressure only 1 cm below my maximum. So if you have an auto machine, you could try a max of 15 and a minimum of 14 and see how that works. An AHI of 1.0 is pretty darn good, so it it were me, I would not torture yourself with high pressures if you can get your AHI to 1.0 with lower pressures. And if you use SleepyHead you might want to start with the minimum set somewhat lower, and then adjust higher as needed.

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wiredgeorge +0 points · about 2 years ago Sleep Enthusiast

Not sure how things are done outside the US, but here a machine is done by prescription as well as the settings. The doctor who makes the prescription is responsible for altering it, if alteration is needed. I would truly hesitate taking advise from a layman, no matter how well informed regarding changing facets of a prescription made by a sleep doctor regardless of how well informed the layman is. If people in Canada do things differently due to circumstances with respect to their medical system not allowing for professional after diagnosis and prescription help, the folks in the US are generally not in that position. If a specific doctor drops the ball here in the States, we can generally visit another doctor for a second opinion or even change doctors.

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Sierra +0 points · about 2 years ago Sleep Patron

I gather from another post made by the OP that his doctor gave him permission to change the pressure settings.

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wiredgeorge +0 points · about 2 years ago Sleep Enthusiast

From the OP's other posts and the original in this thread, the doctor seems to not really want to engage. I can't imagine having a patient endure a sleep study and titration study and then tell them to fiddle with the prescription based on comfort. I personally would have some hesitation fiddling with as it is obvious the OP doesn't understand what type therapy setting the machine is set to nor dropping the pressure 6 for comfort will have in the long term. The doctor should be much more engaged or a new doctor seen. We pay a lot for medical care from one insurance provider or the other and should receive professional care that has been paid for.

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mywifesaysisnore +0 points · about 2 years ago

Similar question so I hate to start a new thread. Recently diagnosed with moderate sleep apnea (15.1 AHI) and now have a Resmed Airsense 10 Autoset. Trialed the Philips Dreamstation for 1st 2 weeks and am now on my 1st week with the new machine. My doctor turned off ramp and set the range to 5-20. I pulled the card and looked at Sleepyhead. Max pressure over the last 5 days is 10.56. What does the ramp function do that the automatic function of the machine not already do?

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Sierra +0 points · about 2 years ago Sleep Patron

I think the AirSense 10 is superior to the Dreamstation, so first I would suggest you keep that machine. One of the best features I enjoy with the A10 is the Auto Ramp feature. Instead of it being a set time, it watches your breathing pattern and holds the pressure until you are asleep. A start pressure which defaults to 4 cm is too low in my opinion and can leave you wanting more air when you are trying to go to sleep. A start pressure of 7-8 cm is what most find comfortable. Since you have taken the step to using SleepyHead, you will be much more informed than most on what the machine is actually doing.

In my opinion a 5 cm to 20 range is far too wide. After 2 weeks with the Dreamstation, the doctor should have known that this range was not necessary for you. Based on your reported maximum of 10.5 cm over 5 days, I would suggest your maximum pressure should be set at 10 cm or 11 cm at most. It does not hurt to limit the pressure a bit, if there are no apnea events occurring when the pressure is limited. SleepyHead will tell you that. Minimum will probably be about 8 cm. But again look at SleepyHead. I like to see the minimum setting keeping the pressure from going lower for a good part of the night -- 30-40%. Limiting how far it drops can prevent apnea events and improve AHI.

Here is how I would set your machine as a first try:

Minimum Pressure: 8 cm

Maximum Pressure: 10-11 cm

Ramp: Auto

Ramp start (pressure): 7-8 cm (based on what you find comfortable while going to sleep)

EPR 3, Ramp only

The EPR will make it easier to breath when you are going to sleep and turn off when you are asleep. With EPR off, the machine should be more effective while sleeping.

If you have any questions just ask. If you want to adjust your own machine, I can give you a link to the Clinical Manual which provides the detail on how to do it. Not hard.

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sleeptech +0 points · about 2 years ago Sleep Enthusiast

As long as the patient is comfortable at 4 cmH2O then 4 is a fine minimum pressure. The minimum pressure is set for comfort. The only reason to lower the max pressure is to stop the machine getting confused for some reason and going too high. If this is not happening then there is no reason to lower the max pressure. If an auto CPAP is working properly then leaving it with a range of 4 - 20 should not cause any problems. Some patient require tweaking for some reason or another but for the vast majority it should be adequate to let the auto algorithm do its work.

Likewise I have found more people who find CPAP less comfortable with EPR than more comfortable. Whether it be min and max pressure settings or EPR, it's all about tailoring treatment to suit the individual.

Also, The DreamStation has auto ramp too.

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Sierra +0 points · about 2 years ago Sleep Patron

I find that for those who use SleepyHead and really look at what is going on, then improvements can usually be made by increasing minimum pressure and reducing maximum pressure, and quite often by increasing the minimum start pressure. Yes, people are different, but there is no way I would be comfortable with a minimum start pressure of 4 cm. It is just too low and I get a suffocating feeling.

An APAP is a reactive, not a predictive machine. There may be artificial intelligence predictive machines in development, but todays machine has to see an issue before it reacts. If you start every sleep session with 4 cm of pressure and you really need 10 cm for effective treatment, then you have to have enough apnea events in the early sleep to ratchet up the pressure to the effective level. By setting the minimum pressure at 10 cm you put your knowledge from viewing SleepyHead data into the machine. That makes the so called "automatic" method much more effective. The machine does not have to play trial and error on you every night. I think setting the minimum up in a Dreamstation is more important than with the ResMed. The Dreamstation algorithm seems to be slow to increase pressure and quick to reduce it, so it is going up and down all night, if you give it the freedom with a wide pressure range.

There is less treatment effectiveness to be gained by setting a lower maximum pressure, but some comfort can be gained. From viewing SleepyHead you can find times when the machine tends to become over responsive and push pressure up. Mild snoring and flow limitation can run it up even when apnea events are not occurring. If the individual is having issues with higher pressure such as leaks and waking up, it may be of benefit to tolerate a bit of snoring and flow limitation in exchange for lower pressure. And since apnea events are not increased, AHI stays low. My wife is in that category.

But if you set tight limits then you have to monitor your results more diligently.

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sleeptech +0 points · about 2 years ago Sleep Enthusiast

Short answer: if your minimum pressure is set as low as yours the ramp does nothing really.

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snuzyQ +0 points · about 2 years ago Sleep Commentator

Hi mywifesaysisnore:

The ramp gives you a starting pressure of, let's say 7, and sets a time of, let's say 5 minutes to "ramp up" to your necessary treatment pressure. With auto CPAP, the needed pressure fluctuates with the apneas to keep the airway open. The purpose of ramp is comfort while you are transitioning into sleep. It is most often used with "fixed" CPAP (the pressure is set at one fixed pressure such as a patient's maximum recommended pressure). It is often uncomfortable to transition directly to one's maximum pressure of, let's say 12, when getting to sleep. The pressure is felt too strongly at first and sleep is prevented. So a ramp is used to help the patient ease into their prescribed pressure setting. Once the patient is asleep, the strength of the necessary pressure isn't noticed.

My husband's ramp is also turned off. He has auto CPAP and doesn't mind his minimum pressure set at 9 (his maximum pressure is set at 11). He goes to sleep without any issues.

The ramp is on for my auto CPAP. I have a start pressure of 7, which I like - it feels good to me. My minimum treatment pressure is also 7. My ramp is set for 5 minutes and my maximum pressure is 12. I suspect my ramp could be turned off and I wouldn't even notice. As it is, my starting pressure will never immediately jump to 12 because my ramp is there to hold things back. It will take at least 5 minutes for it to do so. It's like starting horses at a trot, then breaking into a gallop at 5 minutes because you need to get there quick.

Hope this helps.

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