Need Some Urgent Advice

[mdmarmd]

I had always made sure my AHI was < 1 for all these years, at a max pressure of 13, using the AirTouch full face memory foam mask.  It was so stable that in the last year I rarely even looked at my CPAP screen when I turned the machine off in the morning. But in late January I happened to look and the AHI was 20!  I tried to see when this started but unfortunately when I got my new AirSense 10, I didn't bother to move the SD card  over to the new machine, so I couldnt see the past data.  But I put a SD card in and noticed that the Machine had kept the basic data in its memory for about the last month . I could see that there was a dramatic change in AHI starting in the beginning of this January. It started to creep up in December but prior to that it looked like it was pretty much in the <1 range.

I started recording the night's data and had four days to view in the OSCAR software.  The patterns looked bizarre to me and I wondered if it was like a Cheyne-Stokes pattern. But it seems like I would be a lot worse clinically if that was the case.  I did notice that I had some increased memory problems resurface in the last month or two. I have no history of CHF, hypertrophic cardiomyopathy, or pulmonary disease.

I went to Kaiser Sleep Clinic yesterday and only saw a tech.  She didn't seem too concerned but we wondered if the way I used the mask could be a contributing factor.  I use the AirTouch F20 but because I can't stand air leaks, I really tighten the straps, especially as the headgear begins to get stretched.  I switched to online copies because the Resmed headgear stretched out too quickly and easily got to where I couldn't stop leaks even with the straps as tight as possible.  The copies don't stretch very much so I can really tighten them. Probably be too uncomfortable for a lot of people, but I have just adjusted to this over time.  

But now I wondered if the over tightened straps could have actually pushed my jaw and tongue backward over time to where it increased the level of airway obstruction.  Since many remedies try to advance the tongue or lower jaw forward, maybe I am doing the opposite of what would be beneficial.  But my bite doesn't seem askew, though if this is a gradual shift, maybe my upper teeth just slowly accommodated the retrograde movement of the jaw.  Anyway, just a theory since there has been no weight increase to account for heightened obstruction.

Thanks,
Doug
After seeing the sleep tech, I decided I was not happy with her assessment and treatment plan.  She just gave me a trial using the F&P Evora full mask.  It blows like a storm but seems to not leak with much less headgear pressure, so I will continue this for the time being.  She just scheduled me for a follow-up in March.  But I had such severe neurocognitive impairment when I first got treatment that I really don't want to risk waiting for a more definitive answer as to what is going on.  I requested an appointment with a sleep doctor to review these developments and will request a full sleep study when I see the tech next week. (I guess she needed to see me again before refering me to the doctor.)

I haven't been paying much attention regarding my OSA as it has been very stable for many years.  I have never really studied these more complex OSA conditions but I know there are many on this forum with great experience and expertise, so I am reaching out for any advice you can give me. I have attached the limited OSCAR data that I have gotten so far.

[staceyburke]

You are having positional apnea.  You can see positional apnea where either H or Oa events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.

[DaveSkvn]

Doug,

From the OSCAR guide...

"Note: ResMed (incorrectly) labels all periodic breathing as CSR. All Periodic Breathing should be viewed in a zoomed view to identify its properties."

https://www.apneaboard.com/wiki/index.ph...R.2C_PB.29

Without further evidence, I would assume its not true CSR. The rest of the screenshots look dreadful. It would be worth checking that there is not a fault with the machine. Do you feel different to normal? Do you feel the machine behaving differently since the change - do you feel the increased pressure?

If you have access to a recording oximeter, you could give it a try. It would certainly show up all those events.

Good luck

[Deborah K.]

Stacey is right. Your Positional Apnea needs to be corrected before you make any settings changes. Most drugstores offer a few soft cervical collars, and Amazon offers many. You need one that fits around your neck comfortably but not too tightly. It also needs to be high enough to stop your chin from dropping. Lots here like the Caldera Releaf Collar, as it is very comfortable, but you need to make sure theirs is high enough for your neck—others like the Velpeau collars.

[mdmarmd]

Thanks for the input. I hope this is the cause and I have made a change in my sleep position and I want to get a few more nights of data before I post my findings.

[mdmarmd]

I have enough data to report back on my findings.

First, let me say I am relieved that this is not some more serious health problem.

I am surprised that this developed with what did not seem like a sufficient postural change to evoke this rather drastic response.  I have normally slept about 50 % of the time on my back.  The reason for this is that shoulder and hip arthritis tends to make me sore when I sleep on either side.  However, if I get in just the right position—right leg flexed and left leg straight out—I can comfortably sleep on my right side, which I usually did for the other 40-50% of the time.

The one recent change was that I tore my right medial meniscus mid-October and had quite a bit of pain that required me to use crutches for almost a month.  Early on, I had tried to sleep in my usual right sided configuration, but I awoke in the morning with my knee getting increasingly more painful.  I puzzled why this occurred but theorized that when I slept on the right with my right knee flexed, I was partially replicating the action that injured the knee.  With the knee flexed and turned to the right, it would tend to open up the lateral joint space and narrow the medial joint line which is where the meniscus attached.  I thought that as I slept for hours on the right side, crimping the injured meniscus, it was just exacerbating the injury.  The result was that I had to force myself to sleep on my back all the time.  (Turning to the left side also tended to put torsion on the right knee and hurt it as well.)

But lying on my back made the leg hurt if it was laying flat and extended on the bed since the meniscus gets squeezed when the leg is fully extended.  To alleviate this I got a large, inflatable wedge that rose steeply to 15-inch peak and tapered down the distal side.  This allowed my knee to heel and I stayed on my back whenever sleeping.

So, the question is, since I had slept a lot on my back before and had AHI consistently less then 1, why did sleeping on my back now cause such a dramatic change in my airway? I do not think that my neck or back was abnormally positioned now. The only thing I can think of would be if having both of my legs raised entirely above my torso changed the hemodynamics of my system, increasing the flow of blood volume into the circulation of my head and neck that possibly could cause soft tissue congestion leading to positional apnea.

If anyone has a better explanation I would like to hear it.

RESULTS. When I made no other change except to discontinue the use of the wedge, the apnea abruptly disappeared.  In fact, the first night the effect was so dramatic that I thought maybe it was spurious because the AHI was zero, and I’ve rarely seen that.  But subsequent nights seem very normal again.

I have decided to get a collar anyway, since this shows I have some vulnerability to this phenomenon.

           

[staceyburke]

I couple of nights looked much better.  I would make another change after you have stopped the positional problem fixed.

later try the following

EPR set full time
EPR 3

see if that setting is better for you.

[mdmarmd]

So, I'm curious why the EPR would be helpful. I used it years ago, but somewhere in my interaction on the forum I was told I was better off not using it. So, I discontinued it and never experienced any adverse effects. I never really felt the pressure on expiration was particularly uncomfortable. Even when I recently increased the pressure to 15 after the resp tech told me to, I didn't really feel that uncomfortable but I really didn't like the great flow of air from this new mask--F&P Evora . It's a great difference from the greatly diffused ventilatory outflow from either the P10 or the AirTouch F20. I do find this mask seals well with much less tightening of the headgear and my mouth is not as dry--a very welcomed improvement. I may try to make a hybrid and attach a different tube connector that at least swivels because the fixed, downward direction of the tube really tends to get stuck on things.

[mdmarmd]

I had the return of some brief bouts of positional apnea last night. Around 3-5 AM I had a run of AHI and my AirSense read about 10.3 this morning. (The OSCAR read 7.4 so I'm wondering why there is this discrepancy between the two systems?)
I have started trying to spend more time on my left side with my right leg flexed on a foam pad. This puts me in a semi fetal position and perhaps it's easier to tuck my chin down in this position.

I'm waiting for my Coreflex collar to arrive to see if that prevents these episodes. I would still like to know how the EPR can help with this as I am willing to activate it again but just like to understand the basis for how it helps.

Thanks,

Doug

[staceyburke]

We use EPR to help with Flow Limits.  FL are apnea they just do not last at least 10 seconds to be classified as O or H events.  Your machine raises pressure when it finds FL so they do not last and turn into O or H events.  FL causes pressure swings and stops people from getting into deep sleep.


Some people have problems with EPR and IF they do then we would turn it down or off.  But if you are like most people you will benefit with the use of EPR.  Your choice of course.