[CPAP] Sudden spike in AHI

[Airo]

Hey guys,

I would love it if you could look at these graphs and give me any suggestions, because my therapy seems to be going downhill and I don't know what to try now.

I've been diagnosed with apnea in september last year and have been using CPAP ever since. After the initial scare, getting used to the machine and trying some different masks I settled on the awesome dreamwear mask and all went quite well. During the whole winter/spring I had AHI's of 0,5-1,5 with a maximum of 3-5 on bad days. Quite good right?

Now despite not changing the settings or anything suddenly my AHI spiked, it's 10-15 now regularly and even on the good days it's still 3-5. So quite bad. I also feel horrible on these days.

Here are the graphs I think are most relevant:
   

Some possible causes:
- i lost a lot of weight since half May, about 15 kgs so far, can this be a factor? doctor at sleep center thinks it would only improve AHI and could not cause this.
- Average median, 95% and max pressure seem to have decreased compared to this winter. Don't really know why, could it be the reason for the increased apneas? and if so why is it decreased?
- Minute ventilation also decreased
- Season? this is my first summer using cpap and it has been particularly hot & dry, but for last 10 days temperatures are better and it's raining again and scores have not improved
- Related to that I first tried to decrease humidifier setting on CPAP machine for a night, from 5 to 4, since that was a bad night as well next night I increased it to 6, that gave me some reasonable days (but not great) but that would also just fit into the random pattern. And since doctor also increased pressure some really bad scores happened again. Also having humidifier this high causes a lot of condensation, even though it's the middle of the summer, I have a heated hose at 27 degrees (more really feels uncomfortable) and even a cover over it. Must be impossible in the winter.
- Dreamwear problems? Has quite some leakage, never really above the threshold for long but still.
- Mouth breating? I tried sleeping with the HORRIBLE HORRIBLE chinband I also used in the first month of therapy, for the last couple of days, but scores were still bad. Maybe I could make it tighter though leak graphs  don't show any increase of leakage though.  
- Something with my nose blocking/being too dry? i breathe through my nose without problem when i have the machine on and am awake, but after i wake up it often still feels my nose is 'stuck' somehow, although not really blocked. Hard to explain. Anyway have been to ENT specialist when starting CPAP and he looked at my nose and said nothing was blocking it, and i use budesonide nosespray before sleeping. So I have a feeling ENT specalist will just laugh at my face if I go back with such a vague story.

Now I had an extra appointment with a doctor at the sleep center last monday. Got a doctor who I never had before and she didn't show much concern 'you're looking too much at the numbers', 'anything average under 15 is fine really and you still have an average of 1 over the last half year', 'maybe you score is so high because you're too concerned about the numbers, stress is proven to increase AHI'. Still she increased the min. pressure from 7 to 8 and the max pressure from 12 to 14. But as you can see in the graph that doesn't seem to have solved it.

So do you guys have any idea how to get out of this? I'm quite desperate since it all seems so vague 


any ideas of what's happening / what i can try to fix / what i can try to rule things out?

[Sleeprider]

Airo, it would help if you would post a detail graph typical of what is going on. The summary overview shows CA events seem to have begun in late May and this was accompanied by a decrease in median and 95% pressure output. More recently we see some mixed apnea, but OA seems to be predominate, so the increased pressure suggested by your doctor makes some sense. Part of the reason I'd like to see the detail graph is to see your EPR and correlation of events to pressure, leaks, flow limits and other things.

I'm not a fan of chin straps because they tend to pull the jaw back. If the OA occur in clusters (detail chart again), then we might try a soft cervical collar or some other way to keep you from tucking your chin towards your chest. I can only speculate with the overview chart, but would be glad to help understand the details.

[mesenteria]

...

I'm not a fan of chin straps because they tend to pull the jaw back...

I was not aware of this issue, not having attempted to use a chin strap to date to stop me lips from flappin'...which they certainly do if I don't tape.  I am surprised those who craft the chin straps don't provide a 'sling' pouch that nests around the corners of the lower jawbone and draws it both upward and forward.  Would be simple to do. Maybe not comfortable though, with the force it would take at that small location.

Anyway, back to the topic...

[Airo]

Yeah but why now, I have been doing perfectly fine for 6 months without a chinstrap or a cervical collar or any other claustrophobic torture device. Why is it all fucking up? What can I do to go back to how it was?

That's why I posted the long-term graphs, because of the change.


Anyway, here are some details of particularly bad days, there's quite some clustering, but my apneus have usually come in the form of clusters, also in winter/spring when everything was going well,it was just never that bad. (it has the date in the attachment title so you can correspond them to the overview graphs)

                   

---

   
and one more

are these the right ones or do you need anything else?

[Airo]

Put on the chinstrap extra tight tonight, dreamwear is also a lot tighter with chinstrap underneath it, this has resulted in minimal leakage but still a 9.12 ahi and 6:00 I woke up so frustrated and couldn't go back to sleep anymore even though I have this endurance race today

I  guess humidifier goes back to 5 because the higher humidification isn't helping anyway and it gives too much condense, i'm also raising minimum pressure to 9 for next night but I'm still just blindly throwing darts in all directions

   

[Apnea Infant]

Hello Airo

Welcome to the ApneaBoard.

Congratulations on your weight loss-15kg is a phenomenal amount to lose and will definitely have changed the shape of your face. Is your mask still feeling like it is the right fit? Have you thought of changing your mask? However looking at your overall stats, the leak amount has not reduced since you started when your numbers were good. Despite this I would give this serious consideration as this would impact on your therapy. I do not know the dreamware mask but most masks have a silicone part which has to be replaced with time. Have you investigated that?

When I started on my journey, EPR helped in getting used to wind blowing. However this was causing clear airway events which were reduced almost completely but slowing reducing EPR from 3, 2, 1 and then 0. Try that but slowly, ie a week at a time.

There are large clusters in your charts signifying in all probability that your chin drooped and caused obstructions. You have confirmed using the chin strap helped with this. Also consider the tongue suck technique, ie pressing your tongue against the roof of your mouth-it serves to close the mouth to stop air coming through.

Also click the triangle in the calendar to omit it so as to allow for more stats to be shown.

The best to you.

[Airo]

Thanks Apnea Infant!

Health insurance in my country is only covering mask replacement once a year, but I don't think it's a leak issue. These last 2 days I've been sleeping with chin band and because dreamwear is on top of that it's extra tight, and it is hardly reporting any leaks but still scoring an AHI of 10, and even before that leak averages are not above what they were in the good period.

Gonna try turning off the pressure relief although my resmed 10 only has the settings on and off.

You have confirmed using the chin strap helped with this.

huh no? i used chin strap last two days but results are still bad

[Airo]

Turned off pressure relief but didn't fix it, days in between were kinda average-bad with scores of 3-5 but today was horrible again. Still no one with any idea of what caused the sudden change?

I guess I should try one of the collars. I saw this one come highly recommended:
[commercial link removed-- instead, search Amazon for "Caldera Relief Neck Rest"]
but what size do I need? also for standard medical ones

   

-----
Moderator Action: Link Removed

To maintain our status as an educational organization, the only commercial links allowed in this forum are to CPAP-related manufacturer websites. This is stated in the Apnea Board Rules with details given in the Commercial Links Policy section.

-----

[Airo]

You guys were not able to help but in case someone with the same problem stumbles upon this thread I thought I would let you know that I managed to fix it!
In summary: lowering the lower pressure solved it

Problem case: After a very successful first half year on CPAP with very good scores suddenly I started to get higher AHI's with peaks of 8-15 AHI even though I had not changed settings or gear.
Solution: lowering the lower pressure from 7 to 6
Explanation: (well my theory at least) Weight loss (25 kilo by now) and increased physical fitness because of sports (lower rest heart rate and such) caused less oxygen requirements during sleep, and because the machine was pumping in air at such powers, I think my breathing became very passive, causing the apneus. This is backed up by a decrease in average minute ventilation scores: max from 30L to 20L, median from 8-10L to 6-7L.


Whole story:
First I lowered pressure from at that point 9-12 (7-12 at the start of the problems) to 6-10 at suggestion of the sleep clinic, although they said it was basically a gamble 'we tried raising it and that didn't work so let's try this'. I had some good days but at that point I didn't really have the feeling anything was fixed, because I still had some very bad days, including one with an 18 AHI.
After another visit to the clinic the doctor and technicians there were without a clue, and the doctor wanted to raise the pressure again to the original 7-12, since both increasing it and decreasing it had not solved the problems and then basically wait things out. I agreed with bringing the upper pressure back up, but suggested we keep the lower pressure at 6, because the only reason it was at 7 at the first place was because 6 made me feel like I was not getting enough air when I started CPAP treatment, but I didn't have that any more, and I thought the lower the pressure the better, and I did have the feeling it had maybe slightly helped, since I did have some good days. Anyway, I didn't go home too optimistic...

And then... It was solved
Lowering the pressure to 6-10 probably already solved the original problem I was having, but caused a new problem because the upper pressure was not enough to stop apneus in bad periods.
The combined lower low pressure of 6 and original max pressure of 12 solved everything!

After that I didn't have a single really bad night any more! It's been 6 weeks now

I did experience some true mouth leakage (short periods of large leaks showing up at sleepyhead that were not there before, extremely dry mouth when waking up, sometimes feeling of air blowing out between my lips as I was in a stage between awake and sleep). I now know that before that I never mouth-leaked before. It often happens at moments after the pressure just increased, I guess the difference between 6-12 is quite big and the mouth opening is a response to that. Still scores were good again and mouth leaks were only short periods so I left things be for about a month (+2 weeks delivery time). Now I got a neckband and the last three days were large-leak free with scores of 0.00, 0.66 and 0.18

[ario]

You guys were not able to help but in case someone with the same problem stumbles upon this thread I thought I would let you know that I managed to fix it!
In summary: lowering the lower pressure solved it

Problem case: After a very successful first half year on CPAP with very good scores suddenly I started to get higher AHI's with peaks of 8-15 AHI even though I had not changed settings or gear.
Solution: lowering the lower pressure from 7 to 6
Explanation: (well my theory at least) Weight loss (25 kilo by now) and increased physical fitness because of sports (lower rest heart rate and such) caused less oxygen requirements during sleep, and because the machine was pumping in air at such powers, I think my breathing became very passive, causing the apneus. This is backed up by a decrease in average minute ventilation scores: max from 30L to 20L, median from 8-10L to 6-7L.

Whole story:
First I lowered pressure from at that point 9-12 (7-12 at the start of the problems) to 6-10 at suggestion of the sleep clinic, although they said it was basically a gamble 'we tried raising it and that didn't work so let's try this'. I had some good days but at that point I didn't really have the feeling anything was fixed, because I still had some very bad days, including one with an 18 AHI.
After another visit to the clinic the doctor and technicians there were without a clue, and the doctor wanted to raise the pressure again to the original 7-12, since both increasing it and decreasing it had not solved the problems and then basically wait things out. I agreed with bringing the upper pressure back up, but suggested we keep the lower pressure at 6, because the only reason it was at 7 at the first place was because 6 made me feel like I was not getting enough air when I started CPAP treatment, but I didn't have that any more, and I thought the lower the pressure the better, and I did have the feeling it had maybe slightly helped, since I did have some good days. Anyway, I didn't go home too optimistic...

And then... It was solved :)
Lowering the pressure to 6-10 probably already solved the original problem I was having, but caused a new problem because the upper pressure was not enough to stop apneus in bad periods.
The combined lower low pressure of 6 and original max pressure of 12 solved everything!

After that I didn't have a single really bad night any more! It's been 6 weeks now :)

I did experience some true mouth leakage (short periods of large leaks showing up at sleepyhead that were not there before, extremely dry mouth when waking up, sometimes feeling of air blowing out between my lips as I was in a stage between awake and sleep). I now know that before that I never mouth-leaked before. It often happens at moments after the pressure just increased, I guess the difference between 6-12 is quite big and the mouth opening is a response to that. Still scores were good again and mouth leaks were only short periods so I left things be for about a month (+2 weeks delivery time). Now I got a neckband and the last three days were large-leak free with scores of 0.00, 0.66 and 0.18 :)

This is FENOMENAL, thank you so much for posting and keep updating it with the solutions!!