Frustrated, Cannot get AHI Down After 2 Weeks

[asuter060514]

Not sure why I’m not getting notifications for this thread anymore, but thank you Dave.

I highlighted the events. It happened between 4:00am and 4:45am. It appears that I had a cluster of 9 OA events and 11 CA events during that. My wife said that our baby did not wake up, so I’m not sure what happened at that time. She did tell me that I have been sleeping on my back much much more.

During this cluster, my heart rate rose to 79 beats per minute, but my O2 was at 97% so it doesn’t appear that I suffered any drops in O2 saturation at that time. I actually am not seeing any O2 drops during these events, so that’s encouraging. 

My wife did say I was talking in my sleep, could this have been a vivid dream?

[SarcasticDave94]

It is a possibility, it seems.

On the several obstructive events... Had we talk yet about any positional apnea clustering? Maybe the soft cervical collar needs to be considered.

[asuter060514]

Interesting. I’m also letting my anxiety over analyze these events, I’m sure.

[SarcasticDave94]

It's ok, PAP machines, masks, and such aren't normal. The alien mask creature stuck onto your face, blowing air up your nose, with its 6 foot umbilical cord connecting it to the Mother PAP just ain't exactly normal.

[Ratchick]

I think this may just be the same thing as we discussed before - that you're rolling onto your back, you may well be in REM sleep which tends to be the stage of sleep when more obstructive events occur. So you're having a cluster of obstructive events (either due to sleep stage, chin tucking, or both) and that is probably triggering these treatment-emergent centrals. The obstructive events push up the pressure, which makes centrals more likely to happen, then after a while, the centrals settle down (either as the pressure drops or your carbon dioxide levels even out whereas during the apneas it's swinging wildly) then because the pressure has dropped, and you're still on your back (or in REM, or both) the machine starts to detect that your airway is starting to obstruct again, so the pressure rises again, which ticks off another few centrals, then the pressure drops again (because you're not having any signs of obstruction at that pressure) and then when the pressure drops below 9 or so, you start the signs of obstruction again, which boosts the pressure etc.

The great news is that your oxygen levels are fine. So you don't need to worry so much about these centrals for now.

The problem here is that even at max pressure, you still had those obstructives. I am guessing that if you scroll down to find the Flow Limitation graph, that before those obstructions, where the pressure started ramping up towards 10, and every time the pressure ramped up later on triggering the next few centrals, you will see your FL value is higher. That's because this is one way that the machine judges whether to push up the pressure. If there are a lot of flow limitations, it will keep pushing the pressure up as far as it will go until they're reduced... normally, this is great, because that's how it stops you from having obstructive apneas and hypopneas (as well as boosting the pressure in response to obstructive apneas too - but NOT boosting it because of centrals).

The issue is that your obstructive events that are remaining seem to be positional due to chin tucking when you're on your back. And this is where a soft cervical collar is probably going to prove to be the best bet. Any time your chin tucks, whether on your back or any other position, it could trigger obstructive events. The machine tries to fix that by raising the pressure, but that just triggers more centrals right now. So what you need to do is "fix" your chin in a position that keeps it from dropping. That's where a cervical collar comes in, making sure your pillow isn't too high, trying to sleep in positions that tend not to trigger it etc.

My next suggestion would be to combine a soft cervical collar with dropping the maximum pressure down to 9 and increasing the minimum pressure to 7. We don't necessarily want to eradicate ALL the centrals - leaving a few means that your carbon dioxide levels are in a place where your body can get used to that "new normal". And between these two, with the pressure not changing as often, with the reduced apneas, and less flow limitation - all of which cause arousals that are basically you waking up dozens of times a night, even if you don't remember it - then you will end up hopefully feeling a lot more rested.

There's genuinely no reason right now to worry, IMO. Your overall scores are great, and I see no reason why this can't be managed. You might see a few more hypops or obstructives with that lower pressure but, as most of them seem positional anyway and the higher pressure isn't helping them, you might not. The odd event here and there isn't an issue. The fact that your oxygen levels are so routinely good is proof positive that the apneas aren't causing any kind of desaturations which is great. It just means that your brain is just letting you go a little longer between breaths but it's not causing you harm. As Dave says, if you go for a sleep study and your AHI/RDI is <5, you would be regarded as having "normal" sleep breathing. You're having far less than that (and significantly less than you had on your sleep study IIRC), so you're almost there.

I know with anxiety it's really hard not to get hyperfocused on every little thing. You're doing okay though, even though it still feels tough right now. Not everyone starts to feel amazing immediately, either. for some people, it's like night and day, yes. But for others, it can take weeks to really feel good again. That can be disheartening because you hear how it should make you feel great right away... but it can take a while for your body to adjust, just like getting control over any health issue.

Definitely read the soft collar stuff in the wiki link in Dave's signature, about positional apnea. You've got this.

[asuter060514]

So, I had an excellent night last night with events down to 1.2. I had a hypopnea cluster, but that was around when my son woke up. Other than that, it was smooth sailing. I lowered EPR to 1 and my pressure is at 6-14. The pressure went to the max quite often, but cleared the events. I also moved up my humidity to 80 degrees.

I ran the mask fit program which seemed to help until I drooled a lot, but that was okay! I’m very tired today, but I am chalking that up to non-apnea related interference.

I was very happy with my chart. My O2 levels haven’t dropped below 93% since I started treatment and usually stay within 3% of average. Heart rate stays until 100 always before and after CPAP, so I’m okay. I did wake up feeling bloated and full, but I’m going to try these settings a couple more days

[factor]

I had an excellent night last night.

Awesome.  Hang in there.  You can do it.

[SarcasticDave94]

OK let's touch on the MAYBE it's a necessity to not back sleep. What I do for me, myself, and I...I have 4 large, long body pillows stacked in 2 piles, 2 each that is, with them being end to end lengthwise. I have built a wall of body pillows to prevent back sleeping, or that I can AT MOST roll from my left side sleeping to a 45 degree tilt. Visualize, consider, plan, try.

[Ratchick]

Amazing to hear! If this is working for you, then go with it. If the aerophagia continues to be an issue in the future, you can definitely try dropping the pressure a little to see if that helps... But it sounds like you're going the right way.

The drooling is the one part of mouth breathing I do NOT miss since I've been using a chin strap. Such a gross way to wake up. LOL

Definitely seconding Dave's suggestion to stay off your back as much as possible. That's playing a big part in the obstructive stuff, and the less you have of that, the better all around.

[asuter060514]

Yeah, I’m trying to stay off my back. I keep waking up on my side, so that’s encouraging. The aerophagia is definitely a concern as it’s triggering my GERD so I’m just bloated and breathless all day after meals, but I’m hopeful that will pass