Worrying session last night - hypopneas increased tenfold!

[BigWing]

I've been on PAP for almost 4 months now and I thought I was beginning to understand it all pretty well....but last night's results have left me totally flummoxed! My AHI shot up suddenly to ten times my average and I have no idea why!!

   

My history (I'll try to keep it brief)....my PSG at the local hospital last September yielded an AHI of 25.2 (OA 2.8, H 15.3, CA 4.8). However, that included some particularly bad supine sleeping which I never normally do....but with all the wires and tubes there, I did! So I really compare my new figures (with PAP) against their non-supine findings of 21 AHI (OA 0.8, H 15.3, CA 3.2). Either way, the main culprit is clearly hypopneas.

The UK's 'National Health Service' will kindly provide me with PAP equipment and guidance/monitoring for free....but sadly not for many months! So I bought my own ResMed Airsense 10 Autoset and paid for some (remote) initial guidance from ResMed's own clinic in London.

They quickly set me up at 4-10 in APAP mode and after the first few days I now rarely go over an AHI of 1 - the 14 week average AHI is 0.8 (OA 0.2, H 0.5, CA 0.1). This includes use of both P10 nasal pillows and F20 FFM (after a few days of the pillows I give my sore nostrils a rest - then after a few days of the FFM I give the sore bridge of my nose a rest). It also includes use of a Chin Strap AND more recently a Soft Cervical Collar.

I also bought a 'Wellue SleepU' oximeter as an extra tool, because I thought drops in oxygen should show a good correlation with at least some of the events marked by the AirSense....but it doesn't! It usually shows NO correlation at all....but occasionally it does really well!
 
I study my data in Oscar every day and have read up on Sleep Apnea avidly since I was diagnosed with it. I decided just a week ago to follow ResMed's "CPAP Titration Protocol" as explained by 'CPAP friend' (https://www.youtube.com/watch?v=-IIZdru6vus) by upping my minimum pressure from 4 to 5. So far, that hasn't caused any obvious change in AHI.

However, last night I switched from pillows to FFM and my AHI went through the roof to 4.9 (OA 0.4, H 4.5, CA 0). A change to FFM has never done anything like that before, so I can't understand what happened. Hence my first post on here, as I have seen how much you people know about this subject.

In case they are relevant, I should mention a few things:

1. I have been noticing some weird Flow Rate waveforms lately (see example attached) which are labelled in the Oscar Guide as "Palatal Prolapse" - though elsewhere I see it said that they are caused by mouth-breathing when using pillows. That's why I started wearing the Soft Cervical Collar a few days ago, to see if they would go away - but they haven't. Is there some hypopnea-causing side effect to wearing one - especially in conjunction with a FFM - of which I am unaware?

   

2. It is clear from the charts that my Pressure stayed at the max almost the whole night - but is that a cause or effect? I usually suffer from a small amount of aerophagia but today I am feeling it more - no doubt due to the consistently-high pressure.

3. My wife noticed that I was snoring again last night for the first time since I started PAP (though not as loudly as I used to). Looking at the Snore chart in Oscar, which is usually virtually empty, I can see what she means!

4. Despite all the above, I slept quite well!

So, my plea is simple....does anyone know why my hypopneas increased to 10 times their normal figure last night, please?

[BoxcarPete]

Palatal prolapse is when the soft palate moves out of place and blocks expiratory airflow, directing it out the mouth instead of the nose, so both "palatal prolapse" and "mouth breathing" are accurate descriptions. This is apparent in the excerpt from your chart that you posted. With this happening on a nasal mask, it just means air goes in your nose and out your mouth. If it's not frequent or isn't bothering you, then it might be something you leave alone, but it often comes alongside big mouth leaks that should be addressed if possible.

Then you moved to a FFM, which pressurises both oral and nasal cavities, and suddenly we don't have such a distinction as to where the air is coming and going from and to. This is probably the source of your snoring and increased hypopnea. I have not known of using a collar to stop PP, as the phenomenon originates in your pharynx where your soft palate touches the back of the throat when it's not meant to.

What was the reason you switched from nasal mask to FFM? I and many others have had the best results using a nasal mask and mouth tape, this may be an option for you. Otherwise, there are a few options to resolving PP. One that a member here in France had done is a Swiss outfit making an oral appliance to wrangle the soft palate forward and keep it away from the back of your throat. Here in the states, it's a little easier to get Alaxostents, which are little tubes you push up your nose and into the pharynx which prevents the palate from sealing it off if it collapses, because there is still a tube allowing airflow. None of these sound particularly pleasant, so I hope you find a simpler way to get back to regular breaths using mask choice and sleep positions.

[SarcasticDave94]

I think it would be helpful to also include the full night's standard type OSCAR charts. This is to give an overview.

[BigWing]

I think it would be helpful to also include the full night's standard type OSCAR charts. This is to give an overview.

Sure - here is the previous night (a fairly typical one).

   

[BigWing]

As I mentioned, I switch occasionally between pillows and FFM to give chance for the sore areas to heal.

I don't like the sound of those PP remedies, though I'm not totally sure yet that I do have a big problem with PP. If I do, could a sudden 'flare-up' in that have caused last night's huge problems?

[Deborah K.]

Your pressure settings are low.  I suggest that you set your starting pressure to 7 and your upper pressure to 12.  You have your EPR set for ramp only.  I think you'd be more comfortable turning ramp off and setting EPR at 3 full-time.  Both of these changes should make your therapy and comfort better.

[BigWing]

Your pressure settings are low.  I suggest that you set your starting pressure to 7 and your upper pressure to 12. 

Thanks for your suggestion. Can you please explain how you reached that conclusion? If my big problem last night was caused by the pressure being too low, how do you explain the pressure never causing such a problem in the previous 100 days?

You have your EPR set for ramp only.  I think you'd be more comfortable turning ramp off and setting EPR at 3 full-time.  Both of these changes should make your therapy and comfort better.

Actually, what I find weird is that the ResMed clinician set the EPR at 3 and ramp only - but the ramp is off! So I never do get any EPR! 

My comfort hasn't been a problem, but why do you think activating EPR will fix the sudden big problem I had last night?

[SarcasticDave94]

I also think increasing to 7 minimum pressure, changing EPR to 3 full time will be a good idea.

Why? EPR 3 full time turns your lower tier AutoSet into a bilevel, making it more useful. To those that need it, this can also be more comfortable. It can reduce the flow limits, which are the beginning of obstructive events, and I believe FL is also the signal to increase pressure unnecessarily.

This proposed Max pressure increase to 12 will keep the same pressure range you have now, just moved up 2 clicks.

PS this EPR (exhale pressure relief) is advertised as comfort, but again there's therapy within this little setting.

[BigWing]

I also think increasing to 7 minimum pressure, changing EPR to 3 full time will be a good idea.

I appreciate your interest in my problem, and will try your suggestion shortly. First, though, before working on titration, I am trying to get an answer to what is worrying me more....why might my hypopneas have increased to 10 times their normal figure last night? What could possibly explain all the charts being so vastly different to normal?

[HalfAsleep]

I can't tell from your chart. Are you changing the settings on the machine when you switch mask types? I haven't done this for a while, but IIRC there's FFM mode and nasal mode and maybe a 3rd mode.