Advice for Clear Airway AHI of under 5

[Lizistired]

I would disregard that 12. It looks like there is a break in the mask pressure line at about 9. There is also an increase in you flow rate. I would assume you were awake or turning over, maybe blocked the vent. I wouldn't even let it go that high.

You are barely going over 8 at all. It looks like when you hit 9, you break the seal or turn the machine off.
I still think your minimum of 4 is too low.
Pick the EPR you are most comfortable with and get your pressure tuned in.

Do you feel like you are waking up a lot?

[Lizistired]

I overlooked this paragraph after I looked at your graphs last night.

You may be sensitive to the changes, which is why I suggested you give cpap a try,

Yes, that's next on my list to try. Have been holding back on it in order to test one change per night while keeping other things constant.
My pressure seems to be in the 4 to 8 range,WRONG! You pressure is in the 6-8 range. The blue line is only tracking the EPR drop, which goes to 4 because that is your minimum setting.
but with the EPR tests in the last few nights, it shot up to a high of 12 on the 16th July when i tested with the lowest EPR of 1. I am now wondering if i should set the max pressure at 8 or 12 when testing on CPAP.
There is no min and max on cpap. It is a single pressure.

I think your need for the EPR is because the machine is going to higher pressures.
You can set the EPR to "ramp only" if you like it before you fall asleep. And set your ramp time for 30 minutes, or slightly longer than you think it takes you to fall asleep.
I still suggest cpap at 7 because it eliminates as many variables as possible, and at that pressure I don't believe you will miss the EPR.
Remember, your goal was to see if you could eliminate the centrals.

edit: Hit Submit instead of preview. Duh.

[padster]

I still suggest cpap at 7 because it eliminates as many variables as possible, and at that pressure I don't believe you will miss the EPR.
Remember, your goal was to see if you could eliminate the centrals.

I followed your advice and tried CPAP at 7 last night. It knocked out the OSA 100% but still had CAs at 3.51 which is about the same or higher than the recent averages. Left the EPR at 2, will try to turn it off tonight. Attached the screenshots below - appreciate your feedback on the results.

Leaks - at about 4am, one of the clips on the FFM came undone as you can see. But generally, when i've turned the EPR down and last night at a constant 7 pressure (which is higher than 4 or 5 in auto), whenever i exhale, it seems to cause the mask to 'lift up' a bit due to the increased pressure so that the air can escape from the sides of the mask. Is this normal? I already have the mask straps on quite tight but this still happens.

[padster]

I reduced the EPR and it seems to have lowered the AHI - why does this happen?.

Hi padster!

I think it works for two reasons:

1. The pressure is high a bit longer (less expritory pressure relief - means - the pressure is not "relieved" that is reduced during expiration) so the tissues are "pushed back" (less perfused with blood and fluid) due to the differance in pressure between the airway passage and the rest of the body.

2. The pressure against your breathing out slows the process down a bit so your breathing is less likely to become unstable.

The fact that it does work is consistant with the fact that Provent works - Provent is simply a valve taped to the nostral entrance which increases expriatory pressure. It is passive other than that. You exhale through a small opening.

This would indicate that the apnea part is not being treated at the pressures you are using but the centrals would indicate you are sensitive to the pressure you have and so going up would not work for you. Your positional approach is not a bad alternative - way to go!

In my case the apnea portion is helped by:

1. Less stress!!!
2. Doing things you love.
3. Aerobic exercise.
4. Anti-inflammitory foods.
5. Anti-oxidant foods.
6. Keeping away from processed foods.

The breathing stability portion is helped by:

1. Less stress!!!
2. Keeping away from violent TV and other media.
3. Aerobic exercise with interval training included.
4. Functional Breathing Training using a pulse oximiter to find the lowest heart rate at constant exercion - with and without PAP - all the time.
5. Keeping carb intake down, espically near the end of the day.
6. Searching for and finding beauty in the world every day.

Above when I say "with and without PAP" I am saying that the training is done during the normal day in all circumstances, that I do it with PAP sometimes during the day and at night with the PAP as I am going to sleep.

It sounds like you are very close to good treatment. Carry on!

Todzo

Thanks for the explaination on the effect of EPR changes Todzo, makes a lot of sense.
I'm glad to share that i'm also doing all the activities you mentioned apart from the Functional Breathing Training.
Btw, what is the best way to observe/analyze 'breathing stability' from the sleepyhead data?

[Lizistired]

Tell us more about the home sleep study you had and your diagnosis.
What am I missing?
Did you go to the ENT, and then he referred you to the DME who sent you home with a machine?
Or did you have a home sleep study and then see the ENT?
What was involved in the "home sleep study"?
Was there an oximetry done?
Did you use the same machine?
Did you use the same mask?
Did you have a choice or fitting of different masks?
How many nights were recorded?
Who reviewed the data?

Remember that pressure will not resolve CA's
Are you comfortable with the mask, or are you conscious of it all night?
You haven't answered the question: "How do you feel?"
Any different?
Are you sleeping through the night? Or waking up repeatedly?
How is your sleep hygiene?

Just copying this for reference.

I've been feeling sleepy in the daytime for quite some time. Like most people, i thought it was because i was one of those people that need to sleep a lot and that the 6 to 7 hours per night i was getting were just not enough. After hearing about Sleep Apnea from a friend, i decided to have a Sleep Study done. These were the results: 193 events (176 OA, 1 CA, 6 Mixed and 10 Hypopnea) with a 23.4 AHI (21.4 OA, 0.1 CA, 0.7 Mixed, 1.2 Hypopnea). Average Oxygen Saturation at 96.5%.

The ENT surgeon suggested surgery but i opted for CPAP. My DME (who also conducted the home sleep study) set me up with a ResMed S9 and let me test it for a couple of weeks to help me decide on whether it was worth buying. The daily AHI ranges between 3 to 6 which is a huge improvement from 23.4, but i still feel sleepy the next day, even when i sleep for over 9 hours. Initially, i thought it may just take some time for the full 'fresh' effect to come along, but its now over 2 weeks and i've yet to experience that magical feeling which many OSA patients seem to have once they use a CPAP machine. Is this normal? Is 2-3 weeks too short a period to feel the full positive effects? I asked my DME and he initially said that most people would have felt better by now.

[brucifer]

The ENT surgeon suggested surgery but i opted for CPAP.

padster, good for you for opting for CPAP first! Glad to hear you chose the non-invasive route.

[padster]

Tell us more about the home sleep study you had and your diagnosis.
What am I missing?
Did you go to the ENT, and then he referred you to the DME who sent you home with a machine?
Or did you have a home sleep study and then see the ENT?
What was involved in the "home sleep study"?
Was there an oximetry done?
Did you use the same machine?
Did you use the same mask?
Did you have a choice or fitting of different masks?
How many nights were recorded?
Who reviewed the data?

Remember that pressure will not resolve CA's
Are you comfortable with the mask, or are you conscious of it all night?
You haven't answered the question: "How do you feel?"
Any different?
Are you sleeping through the night? Or waking up repeatedly?
How is your sleep hygiene?

Just copying this for reference.

I've been feeling sleepy in the daytime for quite some time. Like most people, i thought it was because i was one of those people that need to sleep a lot and that the 6 to 7 hours per night i was getting were just not enough. After hearing about Sleep Apnea from a friend, i decided to have a Sleep Study done. These were the results: 193 events (176 OA, 1 CA, 6 Mixed and 10 Hypopnea) with a 23.4 AHI (21.4 OA, 0.1 CA, 0.7 Mixed, 1.2 Hypopnea). Average Oxygen Saturation at 96.5%.

The ENT surgeon suggested surgery but i opted for CPAP. My DME (who also conducted the home sleep study) set me up with a ResMed S9 and let me test it for a couple of weeks to help me decide on whether it was worth buying. The daily AHI ranges between 3 to 6 which is a huge improvement from 23.4, but i still feel sleepy the next day, even when i sleep for over 9 hours. Initially, i thought it may just take some time for the full 'fresh' effect to come along, but its now over 2 weeks and i've yet to experience that magical feeling which many OSA patients seem to have once they use a CPAP machine. Is this normal? Is 2-3 weeks too short a period to feel the full positive effects? I asked my DME and he initially said that most people would have felt better by now.

Tell us more about the home sleep study you had and your diagnosis. > If there's any specific details that will help in providing a clearer picture, please ask and i'll share the info from the report. I've only got a printed version and no soft copy. With the total AHI of 23.4, the ENT surgeon just gave the normal response ie. that its in the moderate range, there are 2 options (surgery/CPAP), surgery success is 50% reduction in AHI, etc etc. Really standard stuff which was not half as helpful as the information that i've learned from this board.

What am I missing? > I'm not sure but i'm grateful for all your feedback and will dig up any other data that may be useful.

Did you go to the ENT, and then he referred you to the DME who sent you home with a machine? > 1) Went to ENT who referred me to the DME guy who conducted the Home Sleep Study 2) DME guy gave the results/report back to ENT surgeon 3) I went back to see the doc who gave me the standard response. I opted for CPAP so he referred the DME guy to get in touch with me again 4) DME guy came over, explained a lot more about sleep apnea & cpap treatment, loaned me the machine and taught me how to use it 5) I was scheduled to go back and see the ENT surgeon after a week or two but i havn't yet, as i'm trying to get to the bottom of my condition/treatment first and do not feel that he knows as much about cpap as the knowledgeable people on the cpap forums. 6) It is now about 3-4 weeks since i started using the machine. The DME guy says he is fine with loaning it to me until i am comfortable with purchasing it, and is also fine if i return it without buying.

Note: As per my original post, i am trying to get opinions on whether i should just go ahead with the purchase (since it is sorting out the OSA) or should my CAs be an indication of centrals where the Resmed S9 APAP may not be the best solution.

Or did you have a home sleep study and then see the ENT? > Answered above.

What was involved in the "home sleep study"?> Had various sensors connected to a device that was strapped across my chest. I figured it is the standard equipment. Tubing to nose, a couple of other sensors taped to my face/cheek, some other sensor across chest to monitor diaphragm movements (i think), device attached to finger to test O2 sats. The whole thing was rigged up at 10pm and then the DME/homesleepstudy guy came over in the morning 9.30am to collect the machine & process the stats. Let me know if there are any other details that may be pertinent.

Was there an oximetry done? > There was a device attached to my finger to monitor oxygen levels in my blood.

Did you use the same machine? > No, the equipment used to conduct the home sleep study was not the ResMed S9 APAP machine.

Did you use the same mask?> There was a tubing going to my nose in the home sleep study. With the APAP machine, i've tested with a nasal pillow and now, the full face mask.

Did you have a choice or fitting of different masks? > Yes for the APAP, where the DME guy left a nasal pillow and a FFM for me to test. No masks for the sleep study.

How many nights were recorded? > 1 night.

Who reviewed the data? > DME/SleepStudy technician and the ENT surgeon, although i think the ENT surgeon just regurgitates the report/summary provided by the sleep tech.

Remember that pressure will not resolve CA's > Okay.

Are you comfortable with the mask, or are you conscious of it all night? > Quite comfortable, apart from the couple of nights i mentioned when EPR was low and last night on CPAP when there appeared to be leakage n the mask sort of 'lifted up' (due to the pressure i think) when i exhale.

You haven't answered the question: "How do you feel?" Any different? > In my previous responses, i mentioned that i am still sleepy even though my ahi has gone from 23 to under 5. In the couple of days when it was in the low 2's and high 1's, i did feel better compared to when the AHI was in the 3 & 4 range. However, this may be due to the total length of time slept, ie 7-8 hours vs 9+ hours that is resulting in the fresher feeling rather than ahi levels. Having said this ... there was 1 day last week when i slept without using the PAP and i felt very very tired the following day ... so, i think it is having a really good effect, but perhaps just not as good as it can be (in terms of the totally refreshed feeling that others share).

Are you sleeping through the night? Or waking up repeatedly? > Sleeping throughout the night on most nights. Not really troubled by the mask or using PAP.

How is your sleep hygiene? No TV in bedroom and only go to bed to sleep at bedtime. No reading in bed either. A bit of light from the AC so its not 100% pitch darkness but otherwise, everything should be quite ideal.

Please let me know if there's any other info i can provide to help you to help me. Thanks again Liz.

[Lizistired]

So what were your results last night?
Where are these 24 obstructive apneas an hour? That's my question.
Everytime you have lowered your pressure and the EPR, your AHI has dropped, and is still mostly CA's.
I would drop the pressure to 6, then 5 if the OA's don't show up.
You didn't have problems with the mask when you first posted so this was never suggested...
But you should try wearing the hose while you are awake, watching TV, reading, playing solitaire, whatever... at lower pressures and get used to it without EPR.
You could cut to the chase and start at 4 and go up. Do your own sleep study.
IIRC your O2 only dropped to 96+%, so even with that AHI, you still didn't have significant desats.
Where are these 24 OBSTRUCTIVE APNEAS an hour??
Find that point and increase your pressure incrementally from there.
See if the Centrals go away, because your early concern was Do I want this machine?....
CPAP/APAP treats obstructive apneas.
You may only need 5-6 cmh2o to open your airway.
That one night on the home sleep study may have been a fluke.

[Lizistired]

I was thinking about Yarrow's post about sleep position, and wondered if maybe you slept on your back during the home study because of all the "stuff", and maybe don't normally.
It's hard for some of us to tell how we sleep when we are really sleeping though.

[padster]

So what were your results last night?
Where are these 24 obstructive apneas an hour? That's my question.
Everytime you have lowered your pressure and the EPR, your AHI has dropped, and is still mostly CA's.
I would drop the pressure to 6, then 5 if the OA's don't show up.
You didn't have problems with the mask when you first posted so this was never suggested...
But you should try wearing the hose while you are awake, watching TV, reading, playing solitaire, whatever... at lower pressures and get used to it without EPR.
You could cut to the chase and start at 4 and go up. Do your own sleep study.
IIRC your O2 only dropped to 96+%, so even with that AHI, you still didn't have significant desats.
Where are these 24 OBSTRUCTIVE APNEAS an hour??
Find that point and increase your pressure incrementally from there.
See if the Centrals go away, because your early concern was Do I want this machine?....
CPAP/APAP treats obstructive apneas.
You may only need 5-6 cmh2o to open your airway.
That one night on the home sleep study may have been a fluke.

So what were your results last night? > I tried it back to APAP mode and changed from 5-12 cm EPR2 to 5.4-8.4 cm EPR1 in an attempt to simulate the settings when we managed to get the AHI down to 1.86 ... these are the results ...

95% pressure: 8.38
95% EPAP: 7.38
95% Leak: 7.2
AHI: 3.79 (3.2 CAs, 0.24 OAs, 0.36 H)

Where are these 24 obstructive apneas an hour? That's my question. Everytime you have lowered your pressure and the EPR, your AHI has dropped, and is still mostly CA's. > Yes, that's the really strange thing. And in the Sleep Study, there was only 1 CA event, but with PAP, we are seeing CAs but not much of an OA issue.

I would drop the pressure to 6, then 5 if the OA's don't show up. > Yes, i agree. Am finally understanding the concepts a bit better. I'm thinking of trying APAP 4-7cm with no EPR tonight.

You didn't have problems with the mask when you first posted so this was never suggested... > Yeah, never had an issue with it until the other day when i lowered EPR and experienced leaks and then tried to resolve that by tightening the straps. Ever since then, the fit has been causing even more leaks and a lot of discomfort that has resulted in a sore/red-mark on the bridge of my nose.

But you should try wearing the hose while you are awake, watching TV, reading, playing solitaire, whatever... at lower pressures and get used to it without EPR. > Do you just carry the PAP machine all around the house when you do that?

You could cut to the chase and start at 4 and go up. Do your own sleep study. > Yes, i'm going to do this if there's no change tonight, ie go from APAP 4-7cm to APAP 4-6cm .... or do you think CPAP at 4cm would be better?

IIRC your O2 only dropped to 96+%, so even with that AHI, you still didn't have significant desats. Where are these 24 OBSTRUCTIVE APNEAS an hour?? > 23.4 Total (21.4 OA, 0.1 Central, 0.7 Mixed, 1.2 Hypopnea) ... OAs: 22.8 sec (mean), 109.1 sec (longest).

109 seconds seems like a really long time to stop breathing. Is that indicative of anything or a pretty normal number as far as stats from Sleep Apnea patients go?

Find that point and increase your pressure incrementally from there. See if the Centrals go away, because your early concern was Do I want this machine?.... > Ok sure, i agree, gonna try it. Thanks for your feedback.

CPAP/APAP treats obstructive apneas. You may only need 5-6 cmh2o to open your airway. That one night on the home sleep study may have been a fluke. > Yes, that's been on my mind and i may have asked it earlier in this thread that is starting to get quite long ... ie. can sleep studies be inaccurate and whether i should get another one done. I asked my DME/sleepstudy tech and he says that they are normally quite accurate. I asked another Sleep Tech from another hospital and she also said that unless there are a few months in between, there isn't likely to be any material difference. I still scheduled to do another test next week though just to confirm the no centrals figure.

I was thinking about Yarrow's post about sleep position, and wondered if maybe you slept on your back during the home study because of all the "stuff", and maybe don't normally. > Yes, i tried to follow up on that lead by digging through the Sleep Study report yesterday as well.

POSITION / TIME(minutes) / A+H/h
Supine: 181.2 / 23.8
Left: 130.8 / 46.3
Right: 181.8 / 6.6

That got me thinking that most of my high OAs are triggered when i sleep on my left side, and the supine position produces my overall average while the right side has a disproportionately low effect on my apneas.

I tried sleeping on my right side for most of last night, but unfortunately, the AHI was still in the 3+ range (mostly CAs) rather than 1+ or below. I know that the positional apnea data from the sleep study largely applies to OAs (and i'm currently trying to tackle CAs) but i thought is was worth a try anyway.

Hopefully, you might be able to spot something else from the data.

[Lizistired]

These were the results: 193 events (176 OA, 1 CA, 6 Mixed and 10 Hypopnea) with a 23.4 AHI (21.4 OA, 0.1 CA, 0.7 Mixed, 1.2 Hypopnea). Average Oxygen Saturation at 96.5%.

OK... 21 Obstructives per hour. Where are they?
I will repeat this... Pressure will not resolve Central Apneas, but it may cause them!!!
Check your private messages.

[padster]

These were the results: 193 events (176 OA, 1 CA, 6 Mixed and 10 Hypopnea) with a 23.4 AHI (21.4 OA, 0.1 CA, 0.7 Mixed, 1.2 Hypopnea). Average Oxygen Saturation at 96.5%.

OK... 21 Obstructives per hour. Where are they?
I will repeat this... Pressure will not resolve Central Apneas, but it may cause them!!!
Check your private messages.

OK... 21 Obstructives per hour. Where are they? > From the Sleep Study, i can see there are clusters of them throughout the night (11pm to 7.45am), where the time between 3am and 6am had very few events, and the longest apneas were at about 6am. If you are referring to the low OAs during the current PAP usage at relatively low pressures ... i'm not sure, and as we discussed, i'm going to lower the pressure even further to see if they emerge.

I will repeat this... Pressure will not resolve Central Apneas, but it may cause them!!! > Yes, i presume that's why we are trying to lower the pressure to see if we can knock out the CAs without the OAs rising.

Check your private messages. > Done and replied.

[Lizistired]

Have you made any progress?

[padster]

Have you made any progress?

Hey Liz, it's been over 2 weeks and the Centrals are a little lower, between 1 and 3, when they were between 2 and 5 previously, but even after using a 4cm CPAP setting, the OSAs are still almost non-existent, which is why i posted a new thread asking about whether such a low pressure can fully knock out OSAs in viewtopic/t80934/Is-it-possible-for-4cm ... -OSAs.html

Not sure what else to do. I thought i would try this new setting for a week or two before reporting back, and it appears there's a marginal improvement, but the overall situation of OSAs+No-Centrals in the sleep study vs Centrals+No-OSAs while on CPAP is still puzzling. My last resort is to have a full sleep study done with EEG to see if it can provide a clearer picture.

[Todzo]

Have you made any progress?

Hey Liz, it's been over 2 weeks and the Centrals are a little lower, between 1 and 3, when they were between 2 and 5 previously, but even after using a 4cm CPAP setting, the OSAs are still almost non-existent, which is why i posted a new thread asking about whether such a low pressure can fully knock out OSAs in viewtopic/t80934/Is-it-possible-for-4cm ... -OSAs.html

Not sure what else to do. I thought i would try this new setting for a week or two before reporting back, and it appears there's a marginal improvement, but the overall situation of OSAs+No-Centrals in the sleep study vs Centrals+No-OSAs while on CPAP is still puzzling. My last resort is to have a full sleep study done with EEG to see if it can provide a clearer picture.

Hi padster!

Try this simple experiment. While at your desk after doing something that you love to do for at least five minutes (look at favorite pictures or whatever) breath out gently and then stop and count seconds - - until you feel the urge to breath --- until the first diaphram muscle pull against your willfully closed airway. If time to urge to breath is over ten seconds and if time to diaphram muscle pull is longer than 15 seconds then consider that what you are dealing with may be simply a more healthy chemoreflex system that the average CPAP user. "Centrals" as you call them here are simpy times when you do not breath at night even though your airway is clear. It is not necessairly a bad thing at all. Indeed, it may be an indicator of health.

Simply, something to think about,

Todzo