Clusters of mixed events - what is causing them?

[TexasTiger]

Thanks to all for getting my AHI reduced - now down to average about 5.0 - would like to get it better with no days over 5.0.  Saw my sleep Doc. & he's ok with where I am but did get him to script a new FFM (on mirage liberty hybrid now and cannot get nasal pillows to stay in even pushing them half way into my nose!). 

Went almost 2 hours one afternoon with no events or large leaks so I know longer periods of good sleep are in there somewhere!  Started at average AHI=9.0 about a year ago with setting for CPAP at constant 9.0 cm. then switched to APAP at 9.0 - 15.0 and AHI went up. 

Tried 10.0 - 15.0 and AHI more than doubled (only tried that 1 night!).  Last settings are 9.0 to 12.0 (no EPR) and AHI averages just under 5.0 with a few nights of about 6.5.  The LL is pretty much under control (hoping to get as close to no leaks as possible)

Most importantly the CA to total AHI was averaging over 50% before the last changes were made and now are down to about 25% with many thanks again to the excellent people on this forum!

I am trying to figure out what is causing the "clusters" of events and make further changes to my settings in hopes of further reducing the events.  It seems that higher pressure caused by events or movement or something else external is starting the whole episode(s) and then it "snowballs" from there.  I need some expert help to try to determine what might be causing the chain of events starting and try new settings.  My first thoughts are that lower pressure is better for me and the ramping up is creating problems?  What do you think a change to 8.5 to 11.5 might do to the events?

Have included a good chart "snippet" as well as some from the clusters of events.  Thanks in advance for helping to solve this question.

http://imgur.com/a/2gpsP

[ajack]

You may not agree, but if it was my chart, I would raise the minimum to 10 to stop the low pressure ones and raise the max to 14. you are hitting 12 with the OA "clusters' and the machine wants to go higher. It may raise the CA for a little while, but they seem to settle for you.

[TexasTiger]

You may not agree, but if it was my chart, I would raise the minimum to 10 to stop the low pressure ones and raise the max to 14. you are hitting 12 with the OA "clusters' and the machine wants to go higher. It may raise the CA for a little while, but they seem to settle for you.

Already tried that - CA's and AHI more than doubled. 
Thanks for the input.

[quiescence at last]

...What do you think a change to 8.5 to 11.5 might do to the events?

it might increase the events, and is highly likely to bump up to 11.5 almost immediately and stay there most of the night.

you have bumped up against 12, and have limited your maximum pressure to reduce your CAs.  I understand that.

It would do you no harm to continue at your present settings for weeks, then sit back and view it.  CAs will probably diminish over the time period (usually takes me 4-5 nights before my CAs diminish to negligible).

If you are still over 5 more than once a week, you might adjust minimum and maximum by 0.5.  (9.5 to 12.5)

good luck

QAL

[ajack]

as you said, one night doesn't count much, I've read you need to give it a week on a new pressure. Obstructives and hypoxemia are treated with more pressure. (leaving aside the help from neck braces to straighten the airways)
I've read for pressure induced CA, it can take a couple of months for the brain to get use to CPAP

[TexasTiger]

...What do you think a change to 8.5 to 11.5 might do to the events?

it might increase the events, and is highly likely to bump up to 11.5 almost immediately and stay there most of the night.

you have bumped up against 12, and have limited your maximum pressure to reduce your CAs.  I understand that.

It would do you no harm to continue at your present settings for weeks, then sit back and view it.  CAs will probably diminish over the time period (usually takes me 4-5 nights before my CAs diminish to negligible).

If you are still over 5 more than once a week, you might adjust minimum and maximum by 0.5.  (9.5 to 12.5)

good luck

QAL

I have been at these settings (9-12 cm APAP no EPR) for about a week now with the results as shown.

I have averaged 8.07 AHI for the first 74 days with this new machine (4th machine - started PAP in 2003) and every day I checked the CA was over 50% of the total events.  I suspect that it was probably the same before that with no one ever checking the results. 

I'm just very fortunate that I found this forum to see why I never felt rested and so irritated.  Last machines were set at 9.0 cm CPAP - same as the first 74 days with this machine.   I do not think that time will bring the CAs down - had lots of time for that already. 

Last time I increased the min. pressure the AHI & CAs more than doubled.

I am going to hold off on changes though to see what ideas everyone comes up with....

Thanks for your input.

Correct me if I'm wrong, but getting the CAs down is probably the most important item to get corrected?

[quiescence at last]

it doesn't surprise me one bit that the CAs doubled.  the change you made was enormous.

I will add this chart, though, to show others how changing settings affected my CA count, and confirm it takes a while for some to recover from pressure induced CA.  See http://imgur.com/GVHK0b0

QAL

ps. others do not get over pressure induced CA, and find they need a more complex device - everyone is different.

[ajack]

"Correct me if I'm wrong, but getting the CAs down is probably the most important item to get corrected?"

one an hour, probably pressure induced by excess o2, or just the brain getting use to cpap. wouldn't and didn't worry me. I found after 2 months they all went away. I don't know if you've seen sweetpea's charts, but she is showing high CA and I would be seeking further investigation there.

[TexasTiger]

"Correct me if I'm wrong, but getting the CAs down is probably the most important item to get corrected?"

one an hour, probably pressure induced by excess o2, or just the brain getting use to cpap. wouldn't and didn't worry me. I found after 2 months they all went away. I don't know if you've seen sweetpea's charts, but she is showing high CA and I would be seeking further investigation there.

Yes, I have seen sweetpea's charts and I agree that she has way too many events.  Just two weeks ago (before sleeprider's excellent help) I was running over 100 CAs a night plus they were well over half of the total events (which sweetpea's charts are less than half).  Keeping the max. pressure lower made all the difference in the total events and the makeup of the events. 

I believe the A-Fib that I now have has been caused by the PAP machines and the improper settings (onset of A-Fib was about 18 months ago).  So far any upward change in pressure has caused the CAs to increase.  I definitely do not want to create any more A-Fib problems. 

Almost every post I read the first option is to increase pressure as if it can force the event to go away.  I believe that there are other causes that start this whole vicious group of mixed events and am seeking some insight to hopefully stop the start of the events.  I know for one for sure that pressure will induce CA events.

[ajack]

I'd hate to count the number of times you were told to turn off the EPR because it can cause clear airway apnea. I'm glad you finally did.

Either the clear airways are harmless pressure/o2 or the brain getting use to cpap that can take up to 3 months, I read. or you are seriously ill. See a doctor if you are concerned. Given that cpap doesn't treat central apnea diseases, my money is on the harmless clear airways