[CPAP] New and need some help lowering AHI

[holden4th]

You can also go back to the Dreamwear mask and try using it with a soft cervical collar to help keeping your mouth closed. Early on you need to experiment to see what works for you.

[CaseyF]

Just got my sleep study faxed over. Quite brief, but here is what it says...

Patient was studied with HST device to evaluate complaints of excessive daytime sleepiness, snoring and witnessed apneas.

Total recording was 650 minutes.
Snoring was present/absent.

Respiratory analysis demonstrated 5 obstructed apneas and 6 mixed apneas with a total of 16 apneas at an index of 1.5. There were 103 hypopneas with an apnea/hypopnea index of 11.0. The lowest desaturation was 86 with 39 minutes of desaturation between 50% and 90%

Minimum Pulse 55
Maximum Pulse 107
Average Pulse 80

Diagnostic Impression:
This study shows Mid Obstuctive Sleep Apnea Syndrome (327.23) with mild hypoxia.
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Anyways that's it. What are y'alls thoughts?

[CaseyF]

I've copied the graph from last night. I went through several videos regarding the AmaraView and adjusting and sleep positions etc. I generally sleep on my stomach and tend to turn my head into the pillow which I think is putting enough tension on the mask to cause leaks. The leaks looked a bit better last night, but if anyone has recommendations on comfortable ways to sleep for a stomach sleeper with a FFM please let me know.

Also I may or may not have said this prior, but the reason I'm using FFM now is because I have bad allergies, congestion and a deviated septum. It makes the nasal mask like the DreamWear quite difficult to get along with.

Thanks again for everyone's input and assistance! Graphs below

[Sleeprider]

Your sleep study points to a potential for complex apnea, with predominately hypopnea and mixed complex apnea. Your study was a home sleep test (HST) which is not up to the same par as observed clinical polysomnography, and tends to under-estimate AHI. You did not have a titration to determine CPAP and were instead given an auto-CPAP for self-titration.

Compared to your last graph, AHI is showing some improvement by the numbers, but the long-term trend will be what we want to watch. The events in the current graph continue to reflect a complex apnea patter rather than obstructive, with OAI at only 0.34, while CAI is 4.85 and HAI is 0.65. There is really no need to consider pressure changes, and in fact limiting maximum pressure to a lower pressure might be beneficial to helping prevent some of the CA events. I would ballpark your maximum pressure limit at 12.0 cm or less based on this graph.

I think you just keep trying, control the leaks and see if time solves the problem. Your leak results after 3:00 are impressive. Whatever you did, do it again. The flat-topped leak pattern from 02:30 to 03:15 suggest leaking through the mouth, but after that the leak line is relatively quiet with some minor, brief mask leaks.

[richb]

Your sleep study showed a preponderance of hypopneas. Your Doc and or Techs do not distinguish the type of hypopneas that you were experiencing. I would like to suggest (based on my own experience) that the hypopneas that you had during your sleep study were central in nature. A standard CPAP machine can convert central hypopneas to central apneas due to the pressures involved. One way to figure out what is happening is to reduce the maximum pressure that is being delivered by the machine to see in the centrals are reduced and the hypopneas increase. Since you also have a few obstructive events, you might see a pressure at which the obstructive events increase. Your 95% pressure is just about 12 cm H2O. You have a pressure relief setting of 1 CM H2O. Your Minimum Pressure is at 5cm H2o. I would set your maximum at 12 and minimum at 7 and continue the PR of 1 CM. This would give you a baseline close to your current settings. Get a few day of data at this setting. Then begin to experiment. First turn off the EPR. That alone should reduce some of the centrals. Then begin to reduce the max pressure 1 CM or even 0.5 CM at a time to see the effect of reduced pressure. You should reach a point where the centrals disappear and the hypopneas take their place. You may also see a point where there is an increase in obstructive events. All of this is to confirm that your apneas are primarily central in nature. You will also be confirming the effectiveness of your machine. As DB pointed out, a standard CPAP machine will not be effective in treating Central and Mixed Apneas. The next step will be convincing your Doc to try you on an ASV machine. Of course your Doc will have to rule out Congestive Heart Failure as a cause of the Central Apnea. You would need an Echo Cardiogram to confirm an ejection fraction at or above 45%. (In August 2015, ResMed notified the American Academy of Sleep Medicine that it has updated and narrowed the contraindication of ASV therapy to patients with symptomatic, chronic heart failure (NYHA 2-4) with reduced left ventricular ejection fraction (LVEF ≤ 45%) and moderate to severe predominant central sleep apnea.)

Rich

[CaseyF]

So I read everything you put down there and just see the words chronic heart failure phrases like that tend to scare me.

Anyways so it sounds like it need to make max pressure 12 and possibly minimum pressure 7 and get another appointment with my doctor about reviewing my data and the possibility for a detailed titration to narrow down my issue and at the presence of central apneas I need to peruse an ASV, but then also hope to not die from chronic heart failure in the time being?

[CaseyF]

Also More for curiosity, but what is the logic behind turning off EPR and thinking it will help with the centrals? I guess I don't understand centrals well enough to know what's causing them to begin with.

[robysue]

So I read everything you put down there and just see the words chronic heart failure phrases like that tend to scare me.

richb brings this up because there are a few studies that show that ASV machines can cause serious problems when used by patients with chronic heart failure. The problems are severe enough where the current recommendations say that ASV therapy is contra-indicated in patients with CHF. In other words, before putting a patient on an ASV machine, the doc should routinely make sure that CHF is NOT an issue.

Anyways so it sounds like it need to make max pressure 12 and possibly minimum pressure 7 and get another appointment with my doctor about reviewing my data and the possibility for a detailed titration to narrow down my issue and at the presence of central apneas I need to peruse an ASV,but then also hope to not die from chronic heart failure in the time being?

Yes, you need to make another appointment to review the data with your sleep doctor.

But: You don't need to worry about dying from CHF while waiting on an ASV machien. Rather, you need to be sure that you do not already have CHF before being put on an ASV machine. Patients with CHF should NOT be put on ASVs even if they have central or complex sleep apnea because the ASV therapy seems to aggravate the CHF and causes the CHF patients to be a higher risk of death than if they are simply left on straight CPAP or straight bilevel therapy.

[Crimson Nape]

Using the EPR will reduce the CO2 levels in your system. CO2 aids in invoking our inhale reflex.

[CaseyF]

What a relief! (If I don't have CHF) haha. Going to setup an appointment and add turning off EPR to the tasks. Thanks all will be in touch with updates!