[CPAP] Unable to achieve lower than 15 AHI

[hwka]

Hi
Back again after a long break. I binned the CPAP as I was getting nowhere but have decided to have another go.
I have finally succeeded in getting my CMS50F  to work on a desktop Mac but the timeline is problematic - the SPO2 needs to be shifted 10 minutes to the right.
Once information such as this is entered there seems to be no facility to amend it or remove it in Sleepyhead - unless I am missing something.
Screenshot attached.
Any comments/advice appreciated.
https://i.imgur.com/wlpXA6Ql.png

[Walla Walla]

I think it would be a good idea to put it on auto with a min of 8cm and max at 20cm and see where the machine goes from there.

A fix rate of 8cm isn't going to work for you.

[hwka]

I have a fixed pressure CPAP.
I believe my problems originated from a poorly supervised Sleep Study and a consequently incorrect prescription of 6cmH20.
As I was clearly going nowhere on the prescription setting - I have recorded an AHI of 60+ - I decided to vary the setting.
A CPAP fixed of 7 showed an improvement - the current 8 resulted in 15 AHI but an increase in CA's.
Not long enough on any of the settings to form firm conclusions just yet.
I think the most significant areas for me are mask fit , mouth breathing and SPO2 readings.
The people like Philips have excellent algorithms but they rely on a single source of airflow which can be  difficult to interpret outside of a laboratory.
I have tried all forms of masks but unfortunately I cannot tolerate the one type I probably need - a full face mask.
The Nuance Pro is the most comfortable for me but I seem to move around quite a bit and I suspect a lot of my problem readings are caused by leaks and mouth breathing.
The SPO2 readings seem to confirm this possibility as apart from a few spikes the percentages seem reasonable.
I am not sure how accurate the CMS50F readings are - but some recent articles suggest it compares very favourably with commercial grade equipment.
I may have to upgrade to an APAP machine but will persevere for the moment and try different pressures on the CPAP fixed.

[Walla Walla]

Sorry I missed that. I would start increasing pressure a little at a time until you see some of those events disappear. You could reduce the EPR to try and get rid of the clear airways. If you can't raise your pressure due to increasing CA's than your probably stuck as far as improving on a CPAP machine. You need to tell your Doctor if that ends up happening.

[Marillion]

The EPR setting definitely caused CA events for me. I would follow Walla Walla's advice and reduce or eliminate it if you can to see if it makes a difference. Also, increasing the pressure gradually and leaving it for a few days to get used to each setting would be a good idea as well.

[Sleeprider]

I disagree, not because the advise is wrong, but because you continue to have moderate AHI with primarily hypopnea and central events.  I think you need to be evaluated for a different machine. Tell your doctor. No one should have to suffer an AHI of over 15. A higher pressure might eliminate hypopnea events, but it might also increase CA event.  your results demonstrated over 2-1/2 months demonstrates a CPAP failure. Use that that get an upgrade to bilevel/BiPAP.  

A dual pressure machine, preferably Auto Bilevel, is the solution to hypopnea like this.  Your OA is controlled, but this is a totally unacceptable level of efficacy.  If your insurance does not provide good coverage, I might suggest the pressure increases, but otherwise, you deserve better treatment, and auto bilevel is probably what it is.  Let your doctor know your AHI is still unacceptably high.  He may recommend higher pressure, and I would concur, but you need to get on the record as having followed prescription unsuccessfully.

[hwka]

I appreciate you taking the time to respond.
I am considerably confused with all the options.
I thought I was basically getting the same as BiPAP by using CFlex+ on my current machine - which incidentally I have just turned off for my next session to see what difference CFlex OFF  might make.
I was planning on going gradually up to 10cmH20 with an eagle eye on the CA's.
I am also telephoning around seeking a trial on an auto purchase because I see the need to get to at least single figures AHI in the short term and below 5 asap thereafter.
What is really confusing - having finally achieved a hookup with my CMS50F on my desktop Mac - is why events like OA and CA do not show major drops in SPO2?
My SPO2 is generally above 88% which I thought was not that bad under the circumstances - assuming of course that that oximeter information is reliable.
Will post a screenshot of tonight's session if anything of interest.
I believe my major mistake was persevering with my prescribed setting of 6cmH20 for so long.

[Sleeprider]

hwka, I agree that with CPAP the normal approach for hypopnea is to increase pressure. If you were on APAP that would have been done automatically. Even individuals on Philips APAP seem to have more hypopnea than those using Resmed because the Philips auto machines are slower to respond to these events, and tend to drop pressure faster, so it is critical to have a high enough minimum pressure to prevent hypopnea, even with that auto CPAP.

CFlex+ does not even closely resemble bilevel treatment. It is basically a rounding of the pressure transitions. EPR on Resmed machines do provide separate inspiration/expiration pressure with a difference up to 3-cm and comes a bit closer.

Your best solution is to start self-titrating by increasing pressure until the hypopnea events are at an acceptable level, or pressure is intolerable, or they are replaced by more central apnea than hypopnea. If the AHI is not resolved comfortably, or is replaced by other events, then bilevel or another solution is in order. It's surprising you have gone since September with this unacceptable AHI and sleep quality. Even more surprising is that your doctor or DME have not intervened and done something about it. This forum exists to help people not suffer through that problem and to empower you to make the necessary changes, because the professionals often don't do their jobs diligently.

[hwka]

I have not posted the last couple of sessions because the results were consistently pathetic and around 20 AHI.
I have continued experimenting.
I have found that higher pressures are intolerable without C-Flex.
A brief session this afternoon was as follows:
Mask Change to Philips Amara View.
Pressure to 10 cmH20
C-Flex + on 3.
Although only 45 minute trial it could be promising as the AHI 8.07 is the lowest achieved thus far.
Mask comfort is a problem but I am going nowhere with the comfortable Nuance Gel Pillows.
https://i.imgur.com/BmxmR85l.png

[ajack]

until you get this sorted, I would use the full face mask. You need to fix the leaks, I think you are going to need more pressure. If the median insp/exp times are right, with breath rate and tidal volume are right, you may need a bpap.
You're an aussie, go get a sleep study, a lot bulk bill. What state are you in, someone will advise.