Please help: Day 9 with CPAP and AHI still over 7 (Oscar data included)

[ashwa]

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Hello.

I recently got diagnosed with mild sleep apnea with an AHI of 7.2. I got my CPAP 10 days ago and have been using it all night ever since. After first night it showed an AHI of 13.2, which is noticeably higher than my AHI during the sleep study, so I called my healthcare provider. They said that it can take a few weeks for the AHI to start improving, and for me to call back then. It has improved a little, but my symptoms are so debilitating that I want a second opinion. I'm going bankrupt because I don't have the energy to work more than 10 hours a week. Resmed MyAir shows my AHI improvement as following:

Day 1. 12.20
Day 2. 13.20
Day 3. 7.90
Day 4. 7.60
Day 5. 9.80
Day 6. 8.80
Day 7. 6.40
Day 8. 7.30
Day 9. 9.50

Not sure if relevant, but I have been a restless sleeper, I move a lot and do weird throat sounds. My girlfriend says that I have slept a lot more still after I started the treatment. Another possibly irrelevant thing is that my left nostril is chronically blocked due to deviated septum, so I breath mostly through my mouth. I'll have a surgery in three to six months and plan on switching to Resmed N30i after that.

TLDR: AHI still not improving after nine days of CPAP. Can it really take this long for the AHI to improve? Or could it possible be fixed by changing the CPAP settings? (Also: I'm lowkey afraid that a mild sleep apnea with an AHI this low can't explain my extreme fatigue that has been ongoing for atleast six years. Any encouraging words?)

[SCgargoyle]

I'll be the first to admit that I don't understand most of what I see and read about this. I'm new to CPAP as well. My so-called sleep study revealed an AHI of 16, and my O2 was dropping as low as 76%! Yet I don't have any symptoms of sleep apnea. I'm very energetic, exercise regularly, no daytime sleepiness, no snoring, etc., etc. How could I do so poorly on the test, when I feel great all day long? I've had zero success with CPAP so far. I've yet to find a mask that doesn't leak, so I'm not getting any therapy, accurate data, or sleep. I know several people for whom CPAP therapy has been life-changing, so I know it can help.

[Gideon]

Welcome to the forum.

To better understand your apnea we need to see your sleep study, The charts and tables too, not just the summary, We need to see both your diagnostic test and your titration study.

What we are looking for is fi you had Central Apnea, and how much you had, prior to CPAP.

In the meantime, reduce EPR to 1 (currently 2) and there is a chance I'll ask you to turn it off after I see the results. EPR can have a large impact on Central Apnea (CA) numbers in some "lucky" individuals. definitely not all.

[Sleeprider]

Ashwa, your predominate problem is with central apnea events.  I have a solution to mitigate that, but want to ask if you have a copy of your sleep study that you can post with the personal information redacted.  Mostly want to see if the central events were present before CPAP therapy.  Normally for a central apnea index  (CAI) this high, my recommendation might be to  hold out for a higher level of therapy called adaptive servo ventilation (ASV).  ASV is able to treat obstructive sleep apnea and provides breath by breath pressure increases to cause a breath during a central apnea or to supplement a shallow breath during hypopnea.

To minimize these CA events we need to change your settings to provide low steady pressure without the EPR.  I recommend that you use CPAP mode with a pressure of 7.0 and EPR off.  An alternative would be to remain in Autoset mode and set the minimum and maximum pressure to 7.0.  Either approach will provide your current minimum pressure of 7.0 and the pressure will not fluctuate, or change from inhale to exhale.  We can later try adding in EPR at 1, but the immediate effect of this will be to bring your CAI under 5.0.  I still think you may eventually need ASV, but sometimes people do get CPAP to work with predominately central apnea, so be patient and we will see. The other thing I see in your chart is that OA events are clustered, This may be positional apnea, simply chin-tucking from using a pillow too high or firm. We have some ways to address that, but I want to make you aware that chin-tuck may be a contributor to any obstructive apnea you have.

[ashwa]

Hey, thanks for the reply. 

I do not have a copy of the sleep study, but I can ask for it next monday. But I'm guessing it will take at least a week to deliver, since it'll probably arrive in mail. I turned off the EPR and will report back tomorrow. Do you think I should wait until tomorrow with the pressure changes to see what kind of an effect the EPR had? Or try both right away?

About the positional apnea, it would make sense. Whenever I tuck my chin all the way, even when awake, my breathing gets really shallow.

[Sleeprider]

I still want to see a fixed pressure because without EPR, the flow limits will cause pressures to rise without any real therapy benefit. By using fixed pressures we can more quickly narrow down or "titrate" an effective pressure range. Our objective now is to significantly reduce CA events without an increase in OA. The fixed pressure will tell us if you need higher or lower pressure much better than using the auto-adjusting modes.

[ashwa]

Ok, I will try this night with your suggested settings. I hope my doctor wont give me any slack for taking the matter in my own hands. The healthcare in Finland is supposed to be top notch so I'm perplexed that no one has even mentioned anything about central apneas or ASV. But I am desperate and willing to try anything. Thanks for the assistance.

Also, are you able to tell from looking at the provided data if I have RERAs or not? Is my flow limit activity normal?

[SarcasticDave94]

I'm thinking with how this looks we'll have another ASV user soon. Yes definitely minimize the pressure swings via dropping the EPR. Make sure there's no Ramp also. On the flow limits, it's sometimes a bit high but it's on the other side of the teeter totter. CA and flow limits are on opposite sides of the treatment actions, as in working on one will make the other go up. Me, CA are the one to focus on.

[ashwa]

Hey. I slept last night with the changes you suggested. My AHI now jumped to almost 25. Oscar data included.

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Also, is it concerning how much my respiration rate jumps here and there? Do you have an idea why that is?

[Sleeprider]

You need ASV. The increase in OA events was foreseeable, and part of the reason we went with a low pressure was to see the pressure where OA is reduced, but the increase in CA events is out of character with the usual response to turning off EPR and constant pressure. This is the singular worst result I have experienced with the customary recommendation to use low fixed pressure to improve central apnea. I think you need to be in touch with the doctor's office on their next business day to discuss the extent of CA events that are occurring. I don't think that the increase in CA is actually related to the change to lower, fixed pressure. CPAP does not control central apnea, and the event rate will be consistently inconsistent. Your attempt at fixed low pressure showed me that we are not going to control your central apnea or improve it with CPAP, even with lower pressure or no EPR. Based on this much worse result, I think the best thing to do is restore your previous settings, and send you back to your doctor for a prescription to upgrade to ASV. Following his directions will take away any argument that you went rogue on him. Your event rate is going to fluctuate regardless of settings, and I don't anticipate that CPAP will ever be effective for you regardless of settings.

I believe your previous setting was Autoset mode, minimum pressure 7.0, maximum pressure 15.0 and EPR 2. If you want to try Autoset in Soft mode that might be more comfortable pending your change in therapy. The machine you need is the Resmed Aircurve 10 ASV or the Resmed AirCurve™ 10 CS PaceWave™ (same device but names change in different countries and markets). Alternatively, your diagnostic AHI was 7.2. CPAP is making it worse, so quitting until this is worked out is a logical approach to CPAP therapy onset central apnea.