RE AHI Increased with V-Com

[Swifty]

I have been stuggling with mouth leaks since I began using my CPAP last November.  I have every current nasal pillow mask by F&P, several Resmed and currently using the Dreamwear nasal pillow mask.  I have tried Resmed F-20 full face mask and have has some luck with the F&P Evora hybrid.  I recenly read about the V-com device and tried it for the first time last night.  My ideal pressure is usually around 10.5 to 11.  I set the Resmed 11 to CPAP with 11 pressure, used mouth tape, and found it uncomfortable to inhale and more difficult to exhale. My AHI was not bad at 2.16 put the RE events appeared to occur all night.  Please see last nights Oscar results.

[Old Steve]

Welcome to the forum.

I have never used the V-com.  That being said the chart you posted has more than a V-Com problem.  First why did you raise your minimum pressure?  It is my understanding that the V-com lowers your minimum pressure about 1cm.  So why would you raise it to have the V-Com lower it 1cm.  You would be right back where you started.  Next problem, it appears that you are having positional apnea, this shows up on the charts as apnea clusters.  You need to get off your back, onto your side, or get lower pillows, or perhaps a soft cervical collar to keep your airway straight. (see more info on cervical collar below). Also, see the link below for much more info on Positional Apnea. You leaks, are quite high, not so high that the machine cant handle them but, high enough to cause arousals.  Your flow limits are almost off the chart, have you tried EPR?   EPR lowers your exhale pressure up to 3cm and helps with flow limits, I think that it will work okay with the V-Com. 

 Although, For now I would remove the V-Com, put your machine in APAP mode, set your minimum pressure back to your 10.5cm or 11.0cm, and a maximum pressure of 16cm.  Then set the EPR to 3 full time.  Try these setting for a few days and post some more charts.  When you do post new charts please remove the calendar so we can see more of your information.  Either I or someone else on the forum should be able to help with your therapy once we see your new charts at the new levels in APAP mode.  Good luck.

[Swifty]

Welcome to the forum.

I have never used the V-com.  That being said the chart you posted has more than a V-Com problem.  First why did you raise your minimum pressure?  It is my understanding that the V-com lowers your minimum pressure about 1cm.  So why would you raise it to have the V-Com lower it 1cm.  You would be right back where you started.  Next problem, it appears that you are having positional apnea, this shows up on the charts as apnea clusters.  You need to get off your back, onto your side, or get lower pillows, or perhaps a soft cervical collar to keep your airway straight. (see more info on cervical collar below). Also, see the link below for much more info on Positional Apnea. You leaks, are quite high, not so high that the machine cant handle them but, high enough to cause arousals.  Your flow limits are almost off the chart, have you tried EPR?   EPR lowers your exhale pressure up to 3cm and helps with flow limits, I think that it will work okay with the V-Com. 

 Although, For now I would remove the V-Com, put your machine in APAP mode, set your minimum pressure back to your 10.5cm or 11.0cm, and a maximum pressure of 16cm.  Then set the EPR to 3 full time.  Try these setting for a few days and post some more charts.  When you do post new charts please remove the calendar so we can see more of your information.  Either I or someone else on the forum should be able to help with your therapy once we see your new charts at the new levels in APAP mode.  Good luck.

[Swifty]

Steve, Thanks for the reply.  I increased the pressure to compensate for the pressure lost with the V-com.  Prior nights my pressure was set between 10 and 11 with epr set at 3.  I tried to keep the pressure within a tight range as the higher pressures caused greater leaks.  Please see the prior three days.

[Old Steve]

Do you have any charts for the nights that you were at 3 EPR that you can post.  Can you also post your sleep test with your name redacted.  You should also turn off the ramp, you have been using CPAP long enough that you should not need it.  Try the new settings, work on the leaks, one of the nights you spent 48% of the night over the limit that the machine can compensate for.  When this happens you get almost zero therapy and it skews your AHI readings also.  Try the new setting for two nights then post the new charts along with your sleep test.

[ejbpesca]

I see your pressure line maxing out.  Your median (Med under Statistics) pressure is a tad below 11.  I would raise the min pressure to 11 and max to 18 to see if that gives more effective therapy and head space for your APAP to rise up.

After a time with those settings your Max pressure may be lowered to tighten the gap between min and max.  Right now the machine is hitting max with nowhere to go.  I have had success with this by raising my min. pressure to the Med pressure as shown under Statistics.

Getting leaks under control is essential for therapy.  I see you have leak issues and of course the more pressure the more leaks can occur.  Run the mask fit test.  Move a bit and twitch mouth and nose.  Adjust the headgear's position and strap tension until no leaks happen.

That does not take care of mouth leaks though.  Some tape their mouths for that and/or use a mouth appliance to keep the mouth closed.  Others use chin straps and/or cervical collars.  I had to give up on all those and stick with full face masks as was prescribed by my sleep study.

I tried Evora FF hybrid which was a welcomed change to the ResMed F20 then found the F40 which is even better.  I like its flexibility, light weight and the fact it is not over my nose but under it.  It does not leak much for me unless I move enough during sleep that loses the seal.  As long as I am side sleeping it works extremely well but when I roll to my back (which I cannot control) I begin to mouth breathe and that's when the F40 hybrid's mouth covering is needed.  I tried chin strap/tape/collar/mouthpiece and all failed so I have to use a full face mask to maintain therapy.  I think there are a few other "hybrid," masks and one may be what helps you best without having to go to the hassle of tape/collar/chinstrap/mouthpiece.

So, if that were my OSCAR report I would:
1. increase min to 11
2. increase max to 18
3. run mask fit test with the Evora FF and adjust it until leaks stop
4. keep checking OSCAR for results
5. consider the F40

Goals:
1. Get Large Leaks down to very few or preferably none.
2. Keep Leak Rate down to below 24 (you are right at that threshold)
3. Discover what sleeping positions are affecting your therapy and how they are affecting airflow

On positional apneas:
For some a sleeping position may be closing off the airway beyond what PAP therapy can resolve.  With head lowered the airway may be pinched off like bending a garden hose to stop water flow.  Cervical collars are many times used to address this problem

In my example the position of sleeping on my back allows gravity to collapse tissues causing obstructional apneas and PAP pressure keeps the air flowing well with few events.  When roll to go to back sleeping I begin to mouth breathe and events start.  This problem is often recognized in clusters of events on OSCAR.  Some prevent on back sleeping by gadgetry but those failed for me as well so I'm stuck with full face masks.

What helps me to use a FF mask is to use a very thin pillow.  My head lies on the right edge of the pillow as I sleep on my left side so the mask it barely touching the pillow. A thin pillow can also help with sleeping on the back by not lowering the head down so much.

My OSCAR reports are not wonderful but with what I've mentioned here I keep my AHI below 5.00 and get most reports between .70 and 3.50.  If I get high leaks the AHI is up with it.  I sometimes have to tighten straps to beyond comfortable to get a good seal as the mask cushion ages.  I cannot get more than a month out of one without the Large Leaks and the Leak Rate going up.

[Swifty]

Thank you!  I have been trying for weeks to use nasal pillow masks (p10 and Nova Micro) with mouth tape and still cannot beat the mouth leaks and I think jaw drop.  I tried different brands of mouth tape (Hostage and PapMD) and then Ckeep Kinesiology tape from Amazon, cut longer than the name brands for a better seal.  The Ckeep stops the mouth leaks but is tough to remove.  Last night I switched to the Evora Hybrid, with tape, and had a bit better success.  I have the Resmed F40 and will try it tonight with widening out the changed settings.  Last nights screen shot attached. The first part of the night was with the P10 and then the Evora.

[ejbpesca]

I find something very confusing about your pressure graph.  It only shows the EPR pressure green line slammed to the top for over an hour then the red line shows up about 40 minutes after midnight.  At that point, you see your Red APAP pressure line and EPR pressure Green line on the graph.

An expert may leave a post at any time to possibly explain how the EPR pressure green line hit the top of the graph and stayed there for an hour or so.  What was going on with your mask and machine from 10:45 pm until 12:37 am?  It the Vcom leaking?  Is it secure?

If it were my machine I would raise Max pressure to 18 to see where it goes because once the Red line showed up it is still hitting the top trying to go higher but you have it limited to 12 max.  18 max will allow the APAP machine to raise pressure.  It can be lowered later as the best settings are found.

You had a stop/start at 2:00 am. Once started therapy went okay with 4 events flagged over two and a half hours.

[Swifty]

The chart shows the time that I used V-com without EPR, as advised and CPAP pressure one higher than typical average, also advised. After obviously not doing well I took the v-com out of line and turned EPR back on and switched from p10 to Evora hybrid for the remainder of a very bad night.  Again, struggling since November and grasping for straws!

[ejbpesca]

I do not know what a Vcom will do to pressure readings on OSCAR.

It would be great to get an OSCAR report here with no changes of vcom/mask/EPR during a night's sleep session.  Please post one.

Have the max up high enough to not peg out at the top of the graph.  20 is high as it goes. Set min. as suggested for PAP therapy and let that ride for a few nights using the same mask and no Vcom.  Jumping around between devices and settings disturbs sleep and I think doesn't let OSCAR report properly.  

After a few nights, OSCAR will tell how well the therapy is going.

Or...What were the pressure settings as prescribed by your Sleep Study?  That is a place to start with no vcom, get adapted to a mask that doesn't leak badly, and take it from there.