High AHI after switching from Wisp mask to Nuance Pro?

I recently made the switch from the Respironics Wisp nasal mask to the Nuance Pro nasal pillow mask. It's been 5 days now and my AHI has more than doubled. 

In the Wisp my AHI was normally 3.5 - 5 range, give or take a bit. With the Nuance Pro I've yet to see an AHI below 10, and last night was over 13! I don't know if I'm doing something wrong or if nasal pillows just aren't for me. I did switch the mask setting from x1 to x2, per the instructions with the pillows. Started with my normal range of pressure (6.5 - 14) but had to bump it up. I saw a slight improvement bumping it to 7.5 starting, but a decline in sleep quality starting above that. With the Wisp I was getting a 90% of around 12-13 pressure whereas with the Nuance Pro my 90% seems to have been consistantly around 10.

I really want to make this work as the Wisp's exhaust and overall sound is noisy enough to keep my wife up whereas the Nuance is very quiet. Plus, I can't side sleep on the Wisp without leaks. 

I'm in a bad way to the point I'm considering returning the Nuance Pro and exchanging for a Dreamwear, though I'm not sure how to line up the pillow size between the two. I'm a large on the Nuance Pro. I don't have a DME and buy my equipment independently. Usually from Amazon. For what it's worth I have a prescription (or rather, was diagnosed and can get my prescription from my doctor, but don't physically have it), but the DME my doctor works with was gouging hard it seems like on price. They wanted $1100 for a Dreamstation and basic mask and I bought the exact setup they offered on my own for just over $400. So unfortunately due to this, I don't have a provider to work with per se.


Can anybody help with this?

I have had both masks, and five days may not be enough to get the best headgear adjustments.
You may be more restless getting to sleep because you are not yet used to the Nuance, which can affect your numbers.
Welcome.

Can you tell me what that high AHI is made up of?
What is the event category breakdown?

t0mkatt wrote:I saw a slight improvement bumping it to 7.5 starting, but a decline in sleep quality starting above that.

what was the problem you were having with sleep quality if you used a higher than 7.5 minimum?

Are you using the Flex option for exhale relief...if so which and at what setting?

Consider getting that RX from your doctor and using cpap.com for masks...many have free return insurance.
I guess we can return masks with Amazon...never thought about it but I found that the mask selection available on Amazon isn't as diverse.
Have you looked at other masks besides Respironics masks...you can use any mask with your machine. Doesn't have to be Respironics.

Odd that the AHI changed so dramatically...I can see it happening if you had been using a nasal mask and went to a full face mask but not going from one nasal mask to essentially another nasal mask.

What does your leak line look like...did that change any?

Do you use the software or just use the numbers on the LCD screen or the DreamMapper thing?
If you don't know about the software.
https://sleep.tnet.com/equipment

Pugsy wrote:Can you tell me what that high AHI is made up of?
What is the event category breakdown?

t0mkatt wrote:I saw a slight improvement bumping it to 7.5 starting, but a decline in sleep quality starting above that.

what was the problem you were having with sleep quality if you used a higher than 7.5 minimum?

Are you using the Flex option for exhale relief...if so which and at what setting?
...

Odd that the AHI changed so dramatically...I can see it happening if you had been using a nasal mask and went to a full face mask but not going from one nasal mask to essentially another nasal mask.

What does your leak line look like...did that change any?

Do you use the software or just use the numbers on the LCD screen or the DreamMapper thing?

I use Sleepyhead and DreamMapper. I don't have the sleepyhead data on hand, but I can post the info from DreamMapper here.

For Flex I use 1 on a-flex. At higher than 7.5 my clear airway numbers spiked. It's been a problem with my other mask as well. Just really high clear airway numbers if I start at a high value.

For the actual data, I'll post some numbers from before and after the change to the Nuance, in case it helps.


Wisp (before Nuance):

7-31-2017 / AHI 4.7 / 6:34 hrs / Mask fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90% pressure: 13
Clear airway: 14
Obstructive: 7
Hypopneas: 10

8-2-2017 / AHI 4 5:52 hrs Mask fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90% pressure: 12.5
Clear Airway: 9
Obstructive: 3
Hypopnea: 12

8-3-2017 / AHI 6.4 / 7:20 hrs / Mask fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90%: 11.5
Clear Airway: 17
Obstructive: 5
Hypopnea: 25


====================================

Nuance Pro:

8-9-2017 / AHI 9.8 / 6:55 hrs / Mask fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90%: 8.4
Clear Airway: 30
Obstructive: 4
Hypopnea: 34

8-10-2017 / AHI 14 / 5:00 hrs / MAsk fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90%: 10.0
Clear Airway: 38
Obstructive: 11
Hypopnea: 21

8-11-2017 / AHI 10.1 / 6:41 hrs / Mask fit 100%
Min pressure: 6.5
Max Pressure: 13.5
90%: 9.8
Clear Airway: 37
Obstructive: 12
Hypopnea: 19

8-12-2017 / AHI 10.8 / 4:40 hrs / Mask fir 100%
Min pressure: 7.5
Max Pressure: 14
90%: 10.0
Clear Airway: 26
Obstructive: 5
Hypopnea: 19

8-13-2017 / AHI 13.8 / 5:07 hrs / Mask fit 100%
Min pressure: 8
Max Pressure: 14.5
90%: 13
Clear Airway: 41
Obstructive: 16
Hypopnea: 14


============================

I kinda feel like I'm stabbing around in the dark. One underlying factor that could be affecting the numbers is that I had my wisdom teeth pulled on August 4th. I'm going to be switching to the Wisp tonight and maybe tomorrow and going back to my previous settings to see how I sleep just to be sure that's not affecting the numbers. I'm not sure what's up with my leak reporting in DreamMapper either, since there are times sleepyhead has shown obvious, if minor leaks, but DreamMapper has always reported 100% Mask fit. I think it only accounts for large leaks, but it seems like the mask would have to completely fall off for it to report anything there. Sleepyhead has more granular information.

If there's any other info I can provide to be of help let me know. This is driving me crazy and all I want is a consistent good night's sleep.

t0mkatt wrote:I'm not sure what's up with my leak reporting in DreamMapper either, since there are times sleepyhead has shown obvious, if minor leaks, but DreamMapper has always reported 100% Mask fit.

What part of SleepyHead? The statistics portion or the little warning that SH gives? That's because SH is using ResMed leak numbers and you are using a Respironics machine which uses a different threshold for large leak territory.
That's easily fixed.
Go to Preferences/CPAP tab...on the right you can see the leak red line threshold stuff. It's set to 24 L/min which is ResMed's line in the sand. Since your machine reports leaks differently and has a different threshold the 24 L/min makes SH think you are having large leaks when you aren't.
Respironics never gives us an exact line in the sand because it can vary with the mask and with the pressure as it varies but something along 60 L/min would be a nice conservative number if you want to use the statistics...or turn it off or just ignore it and look at the events graph...if you had large leaks they will be flagged on the events graph.

Your AHI is roughly about half Clear Airway/Central apnea no matter which mask you use.
We can't fix centrals with more pressure with your machine.
Are you spending much time awake with the mask and machine on? Sometimes this elevates the AHI because the machine can flag awake breathing as a central when it really isn't. If the bulk of your CAs/centrals are right around known awake times then that likely will explain them and they can be ignored. If not we can have a different discussion about the centrals.

So are you spending much time with the mask and machine on while awake and are those centrals/CAs clustered around known awake times?

Pugsy wrote:

t0mkatt wrote:I'm not sure what's up with my leak reporting in DreamMapper either, since there are times sleepyhead has shown obvious, if minor leaks, but DreamMapper has always reported 100% Mask fit.

What part of SleepyHead? The statistics portion or the little warning that SH gives? That's because SH is using ResMed leak numbers and you are using a Respironics machine which uses a different threshold for large leak territory.
That's easily fixed.
Go to Preferences/CPAP tab...on the right you can see the leak red line threshold stuff. It's set to 24 L/min which is ResMed's line in the sand. Since your machine reports leaks differently and has a different threshold the 24 L/min makes SH think you are having large leaks when you aren't.
Respironics never gives us an exact line in the sand because it can vary with the mask and with the pressure as it varies but something along 60 L/min would be a nice conservative number if you want to use the statistics...or turn it off or just ignore it and look at the events graph...if you had large leaks they will be flagged on the events graph.

Your AHI is roughly about half Clear Airway/Central apnea no matter which mask you use.
We can't fix centrals with more pressure with your machine.
Are you spending much time awake with the mask and machine on? Sometimes this elevates the AHI because the machine can flag awake breathing as a central when it really isn't. If the bulk of your CAs/centrals are right around known awake times then that likely will explain them and they can be ignored. If not we can have a different discussion about the centrals.

So are you spending much time with the mask and machine on while awake and are those centrals/CAs clustered around known awake times?

That's good info on the leak data, I'll make sure to update that in sleepyhead.

I think most of the CAs are sleep/wake junk. The bulk of them occur in the first 15-30 minutes when I go to bed and the last 20-30 minutes before I wake up. When I did my sleep study if I recall right I had 11 centrals versus 63 obstructives and a number of hypopneas, but I don't recall how many. They weren't concerned about central apnea, and based on the data in Sleepyhead I can't say I'm too concerned either. More worried about sorting the hypopneas and obstructive events. Though I do wish there was a way to ignore that crap in the first 20-30 minutes I lay down, as there've been times I've had as many as 30 clear airway events within 20 minutes of putting the mask on. Or just somehow reduce the CAs it reports. It junks up the data.

If you had the presence of mind to quickly turn the machine off and back on again after those 20 to 30 minutes of awake time there is a way to remove that time from the SH report.
Over under the statistics way down at the bottom are the Sessions. You can turn a session off by clicking on it and the data in that session will be removed from the AHI and the graphs.
But you have to create a new session to do that. We don't often have the presence of mind to reach over and turn the machine off and back on again.

Alternately you can manually omit the known awake time stuff by highlighting only the time on the graph you wish to show.
It won't change the AHI bar graph stuff on the left but it will change the AHI that shows in little bitty letters under the events graph.
Just click on a time where you think you were finally asleep and drag the mouse to the end you want to stop and ...and the graphs will change so that only the highlighted time will show and the AHI under the Events graph will reflect only the highlighted time.

Some of your OA/hyponea stuff could also be SWJ...So maybe your obstructive stuff that is real is actually well treated.

See if you can come up with an AHI from just for sure asleep times and see if it is higher than you want to see.
Play with the graphs and omit the SWJ that you are for sure about. See what's left.
And then decide if pressure adjustments are needed.
In terms of masks...use the one that you feel you like the best, sleep the best with....better/more sleep means less SWJ chances.

In sleepyhead, you can left click on the events graph immediately after the SWJ at the beginning of the night, and then drag the cursor across to just before the morning SWJ, and you will have a new duration and AHI value displayed immediately below the graph.

Pugsy wrote:If you had the presence of mind to quickly turn the machine off and back on again after those 20 to 30 minutes of awake time there is a way to remove that time from the SH report.
Over under the statistics way down at the bottom are the Sessions. You can turn a session off by clicking on it and the data in that session will be removed from the AHI and the graphs.
But you have to create a new session to do that. We don't often have the presence of mind to reach over and turn the machine off and back on again.

Alternately you can manually omit the known awake time stuff by highlighting only the time on the graph you wish to show.
It won't change the AHI bar graph stuff on the left but it will change the AHI that shows in little bitty letters under the events graph.
Just click on a time where you think you were finally asleep and drag the mouse to the end you want to stop and ...and the graphs will change so that only the highlighted time will show and the AHI under the Events graph will reflect only the highlighted time.

Some of your OA/hyponea stuff could also be SWJ...So maybe your obstructive stuff that is real is actually well treated.

See if you can come up with an AHI from just for sure asleep times and see if it is higher than you want to see.
Play with the graphs and omit the SWJ that you are for sure about. See what's left.
And then decide if pressure adjustments are needed.
In terms of masks...use the one that you feel you like the best, sleep the best with....better/more sleep means less SWJ chances.

pugsy! thanks for the info on how to trim off the SWJ. i don't believe i've seen that posted before.

Okie bipap wrote:In sleepyhead, you can left click on the events graph immediately after the SWJ at the beginning of the night, and then drag the cursor across to just before the morning SWJ, and you will have a new duration and AHI value displayed immediately below the graph.

thanks, okie bipap. as i said to pugsy, hadn't seen this trick before. both are going to be SO useful!

Hey Pugsy, just wanted to thank you again for the offer, but I think it won't be necessary. I am going to get the Dreamwear kit, but I think I'll be sticking with the cushions. I've packed up my Nuance Pro for return processing and I'm feeling like based on the experience maybe the nasal pillows aren't for me.

In good news, I've switched back to my Wisp, and realized I was using a poorly sized mask. My AHI was always good with it, but it explains why it never seemed to fit well and leaked easily if I rolled around. I don't know how I missed it over nearly two months of use, but there was a S/M mask still in the packaging, and what I thought was medium was actually the large mask. The S/M is more comfortable, even if still less so than I'd like, but more importantly, my AHI is back below 5. One night on it and my AHI is already at 4 again, and if I trim the SWJ stuff, it's somewhere between a 2.8 and a 3.0, which is fine by me. By contrast, it seems even after trimming SWJ stuff from my view with the Nuance, I never had below an 8-9 AHI in the days I was using it. We'll see how things go when I get the Dreamwear, probably sometime next week.

That's fine. The offer is out there and still good until someone else snatches it up. Never know with this stuff.
I might have it 3 months or 3 days.
Good luck with the DreamWear cushion. I tried it when it first came out and it was okay...drag out the okay..but to be fair I had an inkling that I would do better with the small frame but I just never got around to getting one. Then someone wanted to buy it after I loaned it out so I sold it. While it was ...okay....I am pretty much a nasal pillow person and it just didn't ring enough bells for me.

Fast forward to the release of the gel pillows this past spring and I decided to get the small frame and discovered it made a huge difference in the stability of the mask. So the frame fit can make a significant difference.

Your "kit" will come with the medium frame and multiple cushion sizes. Just be aware there are other sizes of the frame are available separately if it is almost perfect and you think that the frame is maybe not quite the size you need.