Jealous newbie looking for optimization

[sleepyBuzz]

I have been using my Auto BiPAP for 60 days. Thanks to this forum and Sleepyhead software, I have learned a lot. My sleep study report says that I started with an AHI of 32 and it was reduced to 0 with my final BiPAP setting of 20/16. However, I have averaged an 4.35 AHI over the last 60 days with readings that range from 1.48 - 9.37. Although I should be grateful for my AHI dropping from 32 to less than 5 on average, I am so jealous of those of you reporting less than 1.00 AHI's and I would like to solicit your expert opinions to lower my scores. I know I need to post 4 times before I can upload my Imgur Sleepyhead graphs, so I have several topics for you to comment on in the meanwhile.

1) Is it normal for AHI's to vary so widely?

2) I noticed that some of my best days are when I am up late and fall asleep exhausted; or if I didn't sleep well the night before and fall asleep quickly. I don't know if this is because I'm sleeping "harder", but I prefer not to rely on this methodology for my normal routine.

3) I was sick and congested one week and so I slept reclined because I was a little paranoid/claustrophobic about how well my BiPAP would work with my congestion. To my surprise, I registered AHI's below 4 when it was double the week before. This may be a great excuse to replace my 25 year old bed with an adjustable one from a well-known warehouse chain; but before I drop a couple grand, I'd like to optimize all of my other factors first. Although that zero-gravity setting is quite attractive...

4) One drawback to sleeping reclined at a steep angle is that stupid gravity makes my mouth drop open, thus creating large leaks and dry mouth as I've learned from these boards. I purchased a cervical collar but immediately returned it as it was too tall. The fit was fine while sitting up but when I lay down, the collar would push my mask upward and create leaks. Also, the thick padding made it uncomfortable to sleep on my back. So, I'm guessing I need to try a chin strap next?

5) Sleeping on my back (which is preferred) works well for me. When I flip onto my side, I always have to adjust my nasal mask as it has a tendency to slip, either blowing out my eyeball or leaking from below. Per suggestions from other posts, I confirmed that my mask is the correct size for my nose. Are nasal pillows more prone to or less prone to slip?

Despite my desire to tweak these minor issues, I love my BiPAP. I no longer wake up in the middle of the night or covered in sweat. I don't get sleepy in the afternoon and have energy now to go to the gym regularly. I will find out on Friday whether it has helped lower my blood sugar A1C levels now that my body is no longer desparately trying to keep me alive at night (fingers crossed). Thanks in advance for your advice and comments!

[Marillion]

I would say there should not be such a wide variation in your results. Changes from 1.48 to 9.37 to me would indicate that there is definitely room for further improvements to improve your numbers. Before making any recommendations to your settings though, we would need to see your Sleepyhead data. See my signature area on directions and how to arrange the data.

However, I will add with wide variations like you are seeing there very well could be some positional obstruction going on for certain nights. As in your chin tucking in towards your chest at some point in the night and cutting off your airway making it much harder to breath and making it much easier for an obstruction to occur. A cervical neck collar can help with that or a buckwheat pillow or indeed any pillow that helps you to keep your airway more aligned. Perhaps on those nights that you are so dead tired you don't tend to shift around as much and there is less chance of the chin tucking positional obstruction going on. Again, hard to say until we see the data. Other members here are much more expert at diagnosing and fixing these positional obstruction issues.

Depending on the type of pillow you have, it could very well be that your nasal mask gets dislodged when turning onto your side. Especially with the softer high loft pillows. I find with the P10 nasal pillows I use, that I get far less disruptions in that respect and I use a slightly firmer pillow in a smaller size to mitigate dislodgements. I have also gotten more used to sleeping on my back to further reduce those kind of events.

[sleepyBuzz]

Marillion,
Thank you for your comments. It's very likely I'm causing my own positional obstructions as OA's are the biggest component of my AHI score and moving less totally explains the lower score on dead tired nights. I'll try the buckwheat pillow suggestion.

[robysue]

I have been using my Auto BiPAP for 60 days. Thanks to this forum and Sleepyhead software, I have learned a lot. My sleep study report says that I started with an AHI of 32 and it was reduced to 0 with my final BiPAP setting of 20/16. However, I have averaged an 4.35 AHI over the last 60 days with readings that range from 1.48 - 9.37.

Some variation is normal.  But you shouldn't be seeing very many days with an AHI over 5.  It's worth asking whether the really bad days are very rare or not.

It's also worth asking what kind of events make up that AHI.

Although I should be grateful for my AHI dropping from 32 to less than 5 on average, I am so jealous of those of you reporting less than 1.00 AHI's and I would like to solicit your expert opinions to lower my scores.

Focus on teaching your body how to sleep well with the CPAP instead of artificially chasing great AHIs.  I'm not saying that reducing your AHI shouldn't be a priority. I am saying pay as much attention to how you feel as you do to your AHI.

In my case, I tend to feel my best when my AHI is in the 1.5-2.5 range.  When it gets below 1.0, there's always a good chance that the AHI is that low simply because I didn't get enough real, deep Stage 3 sleep or enough REM sleep that night.  On the other hand, if my AHI trends up above 4.0, the pre-CPAP symptoms of OSA come back.

I know I need to post 4 times before I can upload my Imgur Sleepyhead graphs, so I have several topics for you to comment on in the meanwhile.

Some newbies have gotten around this with posts that say, "Post number 2 to get up to 4", "Post number 3 to get up to 4" ..

1) Is it normal for AHI's to vary so widely?

I would say that it's not common for the AHI to vary that widely without some kind of cause.

2) I noticed that some of my best days are when I am up late and fall asleep exhausted; or if I didn't sleep well the night before and fall asleep quickly. I don't know if this is because I'm sleeping "harder", but I prefer not to rely on this methodology for my normal routine.

Best in what sense? In terms of AHI? Or in terms of how you feel the next morning? Or in terms of how you feel the next day?

There is a tendency for CPAP machines to score "false" events when some people use the machine while drifting between wake and a light sleep for extended periods of time.  Normal wake breathing is not as regular as normal sleep breathing, and some people's normal wake breathing patterns often fool a machine into thinking that it is seeing some form of sleep disordered breathing.

3) I was sick and congested one week and so I slept reclined because I was a little paranoid/claustrophobic about how well my BiPAP would work with my congestion. To my surprise, I registered AHI's below 4 when it was double the week before. This may be a great excuse to replace my 25 year old bed with an adjustable one from a well-known warehouse chain; but before I drop a couple grand, I'd like to optimize all of my other factors first. Although that zero-gravity setting is quite attractive...

A good bed is a critical part of getting a really good night's sleep.

But back to the cold: I have found that my BiPAP data often serves as an early warning system that a head cold is on the way.  I've learned through the years that if I see a two or three day spike in my AHI, I am very likely to start feeling head cold symptoms in another couple of days.  Oddly, by the time I actually start with the coughing and the congestion and the feeling miserable, the AHI drops back down to its normal range.

4) One drawback to sleeping reclined at a steep angle is that stupid gravity makes my mouth drop open, thus creating large leaks and dry mouth as I've learned from these boards. I purchased a cervical collar but immediately returned it as it was too tall. The fit was fine while sitting up but when I lay down, the collar would push my mask upward and create leaks. Also, the thick padding made it uncomfortable to sleep on my back. So, I'm guessing I need to try a chin strap next?

If leaks are NOT too big of a problem when you are lying down, you might not need any "solution." We need to see the leak line for a day when you were in the recliner and another typical day when you are in bed sleeping horizontally.

5) Sleeping on my back (which is preferred) works well for me. When I flip onto my side, I always have to adjust my nasal mask as it has a tendency to slip, either blowing out my eyeball or leaking from below. Per suggestions from other posts, I confirmed that my mask is the correct size for my nose. Are nasal pillows more prone to or less prone to slip?

Some people find that nasal pillows are less prone to slipping since the footprint on your face is smaller.  Other people find that nasal pillows are more prone to slipping since the footprint on your face is smaller.

In other words, it varies.

With time, most people also learn how to make minor mask adjustments without arousing all the way to a full wake.

And sometimes a mask liner will fix the kind of problem you are describing.

[Sleeprider]

Marillion,
Thank you for your comments. It's very likely I'm causing my own positional obstructions as OA's are the biggest component of my AHI score and moving less totally explains  the lower score on dead tired nights. I'll try the buckwheat pillow suggestion.

Your profile suggests you are using an Auto BiPAP with fixed settings of 20/16.  If you are still seeing predominately OA, my first suggestion would be for you to try a soft cervical collar.  Using positive pressure with bilevel, obstructive apnea are normally addressed by raising EPAP pressure.   If you go with changing settings, then I think I'd change to BiPAP Auto mode rather than BiPAP S, and set min EPAP to 15, Max EPAP to 20, PS min 3.0, PS max 4.0.  Hypopnea is treated with pressure support, and we are hoping CA is not a significant component here.   Choice is yours, but is very common to have position cause significant OA, especially if you notice it occurring in clusters.

Download #Sleepyhead, and there might be some patterns that we can recognize and interpret for you.

[Melman]

You mentioned using a cervical collar that was too tall. Amazon sells the OTC soft foam cervical collar that comes in 2.5", 3", or 3.5" heights and a wide range of collar sizes for under $10. You may find a size that works better for you.

[xxyzx]

I have been using my Auto BiPAP for 60 days. Thanks to this forum and Sleepyhead software, I have learned a lot. My sleep study report says that I started with an AHI of 32 and it was reduced to 0 with my final BiPAP setting of 20/16. However, I have averaged an 4.35 AHI over the last 60 days with readings that range from 1.48 - 9.37. Although I should be grateful for my AHI dropping from 32 to less than 5 on average, I am so jealous of those of you reporting less than 1.00 AHI's and I would like to solicit your expert opinions to lower my scores. I know I need to post 4 times before I can upload my Imgur Sleepyhead graphs, so I have several topics for you to comment on in the meanwhile.

1) Is it normal for AHI's to vary so widely?

2) I noticed that some of my best days are when I am up late and fall asleep exhausted; or if I didn't sleep well the night before and fall asleep quickly. I don't know if this is because I'm sleeping "harder", but I prefer not to rely on this methodology for my normal routine.

3) I was sick and congested one week and so I slept reclined because I was a little paranoid/claustrophobic about how well my BiPAP would work with my congestion. To my surprise, I registered AHI's below 4 when it was double the week before. This may be a great excuse to replace my 25 year old bed with an adjustable one from a well-known warehouse chain; but before I drop a couple grand, I'd like to optimize all of my other factors first. Although that zero-gravity setting is quite attractive...

4) One drawback to sleeping reclined at a steep angle is that stupid gravity makes my mouth drop open, thus creating large leaks and dry mouth as I've learned from these boards. I purchased a cervical collar but immediately returned it as it was too tall. The fit was fine while sitting up but when I lay down, the collar would push my mask upward and create leaks. Also, the thick padding made it uncomfortable to sleep on my back. So, I'm guessing I need to try a chin strap next?

5) Sleeping on my back (which is preferred) works well for me. When I flip onto my side, I always have to adjust my nasal mask as it has a tendency to slip, either blowing out my eyeball or leaking from below. Per suggestions from other posts, I confirmed that my mask is the correct size for my nose. Are nasal pillows more prone to or less prone to slip?

Despite my desire to tweak these minor issues, I love my BiPAP. I no longer wake up in the middle of the night or covered in sweat. I don't get sleepy in the afternoon and have energy now to go to the gym regularly. I will find out on Friday whether it has helped lower my blood sugar A1C levels now that my body is no longer desparately trying to keep me alive at night (fingers crossed). Thanks in advance for your advice and comments!

everybody is different

congestion can require more pressure 
did the ahi go up when you were congested

sounds like it is working well for you

[trish6hundred]

Hi sleepyBuzz,
WELCOME! to the forum.!
You have come to the right place to get your CPAP therapy fine-tuned to meet your needs.
I wish you good luck on your sleep apnea journey.
.

[sleepyBuzz]

I knew this was a great community to join - thanks for all of the responses so far! 
Here are some follow ups to the questions you asked or comments that were made.

Some variation is normal.  But you shouldn't be seeing very many days with an AHI over 5.  It's worth asking whether the really bad days are very rare or not.

It's also worth asking what kind of events make up that AHI.

Out of 59 days, only 17 days had AHI's over 5. So I guess I'm doing well. Sleepyhead gives me the following statistics for the last 59 days: Average AHI is 4.35, comprising of average CA of 0.69, average OA of 2.71, and average H of 0.95.

Focus on teaching your body how to sleep well with the CPAP instead of artificially chasing great AHIs.  I'm not saying that reducing your AHI shouldn't be a priority. I am saying pay as much attention to how you feel as you do to your AHI.

In my case, I tend to feel my best when my AHI is in the 1.5-2.5 range.  When it gets below 1.0, there's always a good chance that the AHI is that low simply because I didn't get enough real, deep Stage 3 sleep or enough REM sleep that night.  On the other hand, if my AHI trends up above 4.0, the pre-CPAP symptoms of OSA come back.

"Don't get hung up on AHI numbers" is great advice, particularly for an engineer like me. I no longer experience any of my pre-CPAP symptoms (waking up, sweating, afternoon fatigue, etc.). However, I have noticed that I tend to wake up a little more groggy than before. I'm more inclined to hit the snooze button or just lie in bed for a few minutes longer. Is this normal? After I finally crawl out of bed, I have not paid attention to whether I feel better when my AHI is lower.  

Best in what sense? In terms of AHI? Or in terms of how you feel the next morning? Or in terms of how you feel the next day?

There is a tendency for CPAP machines to score "false" events when some people use the machine while drifting between wake and a light sleep for extended periods of time.  Normal wake breathing is not as regular as normal sleep breathing, and some people's normal wake breathing patterns often fool a machine into thinking that it is seeing some form of sleep disordered breathing.

When I mentioned my "best" days, it was strictly in terms of the AHI number. Good to understand the limitations of this magic machine.

If leaks are NOT too big of a problem when you are lying down, you might not need any "solution." We need to see the leak line for a day when you were in the recliner and another typical day when you are in bed sleeping horizontally.

I will keep that in mind when I post my graphs.

And sometimes a mask liner will fix the kind of problem you are describing.

You have my attention - I'm starting to make a shopping list. It also seems like the mask sealed better initially - maybe it's breaking down or loosening over time.

Your profile suggests you are using an Auto BiPAP with fixed settings of 20/16.  If you are still seeing predominately OA, my first suggestion would be for you to try a soft cervical collar.  Using positive pressure with bilevel, obstructive apnea are normally addressed by raising EPAP pressure.   If you go with changing settings, then I think I'd change to BiPAP Auto mode rather than BiPAP S, and set min EPAP to 15, Max EPAP to 20, PS min 3.0, PS max 4.0.  Hypopnea is treated with pressure support, and we are hoping CA is not a significant component here.   Choice is yours, but is very common to have position cause significant OA, especially if you notice it occurring in clusters.

You mentioned using a cervical collar that was too tall. Amazon sells the OTC soft foam cervical collar that comes in 2.5", 3", or 3.5" heights and a wide range of collar sizes for under $10. You may find a size that works better for you.

Thanks to Sleeprider and Melman for your suggestions on the cervical collar.   Duh! I just measured the cervical collar I ordered and it is 3.5" in the front and 4" on the sides. Of course, I should try a collar with a shorter height! Thanks!

everybody is different

congestion can require more pressure 
did the ahi go up when you were congested

sounds like it is working well for you

My AHI went down when I was congested but I think that was from sleeping reclined instead of my back. I was too paranoid/claustrophobic to try sleeping on my back while congested.

---

So my final shopping list consists of: buckwheat pillow, shorter collar, and mask liners. I will hold off on the adjustable bed (sigh...) for right now.

[sleepyBuzz]

For my fourth post, I would like to solicit - how many days of graphs should I post?

robysue suggested one for when I was sleeping reclined and one in bed horizontally. That's 2 days. Should I post 2 days worth for in bed horizontally - one with a low AHI and one with a high AHI for a total of 3 days of data?

Thanks!