Need assistance to break through the 5 AHI wall

[RonICrumpins]

        I started on the CPAP journey in September 2021 and didnt follow through as well as I should have. Fast forward to the end of 2023 and I'm back on the CPAP wagon. I've been casually visiting sleep apnea subreddits and trying to review my own OSCAR data to help me see some better nights but have hit a wall so to speak. I was at the end of April/early May able to get down to 5 and below AHI. Within the last two weeks I have stopped drinking alcohol and now cant get out of a 6-12 AHI Range.

Use a full face ResMed F20 (tried the F30 and didnt like it. I do snore and mouth breath frequently so have yet to try a nasal mask). Typically sleep on back, sometimes side. Male - 5'10", 230lbs. 

Would love to hear some tips that will help me cross this 5 AHI threshold.

[SarcasticDave94]

Welcome to Apnea Board,

Do you happen to have your detailed sleep study? If not, you'll want the detailed version. Or in a request with the prescribing doctor. US HIPAA says you can get the report for asking. You should post it redacted of personal info. My concern is the Central Apnea shown.

Leak rates are pretty consistent which can be hindering your success.

Also there's signs of Positional Apnea with the clusters of both Obstructive and Central Apnea. Maybe they're both tired together, but not certain.

Flow limits are up as well, but to address those, CA may increase.

[Deborah K.]

Did you have a lot of CAs in your sleep study?  Seeing your sleep study will help, but maybe you can answer this somewhat.

Do you have EPR turned on full-time, set to 3?
 
Are you using ramp?  

Answering these will help us help you.  Positional apnea is when your chin drops toward your chest and causes your throat to narrow, somewhat like a kink in a hose, limiting the air moving through your airway.  To solve this you most likely need to buy and wear a soft cervical collar.  You can get one at many drugstores or from Amazon.  PA shows up on your chart where Os and Hs are clustered together. You have lots of these. Controlling them will drop your AHI significantly.

[RonICrumpins]

Hi Thank you for the replies. I havent been able to track down my sleep study results so I have requested those from the clinic. 

Right now I have EPR off and no ramp. Will update with sleep study when I receive it. Definitely interested in trying the soft cervical collar.

Thank you.

[Phaleronic]

Welcome to the forum Ron, the other two replies from Deb and Dave are good, I would raise you min pressure to 12cm and turn EPR on to 2 for now-also as Dave stated there are some CAs but they look to be a bit clustered so likely positional as D stated-so please follow her advise but also raise your pressure as you are hitting an average of 18cm.

[RonICrumpins]

        My apologies for taking a bit to follow up. I have attached two new nights of sleep that include the previous suggestions - adding a soft cervical collar to the mix and moving EPR to 2 and minimum pressure to 12.

I was able to track down my sleep study. Since it was an at-home test, it doesn't appear to have taken into account anything to do with the CAs. Here is the synopsis from my study:

Patient Age: 37 years
Height: 70.0 in.
Weight: 194.0 lbs.
BMI: 27.8 lb/in2
Neck Size: 15.3 in.
Epworth: 5 / 24
Stop Bang: 4 / 8

Date of Study: 8/28/2021

Testing Type & Methods

The study was performed using the Alice® NightOne system. This system is a Type III portable home sleep testing system.
Standards of evaluation are as per the AASM updated guidelines v2.6 (2020). The channels recorded were: Airflow acquired
with a nasal pressure cannula and oral thermistor. Oxygen saturation (SpO2) and pulse was monitored using a pulse oximeter.
Thoracic and abdominal respiratory movements were recorded by respiratory inductive plethysmography. Total monitoring
time (MT) will be reported. Definitive determination of the AHI would require an attended polysomnogram by which any final
cardiovascular risk stratification should be determined. A hypopnea will be determined when the peak signal excursion drops
by ≥30% of pre-event baseline, the duration of the ≥30% drop in signal excursion is ≥10 seconds, and, there is a ≥4% oxygen
desaturation from pre-event baseline. The patient received education and instruction on proper application of the device with a
technician prior to the study, and confirmed an understanding of use.

Impressions

1. Patient had an overall AHI of 42.1/hour. The lowest recorded oxygen saturation was 79%.
2. The oxygen desaturation index (ODI) was 35.3 with an average SpO2 of 92%. The total time spent with an SpO2 <88%
was 12.6 minutes.
3. Average HR was 71.1 bpm. The highest heart rate during sleep was 94 bpm.
4. These findings are consistent with at least Severe Obstructive Sleep Apnea (OSA). 

Recommendations 

1. Severe Obstructive Sleep Apnea (OSA, ICD-10 G47.33), associated with hypoxemia. 
2. Therapy options generally consist of auto-titrating positive airway pressure (APAP) therapy or for mild cases consideration of a referral to a dental clinic for evaluation and fitting of an oral appliance. Treatment should always be in the context of lifestyle changes to promote weight loss (as appropriate) and sleep hygiene counseling. In addition, if clinically indicated a surgical consultation may be obtained. 
3. Recommend initial therapy with APAP using initial settings of 5-15 cm H2O (cwp) and a formal mask fitting. Therapy should be followed by a compliance review to assess efficacy. 
4. Depending upon clinical history a dedicated CPAP titration study may be indicated. 
5. This home sleep study is only intended to diagnosis sleep disordered breathing based upon obstructive respiratory events, and may underestimate the severity of disease, if present. 
6. This test is not indicated for evaluation of Restless Leg Syndrome (RLS), Periodic Limb Movements or other sleep disorders such as insomnia. Clinical correlation for these and other sleep related disturbances is routinely recommended.

[Phaleronic]

Thanks for the updated oscar shots Ron and the sleep study details. Looking at the new charts I'm just thinking you may need to move to bipap since you're needing high pressure to keep your airway open but it's not working well enough to be tenable in the long term. The high pressure ramping up is causing the leak issues too in my opinion. How are you feeling the last two nights after the minimum pressure raised?

[RonICrumpins]

You know - I feel pretty good with these settings and the collar. I dont see much difference in the way I feel between 5-10 AHI. 

Looks like I will need to be looking for a provider in my new city and maybe a new, onsite sleep study, eh?

Appreciate all the help from this great forum.

[Phaleronic]

You're welcome

I see that Deb advised trying a soft cervical collar, I agree with that too, the first easy thing to also try it a flat pillow to sleep on plus another flat (loose down pillow) to use to go over your shoulder and a bit under your jaw to prevent chin tucking and those OA events that show up...

A new sleep study is never a bad idea too

[staceyburke]

I have not been following your thread but looking at your last OSCAR I believe You are having positional apnea.  You can see positional apnea where either H or Oa events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.