AHI tweaking help needed

[rlchau]

Hi, this is my first post. I am a new member (July 2019).
I’m looking for tweaking help to achieve better results than what my Lung Specialist/Respiratory Therapist seem to be happy with, that is, to obtain median AHI’s ≤ 10.
A few facts:
·       I had a myocardial infarction March 14th; doing well, 2 stents; minor damage, my % of infarction is in the 45-50% range.
·       I asked my cardiologist to be tested for apnea despite my low Epworth test result of 2/24; he agreed and got home tested March          31st, 2019; result: severe AHI of 36.2; No significant blood oxygen desaturation.
·       Spent 55 days with a Respiratory Therapist with basically no experience. no significant results; I changed firm.
·       Been with another firm for 40 days now; titration completed; on a BPAP therapy since July 17th.
·       ResMed AirCurve VAuto – min EPAP 14, max IPAP 25, Pressure Support 4, full-face ResMed AirFit F20
·       First 2 days on BPAP, with same EPAP/IPAP but PS of 6: results of 9.6 and 8.5 AHI with too many central apneas (respectively 4.9   and 5.8 central apneas)
·       Therapist changed my PS to 4 with better results for roughly 1 month as follows: median AHI’s  of 4.1 (day 1-7), 4.3 (day 8-14), 3.8(day 15-21)  and 4.5 (day 22-28); I thought: “mission accomplished” but…
·       Now getting worse last 14 days; median AHI’s of 7.0 (day 29-35) and 7.0 (day 36 to 42)
·       Therapist/Lung Specialist don’t want to make other adjustments; they say AHI ≤ 10 is good and that was the objective!
·       I’m attaching two documents:
   o     Spreadsheet in PDF format of daily data since July 17th (date started on BPAP therapy)
   o     OSCAR image August 23rd (typical day lately)
Thanks in advance for your help!


  For Apnea Board.pdf (Size: 39.37 KB / Downloads: 289)
   

[Melman]

Note the clusters of obstructive events starting around 1:50 and 2:50. They are probably due to tucking your chin to your chest. If such clusters show up on othr nights I suggest you try a soft Cervical collar available from most large pharmacies or amazon. It is worn just tight enough to prevent you chin from tucking behind it. It's worked well for me and many others.

[mesenteria]

About the CA's (central apneas):

Many times CA's are not present up to the time of onset of treatment.  Then, they emerge as an artefact, and we call them treatment emergent CA's. They almost always diminish or disappear entirely with time, but occasionally we find that 'pressure support' (PS) is the problem.  

You don't have many, and not enough to warrant concern immediately...PROVIDED they aren't too long.  When you hover your mouse cursor over each event in that top chart, you'll see how long each of them is.  You'll find many less than 15 seconds, often the machine just assigns them the initial 10 seconds.  I have some disagreement here with some members over these, but I treat them as innocuous...personally.  If they become more frequent, and certainly if they creep up into the 15+ second range, now they're becoming intrusive, possibly harmful, and certainly noteworthy.

The point is, for now, disregard them if they are of short duration and if you only get two or three each night.  If they persist, get longer, or increase in density in your charts, you may be advised to reduce PS.  We'll see.

[sheepless]

what Melman said. going strictly by the chart in post #1, ca isn't an issue (just 1 event) but clusters of oa are. judging by your pdf table, your current settings appear to have managed ca reasonably well. but your oa, especially the clusters: your epap is already high at 14cmw; you may be able to tolerate higher but I second Melman's suggestion to try a soft cervical collar. it might be easier to tolerate than higher epap and would likely be as - if not more - effective in bringing your oa and ahi down a fair bit. if you want to experiment, try both (collar, higher epap), one at a time.

[rlchau]

Thanks Melman... well noted... will certainly give it a try with the collar.  More often than other times, I have those clusters and also more often than other times in my first sleeping cycle.

[rlchau]

Thanks Mesenteria, I don't have many CA's anymore... in the range of 1-5 max per night (and often none) with short duration, in the range of 12 minus seconds. I got lots the first two nights I started to use my BPAP with a PS of 6 .. not an issue now with PS 4

---

Thanks Sheepless, will do.

[Sleeprider]

You are in good hands here. The observation by Melman is most likely going to lead to your solution. Melman came to the forum with very similar patterns of clustered obstructive apnea at even higher levels of AHI than your own. He tried the soft cervical collar and had an amazing reduction in events. I think over time, he was able to achieve good results without the collar, but he has been there, and is well qualified to coach for these circumstances. We have a Wiki article that discusses this. Take a look at Optimizing Therapy in my signature links, and go to the "positional apnea" section.

[Melman]

I still use the collar. AHI seldom exceeds 0.5. I never found it very uncomfortable and now hardly notice it.

[rlchau]

Sleeprider, Melman.. thank you.  I went right away to my pharmacy when I first got the reply from Melman yesterday.  When I picked up the box, I read the instructions and got a little nervous reading the following: "A patient wearing a soft collar should always follow the physician’s directions. Failure to do so or to use in any way other than prescribed can result in damage to nerves, tendons and muscles." I then talked to my pharmacist wanting to know what those prescribed directions were about. I told her what my intended usage was without even referring to that warning. She strongly discouraged me from using a collar on an ongoing basis based on similar recommendations. Melman, how long have you been wearing your collar? Any issues?

[Melman]

I've been wearing it for a little over 2 years. No issues at all.