AHI creeping up

I got a new mask about a month ago and at first, things were going very well. This mask never leaks (the machine reported high leak flow on the old one every night).

I've noticed that, since performing some pretty demanding tasks in the aftermath of Hurricane Harvey, I started retaining water and put on quite a bit of weight. I got "water pills" for that and have shrunk down nicely since.

Problem is, my daily AHI never was all that good (range from 9 - 13). It seemed to improve after the new mask (it got as low as but on Monday, 9/11/2017, it went all the way up to 19 and has been creeping up since Friday. I'm still able to get up in the morning in a better state than I had been but I have been tired and usually come home and crash (my behavior before bi-pap). This morning, I slept in an extra hour after unplugging.

It seems my machine doesn't work with SleepyHead, so...

I'm worried I'm reverting back, going to a dark place I never knew I was in before my treatment started.

Any advice on how to proceed?

What are your pressure settings?

Do you get a breakdown of your AHI into separate categories?

Did you get the DeVilbiss software?

Pugsy wrote:What are your pressure settings?

IPAP 14
EPAP 12

Pugsy wrote:Do you get a breakdown of your AHI into separate categories?

It looks like no.

9/11
AHI 19.0
Non-Obstructive Index >-15.75
Exhale Puff Index 1

9/8
AHI 10.0
Non-Obstructive Index 3
Exhale Puff Index 1

Pugsy wrote:Did you get the DeVilbiss software?

I downloaded the software you gave me the link to and installed it but I have not brought data from the machine to the computer, yet. The Intellipap has a huge card that I don't have a reader for. I got sidetracked by Hurricane Harvey and haven't ordered the official card reader. Hoping to do that before the end of the week.

I don't remember what non obstructive meant...it's been probably at least 6 years since I saw any DeVilbiss software reports.
I used to have the guide for it but that was on a computer long dead.
I don't think it is necessarily the same thing as a central.

How come such a small tight range on your settings? Is it fixed or auto adjusting?

Have you ever tried more EPAP and more IPAP? If so...what were the results?

Let me go see if I can find that guide for the software....which will explain what you are seeing on the screen.

Pugsy wrote: How come such a small tight range on your settings? Is it fixed or auto adjusting?

That is the prescription. Fixed.

Pugsy wrote:
Have you ever tried more EPAP and more IPAP? If so...what were the results?

No. I'm kind of hit or miss on getting the stats each day so I've been reluctant to make changes. That, and I don't know what I'm doing.

Pugsy wrote: Let me go see if I can find that guide for the software....which will explain what you are seeing on the screen.

I can upload one of the reports which has a description of all the data.

I'm not using the software to get this data. I am typing the "smart" codes from my machine each day into the DeVilbiss SmartCode decoder online.

I just got authorization from the boss to purchase the official card reader and software.

Here is the definition of "Non-Obstructive Index" from the report:

Non-Obstructive Index
Non-Obstructive Event Index (NOI) represents the average number of non-obstructive events per hour. A non-obstructive event is a respiratory event that is detected but by
design does not result in a pressure change during AutoAdjust or AutoBilevel therapy. The Non-Responding Index reflects a possible central apnea and may indicate a
primary central apnea problem or when PAP pressures are increased, the centrals may be CAUSED by the PAP pressure. NOTE: This only applies to DV5x series data.

I do have a DV5x series machine.

BTW, you're amazing!

http://www.devilbisshealthcare.com/file ... T-2089.pdf
See page 4
This is their "how to titrate" thing...can't find the software explanation document yet that I was thinking of but it does cover some of the software reporting.

NRI includes some items one of which is NOA

Non-Obstructive Apnea NOA which per what they are saying sounds like what we would call a central apnea.

Page 18

Non-Responding Event Index (NRI)
N
RI is provided as a number and as a graph. The NRI includes all the non-responding events
considered by the AutoAdjust PAP: leaks, non-obstructive apneas, and exhale puffs. The NRI is the
average number of non-responding events per hour. If the number is higher than 10, the patient
may be exhibiting primary central apneas and need clinical intervention.

We don't increase pressure with these machines in an effort to kill centrals. It can't. Obstructive apneas and hyponeas yes...NOAs or centrals...no.

How come you have this bilevel machine?
Do you know what your original diagnosis without any machine was?
How long have you been using this machine?

I am afraid to offer "increase the pressure" because it could make things worse if these are centrals.
Without knowing a lot more in depth information and history it's tough just going by the DeVilbiss codes to have any idea what is needed because we don't know for sure what we are fighting.

Wonder what would happen if you used fixed pressure of 12...no difference between inhale and exhale (called PS Pressure support). IF (big IF) these are centrals and you didn't have them until you started cpap therapy...there are a very small % of bilevel pressure users who find that PS causes centrals. I don't know that is what is going on here.

About the only thing I am comfortable offering without knowing a lot more than what is available right now is try fixed 12 and see if the NRI is still high.
Or fixed 10 cm if you can't handle 12. See if removing PS helps reduce the NRI or not. It's not common but I have seen it happen.

Edit...just saw you last post and you found what I found.

Pugsy wrote: How come you have this bilevel machine?
Do you know what your original diagnosis without any machine was?
How long have you been using this machine?

That was my prescription and this was the only bi-level machine I could afford (self-pay), though if I had to do it over again, I'd probably come up with the extra $1000 for a better machine.

The diagnosis was severe sleep apnea (results below).

I started therapy on 6/28/2017 and I immediately felt better the next day, though I would describe my quality of sleep the first night (or first month and a half) as poor.

The sleep study analysis revealed:
AHI = 64
RI: 66.8
Apnea index: 58.4
Unclassified AI: 2.5
Obstructive AI: 39.7
Central AI: 15.3
Mixed AI: .9
Hypopnea index: 5.9
% Flow lim. BR. without Sn (FL): 23
% Flow lim. Br. with Sn (FS): 5

Oxygen Desaturation Index: 63
Average saturation: 94
Lowest desaturation: 79
Lowest saturation: 79
Baseline Saturation: 98

Minimum pulse: 52 (I do take a Beta Blocker)
Maximum pulse: 96
Average pulse: 67

There's much more.

Pugsy wrote: I am afraid to offer "increase the pressure" because it could make things worse if these are centrals.
Without knowing a lot more in depth information and history it's tough just going by the DeVilbiss codes to have any idea what is needed because we don't know for sure what we are fighting.

I agree. I'll purchase the equipment I need to get the data tomorrow. Then I'll come back with better information, hopefully.

And I'm afraid to increase the pressure. I already feel like my head is going to blow apart at times.

Pugsy wrote: Wonder what would happen if you used fixed pressure of 12...no difference between inhale and exhale (called PS Pressure support). IF (big IF) these are centrals and you didn't have them until you started cpap therapy...there are a very small % of bilevel pressure users who find that PS causes centrals.

About the only thing I am comfortable offering without knowing a lot more than what is available right now is try fixed 12 and see if the NRI is still high.
Or fixed 10 cm if you can't handle 12. See if removing PS helps reduce the NRI or not. It's not common but I have seen it happen.

Not sure what PS is. Once I get the data stable so I have a baseline, I'll experiment with this.

Thank you again for all your help!

PS is Pressure support...or the difference between inhale and exhale...in your case with EPAP at 12 and IPAP at 14...PS is 2

I don't want you to increase the pressure...what I propose is a slight reduction to just 12 fixed or even 10 fixed.

I doubt it will make much of a change in the NRI...but worth trying and costs nothing.

You had 15 centrals per hour on the diagnostic sleep study...so prior to starting xpap and thus unlikely PS has anything to do with it. Unlikely that they will reduce on their own since xpap didn't cause them.

If what I suspect is the case...you may need an entirely different machine. I hope I am wrong. They are pricey little boogers.

Was the diagnostic study done in a lab or at home?
Did you have an in lab sleep study where you were hooked up to a machine with mask?

I just realized that you likely don't know how to change the settings to reduce the pressure.

Go here and request the clinical provider manual for your machine ....instructions for requesting via email are about 2/3 down the page.
They show your machine manual being available
DeVilbiss IntelliPAP Bilevel

It will explain how to get to the setup menu where you can change the settings.
You should be able to set the minimum to equal the maximum...or it may have cpap mode available and you could change to that.

I am not all that familiar with the DeVibiss machines...but I am quite familiar with ResMed and Respironics bilevel machines and the basics are the same with all bilevels until you get to the high end specialty bilevels.

Do you have insurance? High deductible? Some reason why you bought out of pocket?
I just need to understand your situation more clearly so I can best plan an attack.

In the meantime...let's see what the software shows. Particularly I want to see when the various event flags are showing up.

I sent you a PM..just in case you don't know where to find it...left side upper light blue area next to User Control Panel link.

https://imgur.com/a/YFpWO







My data from last night. I had a slightly rough day today but better than earlier in the week.

I see one break in therapy where you turned the machine off and back on again.
Did you have other times that you were awake for rather long periods of time with the mask on?
The events flagged right near the known awake time in the middle of the night may not be real. If you had other times during the night when you were awake but kept the mask on there might be other flagged events that aren't real.

On this report hyponeas dominate the AHI and not enough NREs (even if they were all NOAs) to worry about.

It wouldn't be impossible for those hyponeas to be central in nature but the majority of the time they will be obstructive in nature and the fix for obstructive in nature apnea events like hyponeas is a little more pressure.
When using a bilevel device the usual way to go is follow this rule
EPAP for OAs and IPAP for hyponeas. In your situation since the Pressure Support is only 2...I would suggest trying a slight increase in IPAP only...like 14 to 15. Leave EPAP at 12. See what happens. It should still be fairly comfortable.

Thanks, I'll try it tonight.

Now I think I have a pretty good baseline measurement for comparison.

Again, thank you for all your help.

xxyzx wrote: actually it would
central means you stop breathing
even if airway is wide open there is no air flow because you stop breathing

hypops are not centrals

Sometimes the machines don't get it right with what they call something.
Hyponeas can be central in nature but the machine doesn't end up calling it a central.
Sometimes the machine will label Centrals as OAs. I have seen it complete with full blown Cheyne Stokes Respiration but OA labels throughout.

You need to do more reading. Hyponeas can be centrals misnamed.
Also there are "mixed" apneas....they start out as one kind and morph into a different kind.

I repeat it would not be impossible for the hyponeas to be central in nature. The machines can be fooled and apneas do morph. Is it common, of course not but I have seen several instances where it has happened here on this forum alone.

Ok, I have new information. Sorry I haven't posted for a while but I've been trying to figure this out.

When I posted this, it was shortly after Hurricane Harvey came into my area. I take quite a few prescription drugs and I was about out of them and I way overdid it on helping with recovery efforts. I'm pretty sure that's why I felt bad. Got back on the drugs and stopped doing stupid stuff that I had no business doing and I feel pretty good. So, I consider that part of my issue resolved.

As to all the high AHI, I purchased a pulse oximeter and have been using it. I didn't see any kind of pattern in the data until my sleep period last night.

Last night, there were spikes in my pulse that were quite dramatic (compared to other nights). Frankly, they don't look like that big of a deal because both my pulse and O2 levels are in a pretty decent range (for me). In general, that makes it look like my therapy is working well, which I believe, since I feel better than I've felt since I was 19. (a long time ago).

Anyhoo, back on topic: Since I have data that looks like I might be able to learn something interesting, I downloaded Sleepyhead and imported my Devilbiss and my SpO2 data into it. There seems to be a correlation between when the Devilbiss says there is an event and the pulse rate events but the data is slightly overwhelming as presented by Sleepyhead. Don't get me wrong, I love the program, but I haven't figured out how to use it yet.

Sleepyhead also reports that my AHI is averaging around 5, I consider the AHI high portion of this post resolved, too.

Now, I still have a large number of Hypopneas (as reported by the Devilbiss and massaged by Sleepyhead), which seem to be corroborated by the SpO2 data (I think). I also have some questions about Sleepyhead's report that I have a very high leakage rate (Devilbiss software doesn't tell me that).

So, I wonder if I should start a new thread with those 2 questions, start 2 new threads, or just finish it all up here?

Thanks again for all the support.