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Newbie. One Week In... poor AHIs
#1
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Newbie. One Week In... poor AHIs
Hello, AB Members -

As I'm brand-spanking new to this community, I thought I should begin by thanking the members of this group for creating a supportive environment and for sharing their knowledge so freely.  I've read quite a few threads and am hugely impressed with the quality of the advice and the patience given to the less-knowledgeable... like me.  

A quick background:  I'm an early-50s long-time snorer who was diagnosed with sleep apnea about 2 weeks ago via an at-home test. My insurer mandates at-home testing as a first step in the diagnosis process.  I scored an AHI of 25, but no data was shared with me beyond the AHI score. No in-lab sleep study was performed; I was prescribed based on the home study alone.  Late last week, I came home with a Dreamstation Auto CPAP which included the cellular modem card, and a DreamWear Nasal Pillow mask.  

I've slept well on therapy from the very first night.  The first couple of nights I experienced some restlessness but I feel fortunate that I've had very little difficulty adjusting to the mask and the pressure.  My prescription called for a pressure range of 5 - 20, and I've been experience 90% Pressure results of ~11 with the exception of one night where the 90% pressure was 20.

However... over the past 8 nights, my AHI scores are averaging ~12, with a low of 8 and a high of 21.  I've called my doctor/DME (the facility that I chose to use, Sleep Wellness Institute, is both a DME provider and has doctors & nurse practitioners on staff) who routed me to the Respironics Coaching line. I received very little useful information from Respironics, and have left two messages for a callback from the medical staff at Sleep Wellness with no response thus far.  

As I indicated in the title of this post, I've only been on therapy for 8 nights, but I haven't read anything that would indicate I can expect AHI scores improve with time, so I'm concerned as to what's going on.  Below are Sleepyhead results for the past 3 nights for a sample of what I've been experiencing.  Many thanks in advance to anyone who can interpret the data.  I've only just started reading the Sleepyhead documentation and don't yet have any real grasp of how to interpret the graphs on my own. 

-Epsan 

ps - I just received an error message saying that as I'm new, I can't include images until I have made four posts.  So.. just thumbnails for now. 

   
   
   
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#2
RE: Newbie. One Week In... poor AHIs
First let me welcome you to the forum.  

Thanks for your daily charts, they tell us a lot.  There is more to your home study than you have been told.  It is your record and under HIPPA you are entitled to a copy.

Please keep all posts about your therapy in this thread, that way we will have a history.

The first thing I noticed is that you are running your CPAP wide open.  That is not bad for a start as it lets you see what is happening and at what pressures.  Expect both your min and max to narrow your range as PR machines perform better when closer to the pressures they need to control your events.

All 3 of your charts show some positional apnea/chin tucking especially the 16 Jan chart.  See the clusters of OA events?  That indicates a high probability of positional apnea.  A loose fitting soft cervical collar is the best, and usually the cheapest fix for that.

\Another observation is that about 1/3 to just under 1/2 of your events are Central/Mixed/Complex apnea.   The question is are these treatments Emergent CA events, in which case they should disappear in about 8 weeks, or are they true Central events which require a different approach.  Your APAP will not treat these at all and with your machine, the treatment for these is to try and avoid them.  How do we do this?  Central events typically go up with increased pressure and increased pressure variance.  So we do the opposite.  Unfortunately, this is the opposite of what we do to treat obstructive events.

Hypopneas are prominent in all your charts.  The best treatment for those is to Increase the difference between your inhale and exhale pressures.  We can try but PR machines do this poorly since Flex is just a comfort feature.  What Flex setting are you at?  I would bump it up to the next level to see if it will work for you.

I'm going to suggest setting the minimum to 9 and the Max to 13 and the Flex to 1 over its current setting.  We need to seek a balance between the Obstructive and the Obstructive events for now.

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Newbie. One Week In... poor AHIs
Epsan, I think we can improve your results with less variation in pressure and perhaps using a soft cervical collar, but I think the best approach in this case is for you to let your doctor know that you are experiencing a high number of mixed apnea events. The mixed events occur at all pressures in your wide range of settings and obstructive events are unresponsive to increased pressure. You might have complex apnea (a combination of obstructive and central events) that we can improve, but never fully control. The reason to involve your doctor is to request a clinical titration and to evaluate if bilevel or ASV may be appropriate. Your current results show that central apnea is more than 50% of total apnea, and we can't really classify whether hypopnea is central, obstructive or mixed. You only had a home sleep study, so your doctor does not have a good diagnostic indication of whether central sleep apnea is present, and a clinical titration will help to make that determination, as well as identify optimal settings to reduce events.

It is still early in your therapy, and often these events will diminish with time, and sometimes, especially with complex apnea, the results will be consistently inconsistent. With that said, a few wiki articles to read are
Flow Limitation http://www.apneaboard.com/wiki/index.php...Limitation
Optimizing Therapy http://www.apneaboard.com/wiki/index.php...ng_therapy

In addition to the mixed events, your charts show normal respiratory rate with good tidal volume and minute vent. The fact that expiration is much shorter than inspiration is a typical error of Philips Respironics machines and tends to be an indication of flow limitation. I think your best results may be achieved by adding a soft cervical collar as discussed in the wiki articles above, and moving to a narrower range of pressure, starting with 8 or 9 cm minimum pressure. If these interventions do not significantly reduce the AHI, or if central events remain predominate, then I think it's time to involve the doctor.
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#4
RE: Newbie. One Week In... poor AHIs
Fred and I posted at the same time. It's not surprising, advice is about the same. Good luck and keep us posted.
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#5
RE: Newbie. One Week In... poor AHIs
Thanks so much, gentlemen.   You've given me quite a bit to think about.  I'm going to read the wiki articles, study up on the concept of central apnea, ASV treatment, and more.  

I'm actually glad to learn that it takes several weeks to determine whether the CA events are emergent or true.  It makes me a bit less concerned about day-to-day results.  However, the fact that I continue to experience OA events even at 20cm max pressure on the 16th worries me.

I can see that I'm going to need to continue to educate myself, especially if it develops that I have complex apnea.  

One followup question:  is there any obvious indication for why my machine applied significantly higher pressures on Jan 16th (frequently maxing out at 20cm) than on any other day?   

Bonjour - my machine is already set to the maximum Flex value... 3, so obviously can't take your advice regarding an increase in that value.
Regarding narrowing the range: I can certainly see increasing the minimum to 8 or 9.  But should I really reduce the maximum, given that the machine has seen fit to use the current maximum pressure?

Epsan

Almost forgot to mention cervical collar.  I'll definitely get one - what a simple solution!


Epsan
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#6
RE: Newbie. One Week In... poor AHIs
By lowering the max is an experiment to see if we would get lucky and lower your CA events.  I seriously expect this to fail in your case.  The ROT says by lowering your max your Central events would go down.  Unfortunately, that also means the Obstructive events may go up.  You had 2 nights that you showed us where lowering your max would not have a noticeable impact and that also led to my choice.  With Mixed Apnea, Obstructive and Central, treatment with a basic CPAP or an Auto CPAP or even a bilevel without backup rate will fail.  The target machine is an ASV.  Unfortunately it is the most expensive, and as such insurance, and by trickle-down effect, doctors try the ess expensive options first.

Read this article  Justifying_Advanced_PAP_Machines

Fred

and as an experiment set Flex to 1, let's see how your body reacts to that.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Newbie. One Week In... poor AHIs
Fred is suggesting you REDUCE the Flex setting to 1. We have found higher Flex settings unhelpful, especially where mixed events are happening. The Philips machines will increase pressure for VS (not VS2), FL, H and OA events. It is less responsive than the Resmed Autoset to flow limitations. I don't think higher pressure is providing better treatment efficacy, so the recommendation to lower the maximum pressure is a good one. Fred suggested 13, I was at 14, but same idea. Mostly, we want to tame the machine and see where this takes you.
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#8
RE: Newbie. One Week In... poor AHIs
Thanks for the explanations. I'll set the machine to 9 min, 13 max, Flex=1 and see what happens over the next couple of nights.

You'll hear from me again soon...!
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#9
RE: Newbie. One Week In... poor AHIs
I have no expertise to offer here.. only personal experience..

My experience has come to see that "instant improvement" isn't instant. 

It can take some months to start to see benefits, view it as "a work in progress" and be patient.

Small adjustments to settings with time between adjustments to see if they have improved or lessened the effect of CPAP are what is required.

I'm coming up on two years of CPAP use, I have not reached perfection, but I am well within my compliance requirements ( I'm a professional driver ) and I'm sleeping better most nights.

Some nights I have problems with sinus blockages and in the end give up if I can't get it cleared, but for the most part I have most aspects settled with my CPAP use. 

Stick with it, and ask for feedback and suggestions from the group here when you need to. 
Coffee


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#10
RE: Newbie. One Week In... poor AHIs
Thanks, Rocket.  Prior to starting therapy, I naively believed that a CPAP was a guaranteed cure for apnea, and that I'd experience better sleep from the first night.  As I've come to learn, it ain't that simple.  I'm very glad to have found this forum, and am committed to sticking with this as long as it takes to get my apnea under control...  to whatever extent is possible.

Speaking of which...  per the advice I received yesterday from Fred & Sleeprider, I slept last night at 9 cm min, 13 cm max, and Flex = 1.  Here's the result.  To my untrained eye, it looks pretty much like any other night.  I wasn't able to acquire a cervical collar yesterday, so it's no surprise that the positional apneas still seem to be occuring.

   
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