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Frustrated, Cannot get AHI Down After 2 Weeks
#1
Frustrated, Cannot get AHI Down After 2 Weeks
As my thread title says, I cannot get my AHI down. The Centrals will not go down and I keep having frustrations with leaks causing central airways and hypopneas. I'm not sure what to do, but my sleep is worse, my anxiety is worse, my appetite is gone and I think I'm suffering much worse than I did prior to treatment. Prior to treatment, I never woke up, my heart rate was stable, and I had no effects from my apnea. I slept straight through the night, but my snoring was really loud (position dependent).

Now, I wake up with a mouth full of air, my belly is constantly bloated and I'm so tired and anxious.

I've attached two charts from the last two nights to see if anyone can help me figure out what is going on. I'm at wit's end and I'm considering just quitting because I cannot keep getting this bad of sleep. I have a son to take care of and a job to do. I cannot do either of these things with how tired I am every day because of the stupid cpap. I am probably 3-4x's more tired and anxious than I ever was before cpap.

I've tried switching masks, I switched my pressured to 6-10, 6-11, 6-13, lowered EPR to 2, but I'm just frustrated and upset and tired.

help me.


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#2
RE: Frustrated, Cannot get AHI Down After 2 Weeks
Welcome to the board!

I'm sorry you're having issues but I think we can help out here.

First off, do you have the sleep study report? Or do you know what the results were? Ideally we would need to see if the centrals were present before you started therapy, and whether you have obstructive apnea or something else (often doctors label everything OSA even when it's not).

Second, your machine is set with the default, wide open settings. At 4cm, that is a pediatric pressure. Most people need higher than that to feel like they're not air hungry or short of breath. Secondly, the aerophagia you mention is probably caused by the higher pressures so we can drop that off

Could you take a screenshot with the Details tab showing and the calendar closed? If you look under the view menu, there is an option to Take Screenshot. It will hopefully provide the correct info and charts we need for best advice.

Perhaps you can also zoom in on the large cluster of centrals towards the end of the nights - maybe at 10 minutes and 2 mints?

The dry mouth means that you're probably mouth breathing. This is something we can make suggestions for, too, but in the meantime, you might find that increasing the humidity level can help with that, too.

I totally understand your frustration. The first few days or weeks can be really tough, and it's easy to feel like giving up, but hopefully, we can give you some more advice.

For a start, I would suggest that you change the pressure. The highest you got on that chart was 11cm, so you probably don't need much more than that. If you're struggling with aerophagia. perhaps set it to 10 for now. The lowest pressure was 5.8 so maybe try switching that up to 6 or 7.

Centrals can sometimes occur as a result of treatment (if you had none on your sleep study - hence why it would be useful to see). This is fairly normal initially, but there are ways we can try to reduce them (such as reducing pressure and/or EPR if it's on). If they are treatment-emergent, that's actually a sign that the therapy is working to give you better night respiration but it's a little too effective. The drive to breathe comes from rising carbon dioxide levels, not low oxygen levels for most people. When you start PAP, your body is used to having higher levels of CO2 because of your reduced overnight breathing and when you start breathing properly with the machine, you end up blowing off too much CO2 and your brain doesn't prompt you to breathe as much. This usually improves in the first few days, weeks or 2-3 months in most cases, and we can reduce it to just a minimum of events to let your body adjust to better levels of ventilation without causing too many centrals. It's normal for many people to have the odd central - especially when falling asleep or during arousals when your body is shifting from conscious breathing to unconscious breathing. By looking at the charts, we can help figure out what's going on.

I hope this is at least some help and reassurance so far, please post those new screenshots so we can see the details tab and the clusters from last night, which will allow us (especially the other awesome people here who know more than me) to advise you on other tweaks to your settings.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#3
RE: Frustrated, Cannot get AHI Down After 2 Weeks
Okay, I've tried to take some of the screenshots you asked for. I did not take a picture of the ones at the end as I know that was SWJ because I was up around 7:40 deciding if I wanted to sleep in for Father's Day.

I actually changed my pressure to 6-11, but I'll move it down to 7-10. I seem to breathe easiest at 7-10. I also seem to notice that my CA seems to go up when the pressure is higher.

My sleep study showed nearly all hypopneas or apneas, less than 1 CA per hour. I did wear one of those belts that showed effort, so I feel confident in the report, however, this was a sleep study done at home. My sleep study had me at 15.3 AHI, but that was mostly made up of supine events. My non-supine events were barely over 5, supine was over 26, though.


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#4
RE: Frustrated, Cannot get AHI Down After 2 Weeks
This seems to suggest that these are treatment-emergent central apneas (and/or SJW as you said). In the first zoomed shot you showed, the centrals seems to have been triggered by the initial arousal from the obstructive event, which would have caused you to take a deep breath and that resulted in a few centrals until your body got back into balance between exhaling too much CO2 and not enough. That should improve with more time. As you've noticed that increasing the pressure makes it worse, I would keep it where it is for now, and you may want to try lowering the EPR as well, to see if that eases the centrals too.

The second run in the last screenshot may also have been triggered by the prior obstructive apneas as they're in close proximity. 

I'm also now wondering if the remaining hypopneas and obstructive apneas are perhaps down to positional apnea (aka chin tucking). Especially as you say your snoring was also position-dependent. You might want to look at the wiki link here

One other thing to suggest is that some people are disturbed by the changes in pressure during the night. If you think that might be part of the problem, too, then at some point you may want to try a fixed pressure.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#5
RE: Frustrated, Cannot get AHI Down After 2 Weeks
Okay, that makes me feel so much better. I have no idea how to analyze this information.

I moved EPR down to 1 and set pressure to 6-10. The prior evening, my pressure never got over 10 and my AHI was half of that. 

My wife says I always end up on my back, but she often taps me and I roll over without an arousal.

I also wonder if some of these arousals/breathing issues have more to do with me being woken up my dogs and babies in bed. Is that possible?

I’ll try EPR at 1 for a nap, but typically my naps don’t record any events at all no matter how I sleep.
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#6
RE: Frustrated, Cannot get AHI Down After 2 Weeks
Honestly, that's the same for me, my naps are almost always far lower in events (as is the first hour or so of my night sleep, usually). It's why I know I need to get an average AHI without my naps counted in for when I finally speak to the doctor again because it's going to raise my average AHI significantly. At least with the nap, it will give you some idea if you're comfortable with the reduced EPR.

It's entirely possible that those arousals are being caused by other factors - any arousal, be it dog, baby, or your wife making you roll over, is going to potentially do it. Just rolling over itself is definitely a common arousal, even if you don't remember waking up, and it's very common to have an apnea when changing position.

So hopefully, with a little more time, you'll find these will ease up as you spend a bit longer on APAP. You have definitely improved your issues with the obstructive events, for sure, and if you're still sleepy or having more than the odd event, then you may want to consider a soft collar to see if that helps stop your chin tucking (and save your wife from elbowing you to roll over!).


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#7
RE: Frustrated, Cannot get AHI Down After 2 Weeks
I was thinking about the collar earlier. The reduced EPR definitely took some getting used to as it certainly feels like I’m suffocating when exhaling, but once I fell asleep it was ok.
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#8
RE: Frustrated, Cannot get AHI Down After 2 Weeks
If you can tolerate it enough to give it one or two overnights, we can hopefully get some idea if that's changing things. If not, then you can go ahead and up it again to where you're more comfortable. Otherwise, I would expect that over the next few weeks, those centrals should ease up a little as you adjust. And hopefully, if you're not a little less anxious about what's happening, that's only going to help as well.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#9
RE: Frustrated, Cannot get AHI Down After 2 Weeks
You will get treatment emergent central apneas with increased pressures and EPR no matter what, BUT they will typically go down (all the way to zero) over time, and as such indicate only that you should increase your settings gradually.

Also remember that EPR subtracts from your EPAP, so 6 EPAP with 2 EPR will be like 4 EPAP with 2cmH2O extra on inhale. Try to compensate for that, e.g. for EPR of 1/2/3, you want to increase EPAP by +1/2/3.

Most importantly, look at how much the machine is increasing the EPAP - it should ideally remain relatively stable, only increasing during the messier periods. Increase your settings gradually(keep them within a range you can tolerate and have less than, say 2-3 centrals/hour), but you probably will want your EPAP much higher - high enough that it only jumps up rarely.
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#10
RE: Frustrated, Cannot get AHI Down After 2 Weeks
Please read my post about the FOT pulsing that your Resmed machine delivers (without telling you).  You're likely exposed to FOT pulsing all night as you have centrals, which is disrupting your sleep (without always waking you up), and why you feel terrible.  You can read more about the issue here:

http://www.apneaboard.com/forums/Thread-...+Technique

I have centrals all night long (usually AHI 5-9), but my SPO2 never drops, and so I don't worry about them.  Once I got a machine that didn't wake me up every time I held my breath for 10 seconds, I started sleeping great.

And if you're using an autoset mode, be aware that the FOTs both disrupt your sleep, and aren't even very good at doing what they're supposed to do, which is distinguish between central and obstructive apneas.  As a result, your machine may be increasing your pressure unnecessarily in response to centrals that it incorrectly classifies as obstructive, and thereby INCREASING the number of centrals that you have.

You may also want to set-up a camera system with IR to record you while you're sleeping.  You can then compare the apneas clusters reported by your CPAP with the video.  That can help you identify if/when you're mouth breathing, or having acid reflux, which can also cause you to have a dry mouth.  It is also sometimes possible to tell if you're having central or obstructive apneas by looking at the rise and fall of your chest on the video.  These are much better methods to tell what's going on than trying to make inferences from the data in the machine.
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