AHI settling down, advice please on charts

[FrankNichols]

I am a little over 2 weeks into my new machine (AirSense 10 Autoset) running in CPAP mode at 10, most comfort settings off.

This chart from last night is pretty typical of the last week with AHI's ranging from 9.7 to 7.28.

In almost all cases there is a cluster around either going to sleep, waking up or where it appears I am in REM sleep. If I ignore the cluster the AHI is in the neighborhood of 4.5 or so, almost always under 5.

The second chart below shows a couple events and a disturbance in the mask pressure (leak?) which seems to always occur just before the apnea event.

So, I thought it was time to quit pretending I know what I am doing and ask some kind folks who have experience what they think of the chart and what might help improve the numbers.

Thanks in advance for all your help and advice:

[PoolQ]

Thoughts:
1. I may have missed it in another post, but why are you using CPAP?
2. your flow limit activity is quite high and your machine cannot respond to it
3. there are many reasons people go after their numbers, the most important reason is if they feel that something is not letting them sleep and are trying to fix it. Those that are now sleeping well tend to not worry about their numbers, for some it becomes a personal challenge (more power to them).
4. how are you sleeping? Are you trying to get the best possible results? Many would consider your numbers just fine as long as you are sleeping well.
5. normally after an apnea you will see a recovery breathe. I am pretty sure this happens for OA's and not so sure about CA's, someone will chime in. the point is that you don't seem to be doing this and that makes me go hummm
6. the leak right before the middle apnea (CA) looks like a response to the leak, perhaps shifting around and holding your breathe while doing it.

[FrankNichols]

Thank you for the reply!

Thoughts:
1. I may have missed it in another post, but why are you using CPAP?

Since I am just starting I want to go with the doctors recommendation for a while and let my body become adjusted before I play too much. The doctor did emphasize that auto was not indicated for my symptoms. I think he is heading toward a ASV if this doesn't work. He wrote the script for a Elite (CPAP) and the DME game me the AutoSet and I didn't argue with them

I did a few days of experimenting at first (using APAP mode etc) and decided to just slow down and see how it works using my prescription. I think now that the numbers are settling down (initially I was getting swings from AHI of 15 to 30 from one night to the next)

I will get some printouts and go see my doctor this week and see what he thinks.

2. your flow limit activity is quite high and your machine cannot respond to it

Okay, good, what causes flow limit to be high? Leaks?

3. there are many reasons people go after their numbers, the most important reason is if they feel that something is not letting them sleep and are trying to fix it. Those that are now sleeping well tend to not worry about their numbers, for some it becomes a personal challenge (more power to them).

I am still waking 10 to 12 times per night. I am still feeling a bit drugged when I wake up in the mornings. I am only invested in the numbers are a guide to if I am doing things right or if I need to "fix" something - like to start with I had massive amounts of leaks, I made some adjustments and now the leaks are isolated instead of constant.

4. how are you sleeping? Are you trying to get the best possible results? Many would consider your numbers just fine as long as you are sleeping well.

As I said above, I am waking about 10 to 12 times per night. (Arousal wakening) And I am tired in the morning still.

5. normally after an apnea you will see a recovery breathe. I am pretty sure this happens for OA's and not so sure about CA's, someone will chime in. the point is that you don't seem to be doing this and that makes me go hummm

Agreed, thanks, that is the kind of thing I want to learn - how to read and understand whats going on.

6. the leak right before the middle apnea (CA) looks like a response to the leak, perhaps shifting around and holding your breathe while doing it.

Hmm, interesting idea, maybe while flopping around I hold my breath! I will try to pay attention to that. Thanks.

[robysue]

FrankNichols,

Thanks for posting the close up data as well as the overview data.

At this point you're only 2 weeks into therapy, if I read the first post correctly. I'd be surprised if the doc was already talking about an ASV because on the surface it doesn't look like you have a big enough problem with machine scored CAs to warrant an ASV. When they switch a person to ASV for complex sleep apnea (CompSA), the usual guidelines are that the treated AHI > 5 on most nights, the CAI > 5 on most nights, and the CAI makes up at least 50% of the events. You're close to those guidelines, but you're not quite there.

Moreover, that snippet of zoomed in data is interesting in that very large breaths preceed each of the three apneas scored. That kind of breathing pattern can indicate the problem is spontaneous arousals rather than real central apneas. In other words, the breathing pattern looks more like you aroused or had a microwake that was unrelated to your breathing, and then inhaled rapidly and deeply enough to cause just a bit of hyperventilation, which resulted in skipping a breath or two (those apneas only last about 10 seconds), and then the breathing settles back down into normal sleep breathing right away as you go back to sleep. In other words, to my (non-professional) eyes, these events look much more like "post arousal centrals" that might not have been scored on an in-lab sleep test because they don't score normal "sleep transition centrals" on in-lab sleep tests as sleep disordered breathing events.

So if these centrals are very, very typical of the events in the clusters you are talking about, then your continuing probem may be spontaneous arousals or arousals due to things like PLMs rather than too many central apneas.

Did any of your sleep tests mention a large number of spontaneous arousals? And what about PLM arousals? Any mention of them on your sleep tests?

Finally, I'll stick my neck out and offer this piece of advice: It seems to me that you need to concentrate heavily on making sure that you are very comfortable sleeping with your equipment for the time being. You may need to focus more on trying to minimize the number of arousals (of any sort) rather than just focusing on lowering the AHI. If those events really are post-arousal sleep transition apneas, the only way of eliminating or minimizing them will be to eliminate or minimize the arousals that are causing them. And an ASV machine kicking in during a mini-arousal-caused sleep transition central apnea, may just cause you to wake up much more fully and be even more disrupting to your sleep than the original arousal was.

[FrankNichols]

Moreover, that snippet of zoomed in data is interesting in that very large breaths preceed each of the three apneas scored. That kind of breathing pattern can indicate the problem is spontaneous arousals rather than real central apneas. In other words, the breathing pattern looks more like you aroused or had a microwake that was unrelated to your breathing, and then inhaled rapidly and deeply enough to cause just a bit of hyperventilation, which resulted in skipping a breath or two (those apneas only last about 10 seconds), and then the breathing settles back down into normal sleep breathing right away as you go back to sleep. In other words, to my (non-professional) eyes, these events look much more like "post arousal centrals" that might not have been scored on an in-lab sleep test because they don't score normal "sleep transition centrals" on in-lab sleep tests as sleep disordered breathing events.

So if these centrals are very, very typical of the events in the clusters you are talking about, then your continuing probem may be spontaneous arousals or arousals due to things like PLMs rather than too many central apneas.

Did any of your sleep tests mention a large number of spontaneous arousals? And what about PLM arousals? Any mention of them on your sleep tests?

Excellent reading, I seem to have a bit of restless leg, I do not recall if the doctor specifically said I have it or asked if I thought I did. I do know that my legs move a lot when I watch tv etc. and I expect while I am sleeping.

Finally, I'll stick my neck out and offer this piece of advice: It seems to me that you need to concentrate heavily on making sure that you are very comfortable sleeping with your equipment for the time being. You may need to focus more on trying to minimize the number of arousals (of any sort) rather than just focusing on lowering the AHI. If those events really are post-arousal sleep transition apneas, the only way of eliminating or minimizing them will be to eliminate or minimize the arousals that are causing them. And an ASV machine kicking in during a mini-arousal-caused sleep transition central apnea, may just cause you to wake up much more fully and be even more disrupting to your sleep than the original arousal was.

Good advice, actually I am not so worried about AHI right now. As I mentioned above, I played around with Auto the first few days and it recommended pressure around 13 or so (I am not sure, since I really don't know exactly how that works) and I tried it with a CPAP pressure setting at 13 and the AHI went down to around 6.47 with Centrals making up about 50% of them and OA's being only about 15% with Hypos being the rest. The clusters were completely eliminated.

So, I expect once I calm down and get consistent numbers that the pressure can be tweaked and get the AHI lower if that is even necessary.

I see leakage spikes that seem to correlate to my awakenings, and I am trying to figure out if it is the leaks waking me up resulting in flopping around, or if waking up and flopping around is causing the leaks...

Mostly what I am interested in is exactly what you addressed, what is going on and why. I might ask my wife unit to do a sleep study on me and watch me for a few hours one night and record what I am doing (flopping around, moving legs, etc.)

Thank you very much.

[PoolQ]

Basically robysue and I have zeroed in on the same things, with varying amounts of detail and suggestions. Personally I have about the same number of events going on and mine also do not meet the requirement for an ASV, I expect that my doctor has exactly the same arousal concerns regarding ASV that robysue is talking about. He does not think it is a problem, he does not think my CA"s are contributing to my waking up a lot, and he thinks that an ASV might make sleeping worse.

[FrankNichols]

Basically robysue and I have zeroed in on the same things, with varying amounts of detail and suggestions. Personally I have about the same number of events going on and mine also do not meet the requirement for an ASV, I expect that my doctor has exactly the same arousal concerns regarding ASV that robysue is talking about. He does not think it is a problem, he does not think my CA"s are contributing to my waking up a lot, and he thinks that an ASV might make sleeping worse.

Thanks, I expect a at home sleep study using my wife to monitor me is the next step to see if I can find out why I am waking.

I appreciate your help.