[Treatment] Understanding rise in AHI

[PedroT]

Hello all,

Hope you guys are having a good week so far.

Been using the cpap machine for the last few months. It has its ups and downs. Trying to understand why some days the AHI is low (<2) but on other days, it will double.

I use a p30i medium cushion with the standard frame. I am more of a stomach or back sleeper.
Wonder if I need to change up the mask to get the smaller frame because of the mask leakage.
Switched standard resmed back strap with the dreamwear back strap. Felt more secure and well my AHI did go down initially.
On the bright side, I am losing weight . Went from 210 to 187 so far. Could losing weight causes issues with mask fit?
Hard to understand what is causing the mask fit since my sleep vendor said the fit looked great when I was in the office (I was standing up with no hose through).

Also started those mouth and tongue exercises (Myofunctional Therapy) to see if they could help in the long run with some symptoms. If they are not useful, please let me know.

Provided screenshot from the last 3 of 4 days of rising AHI.

           

[Expat31]

Leaks leaks leaks.

I think your enemy n°1.
Looks like you are a mouth breather (if I understand correctly you have a pillows mask)

There are many possible solutions:- mouth tape, slim pillow, chin strap etc.

You will see lots of posts on this forum on all the solutions. Good to look through these.

[Gideon]

Welcome to the forum.

First read the mask primer (my signature), especially the section on mouth breathing.

Flow limits are driving your pressure. They are high, 95%stat is 0.10. ePR is your best treatment. Unfortunately someone set yours to ramp only. Was there a good reason? Some people feel EPR causes issues so set it to ramp only. Truth is it may cause issues, the same as any other medical treatment. Try it, is it causes issues react to them.

Set min pressure=7, EPR is less effective below that,
Set EPR to Fulltime, not ramp only

That should help a lot.

[PedroT]

Thanks for the replies.

1)Suspected I had mouth breathing. I have some mouth tape I got from amazon but first time I tried it, my ahi seemed super high in the first 10 minutes (4.4 AHI). I decided to focus on other adjustments in the meanwhile and I guess I'm a little nervous using mouth tape because some articles say its not safe? I bought something from amazon where it covers the whole mouth with a little flap in the middle.

I have a nasal mask and even a full mask. In the beginning I was getting low ahi but in November, I started to get higher AHI then normal (7-10AHI). So I tried a lot of stuff, and i felt very comfortable with the nasal pillows, especially since I could sleep on my stomach and side. Want to stick with the pillows because compared to November, my overall AHI has been lower. I remember the second night I used those pillows, I got an AHI of 0.63 which was the lowest I've had in the 3-4 months I've been using the machine.

2)Will look into the mask primer wiki page and learn more about it.

3)To be honest, I just got the machine straight from the vendor with no adjustments. I've just made adjustments to humidity and temperature otherwise. Will look into ePR and setting that up.

Will report back in a week to see what worked and thanks once again for the advice.

[Gideon]

Don't dial wing it, guessing. Know what changes you make and why. Know the expected and probable results. Do you know how to titrate?

[paulag1955]

You said you tried taping for one night. Be wary of making decisions as to whether something is or isn't working for you based on just one night. Some things take time for your body to adapt.

[Expat31]

In Gideon's welcome message, he gave excellent advice, regarding the initial settings. 

Many initial settings  that are "out of the box" are really not relevant to individual needs, and as Gideon suggested titration is the next step to take.

This is achieved by careful analysis of the results; the relationship between flow limitations and pressure increases, getting the right level of minimum pressure in catching events as early as possible,  and finding the best maximum pressure to cover all eventualities, but not too high to cause discomfort.

It is quite a balancing act, but with advice such as Gideon's and others it will work out really well.

I would like however to focus a little on the leaks. You have between 17% and 20% reported on those sample night's. The algorithms have a difficult time to cope with this. It is highly likely that the reported AHI and flow limitations are not so accurate. 

I personally had for the first 6 months leaks at this level and more. It produced erroneous readings.

I did not understand at that time what was going on. I did a fair amount of titration of pressures, and EPR on 3, but everything was erratic. 

I assumed it was a mask problem, I had no idea it could have been mouth leakage, as I had no clue how to interpret the graphs. It was by chance that one night I caught myself mouth leaking and it was an eureka moment.

I found out that this mouth leaking caused by jaw drop was a result of  during deep sleep when muscles in the body relax. 

Once I taped, my graphs cleaned themselves up. The large number of centrals reduced dramatically, flow limits right down, as well the other events. My opinion is that leaks falsified totally my results.

This is why I like to focus in this area.

I am a "leaks first guy" to get an initial picture before anything else. 

You expressed some reserves on using a mask,  look at this video. https://youtu.be/dGAHEENnatw?si=og4XpxdFhK_YP1KZ

Regards

[PedroT]

Thanks for the replies.

Feeling more comfortable about trying out the mouth tape again and trying to dial in on dealing with the leaks

Part of the anxiety is due the fact that its amazing what it feels like when you have a good night sleep. It's a very nice feeling when people start saying "What's different about you?" and "you seem a lot more smarter now. What changed?"  So I get worried about changing things during weekdays because now I understand how much a bad night of sleep affects me. It's not that I'm lazy or that I'm not disciplined, its just being very unhealthy and borderline obese for many years on top of not treating sleep apnea, you know?

No idea on how to titrate. Been trying to experiment with a few things like raising the bed up on an angle and different pillows (I have a slim pillow right now after trying a few things). I use that notes section in Oscar to keep track what I did the night before. Will keep at it with the directions you guys have posted.

[Gideon]

Titration 101

Manage OA events
EPR=OFF
start with low pressure 7 on CPAP/APAP (7 allows full use of EPR and is above the 5-6 most have trouble with)
BiLevel start with EPAP Min=4 and PS=3 (PS=3 is max EPR, assumes you are migrating from APAP/CPAP)
Increment Pressure/EPAP Min until OA events are well managed
THEN increase EPR (APAP/APAP) or PS (BiLevel) to manage hypopnea, flow limits, RERAS, UARS. Note on CPAP/APAP you may need to increase pressure by the amount of EPR to maintain the exhale/EPAP pressure. As a min you need to be aware of this and watch for an increase in OA events.

[PedroT]

Hello everyone.

So I tried the mouth tape (its some knockoff version of somnifix since I couldn't find it in Canada). I had it for the full night and looks like the leaks went way down.
I had some fragmented sleep because I guess I gotta get used to the mouth tape.

It became very clear that I do mouth breathe. I remember waking up in the last half the night, experiencing my exhale pushing through my mouth tape.
I noticed that I usually wake up with one nostril more congested but not completely closed. It's usually on the side where I side sleep and it clears up 30minutes to an hour at worst.
Must be why I really felt the mouth breathing near the latter half. Still have some dry mouth, but its not to the degree that i had before.

I will go over the mask primer guide again and practice that tongue trick to keep the mouth closed.
I do have a chinstrap, soft cervical collar, and one other brand of mouth tape (where its that X shape) coming in to experiment with that and I see how it goes with the mouth tape over the next week.

The bright side of today compared to two days is that I don't feel that familiar sleep apnea headache, which is nice.
Thanks for pushing me to try out mouth tape.