Apnea More Severe; Prescribed Pressure Decreased

[fwg1947]

fwg1947,

You said you were going to bump the pressure on the new machine back up to what you were using on the old machine last night.  What do last night's numbers look like?

The AHI is much better, down to 0.86 compared to 5.34 for night before last (the last night with pressure set at 7). 

There is a discrepancy between the SleepyHead report and Encore Pro concerning leaks.  Sleepyhead reports 'Time Over Leak Redline' of 9.798%, but Encore Pro and DreamMapper.com report zero large leaks and 100% Mask Fit.  I don't know which is correct or whether this is something to be concerned about.

Most of my Daily Reports are showing periods of Periodic Breathing, but I don't know if this is something to be concerned about.

Here is the Daily Chart for 7/14/17, the first night with pressure increased from 7 to 9, and the best night I have had since starting on the new CPAP machine on 5/31/17:
http://imgur.com/zWtZytr


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Here is the chart for 6/27/17, at altitude > 7000 ft.  This was the worst night I have had since starting on the new CPAP machine on 5/31/17:
http://imgur.com/v5JiUCH


[img][/img]

[CB91710]

Normally, I'd say that 7 is too low for any adult... that level is barely theraputic, but coupled with your high CAs I'd be concerned that you have complex apnea and may need an ASV machine.

But you saw improvement at 9... while higher pressure often causes CA to increase, you're looking ok there.
Personally, I'd bump that to 10 or 11 and bring the EPAP up to 9 (it is the EPAP that supports the tissues during exhalation).

Interesting that you had such a dramatic change with elevation... mine changed very little (actually improved) on vacation in Las Cruces, Austin, Amarillo, and Flagstaff.

[ajack]

you certainly don't like altitude. are you self funded or on insurance with limited copay? The odds are you are going to need an ASV or full ST vaps ventilator at altitude. Your tidal volume is down, it may be because of a nasal mask and leaks, but it needs to be sorted, as to the cause. a COPD or obesity?

When you are on the flats, I'd add 1cm to the pressure for the snores and see how it goes.

[robysue]

There is a discrepancy between the SleepyHead report and Encore Pro concerning leaks.  Sleepyhead reports 'Time Over Leak Redline' of 9.798%, but Encore Pro and DreamMapper.com report zero large leaks and 100% Mask Fit.  I don't know which is correct or whether this is something to be concerned about.

The SleepyHead "Time Over Leak Redline" is from Resmed's definition that an official Large Leak is any unintentional leak that is above 24 L/min.  The PR machines do NOT calculate Large Leaks in the same fashion and I would just discard the SH "Time Over Leak Redline" number. The SH Leak number that would correspond to a number on the Encore Report is the Large Leak % that is in the daily summary data; it is usually between the line for Periodic Breathing (or CSR) and the line for CAI.  That Large Leak % is based directly on the data that is flagged by your PR machine as an official Large Leak.

Most of my Daily Reports are showing periods of Periodic Breathing, but I don't know if this is something to be concerned about.

How much PB?  And do you have any history of heart disease?

Here is the chart for 6/27/17, at altitude > 7000 ft.  This was the worst night I have had since starting on the new CPAP machine on 5/31/17:
http://imgur.com/v5JiUCH

Given that you do not LIVE at this altitude, I don't think you are going to qualify for an ASV machine: At 9cm when you are at the altitude that you live, your apnea is well controlled.

However, since you do regularly visit family living at high altitude, you ought to show your sleep doc the data recorded at high altitude on this trip and ask him what, if anything, you should consider doing when you are visiting family who live at high altitude.

[robysue]

Normally, I'd say that 7 is too low for any adult... that level is barely theraputic,

Please don't assume that everybody is uncomfortable at very low pressures. In my case if my EPAP is at 7 all night, I wake up with what feels like a basketball in my stomach and in severe pain from the aerophagia.

Indeed, I barely tolerate long periods of my EPAP being at 6 (my max EPAP) without it triggering aerophagia disturbances to my sleep. And I'm far more comfortable getting to sleep at 6/4, 7/4 or 8/4 than I am at getting to sleep at even 8/5 or 8/6.

[fwg1947]

Quote:

Most of my Daily Reports are showing periods of Periodic Breathing, but I don't know if this is something to be concerned about.

How much PB?  And do you have any history of heart disease?

Robysue,

The SleepyHead Periodic Breathing Overview Chart for the past 46 days shows minimum PB 0.00%; median PB 3.78%, and maximum PB 38.03%.  The highest numbers were at high altitude, but I have varying amounts on a regular basis at home, usually between 1% and 10%.  For example, 3 nights ago it was 1.11%; night before last it was 7.59%, and last night it was 3.44%.

I do not have a history of heart disease.  Cardiac problems were suspected in 2015 due to symptoms later determined to be non-cardiac related.  At that time I had EKG, echocardiogram, stress test and heart catheterization.  The conclusion from all those diagnostic procedures was "minimal coronary artery disease" and no cardiac treatment was performed.

[robysue]

fwg1947,

Given that you don't have a history of congestive heart failure, my guess is the PB at home is nothing to worry about, but it is something you might want to mention it to the sleep doc the next time you see him/her.

The night at high altitude with 38.03% PB was probably on a night when your CAI was also through the roof.  Clearly there was something in the combination of being at high altitude and at 9cm of pressure that messed badly with your body's CO2 regulation.  Hopefully it was something that can be managed by NOT increasing the pressure on your machine the next time you are at high altitude.

[ajack]

+1
some PB is perfectly normal.

[fwg1947]

Thanks robysue, ajack, CB91710, bonjour and Sleeprider for all the information and advice.  I feel like I have a much better sense of what to watch for and how to evaluate the SleepyHead charts.