Better Sleep = Increasing AHI ?

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Crainnut
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Better Sleep = Increasing AHI ?

Post by Crainnut » Fri Oct 24, 2014 9:17 pm

If REM stage sleep contributes to more events, would it stand to reason that as you sort out all the issues with PAP and you cycle more frequently through REM your average AHI might begin to creep upwards? We're talking fairly minor increases from around 1 towards 1.5 AHI.

After a few months on the blower, I'm finally sleeping through the night ( most nights ) with little or no fiddling with the equipment. But I'm noticing a somewhat disturbing trend line when it comes to the AHI statistic.

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Wulfman...
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Re: Better Sleep = Increasing AHI ?

Post by Wulfman... » Fri Oct 24, 2014 9:22 pm

What are your pressure settings?


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Crainnut
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Re: Better Sleep = Increasing AHI ?

Post by Crainnut » Fri Oct 24, 2014 9:36 pm

Pressure is settings are 6.5 - 12. Usually runs up to around 8 then back to 6.5 with an occasional 10 cm h2o.

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Pugsy
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Re: Better Sleep = Increasing AHI ?

Post by Pugsy » Fri Oct 24, 2014 9:45 pm

What event category seems to be increasing?
1 to 1.5 per hour increase ....from where? AHI of 1.0 to 2.5 or 5.0 to 6.5?

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Re: Better Sleep = Increasing AHI ?

Post by Wulfman... » Fri Oct 24, 2014 9:46 pm

Crainnut wrote:Pressure is settings are 6.5 - 12. Usually runs up to around 8 then back to 6.5 with an occasional 10 cm h2o.
Then, a possible answer to your initial question could be that your minimum pressure is inadequate to prevent events from happening. Including the possibility that some of your apneas are happening without precursor events (Snores or Flow Limitations). Snores and/or flow limitations are what mainly initiate pressure increases to head off Apnea and Hypopnea events. If it's spending a good deal of time at or above the 8 cm. mark, then maybe you need to move the minimum up to 8 and see what things look like.


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Crainnut
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Re: Better Sleep = Increasing AHI ?

Post by Crainnut » Fri Oct 24, 2014 11:43 pm

Pugsy, the category that seems to be increasing is hypopnea. For example on October 2 hypopnea's occurred at the rate of .34. Last night, that had increased to 1.52 . The respiratory effort related arousal measurement seems to remain pegged around 2. All the other measurements are tiny numbers.

And to clarify, the total AHI is now 1.78, just about the highest I've experienced since restarting therapy. Back on October 2, when the current trend line began, the total AHI was .46 . I definitely wasn't sleeping as soundly in early October as I am now. Several mask changes plus increased pillow size from medium to large seems to have helped. The machine is also picking up snores that I didn't have previously on PAP. I snored loudly without PAP when I was really tired and the assumption now is I'm sleeping at a much deeper level with PAP now that some of the kinks have been worked out.

I understand these things move up and down, sometimes without any explanation and an AHI under 5 is great but....I'm looking for a reason the trend towards an increasing AHI is not grounds for concern. Sleeping better and more time spent in REM was the best excuse I could come up with.

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Re: Better Sleep = Increasing AHI ?

Post by Pugsy » Sat Oct 25, 2014 8:32 am

Crainnut wrote:I'm looking for a reason the trend towards an increasing AHI is not grounds for concern. Sleeping better and more time spent in REM was the best excuse I could come up with.
Actually I find it a very plausible explanation.

Did you know that I am one of those people whose OSA is much worse in REM? Like AHI of over 50 in REM and a measly 12 in non REM sleep? When I was first starting therapy and having to do a little pressure tweaking it was fairly easy to spot my REM sleep stages by the clustering of events. In REM I would sometimes need a lot more pressure than other times and other times not need so much more. Never could figure out why the difference in needs. I even built a wall once so I was forced to stay on my side all night with no chance at all of rolling onto my back and used it for nearly a month and I still saw the wide pressure changes some nights and none other nights and some nights modest pressure changes.

You might be able to sort of verify your theory if you can spot some sort of pattern to those events (which may be hard because you don't have very many of them to watch). The RERAs may help in that regard too. If you had your sleep study report and it happened to mention the number of events in each sleep stage and it was higher in REM it might answer your question.
Or maybe you are one of those people who just happens to need a little more pressure in REM stage sleep (or maybe you were on your back some of the time where pressure needs can increase) and we don't know why with some REM we do and some REM we don't.
Back in my APAP days I would almost always see a pressure increase (sometimes markedly high) at around 90 minutes after sleep onset when the first REM stage is most likely to happen. Then again in the wee hours of the morning where more REM stages happen...more frequent and last longer.

If you are consistently seeing RERAs in the 2 per hour range...are they clustered or random? Are they associated with the hyponeas or OAs? RERAs could mean not quite optimal pressures (even though the AHI is probably fine) especially if you are also seeing some snores.
Might be a small 0.5 to 1.0 cm increase in that minimum might clean up things a little more.
I tend to want to use the least amount of pressure possible to keep things pretty much cleaned up. I have found that often with the minimum pressure a little more optimal that the overall pressure needs will stabilize or even reduce...averages and 90% numbers reduce when in APAP mode. Keeps the changes to a minimum and maybe not quite so high and less frequent if it does happen.

In my own case...originally I used 8 cm minimum and used a tight range of 10 max. I saw myself maxing that 10 out pretty much the bulk of the night but sometimes 8 would work (which BTW was what the official in lab sleep study came up with) but it wasn't working in REM sleep. Eventually we ended up with APAP mode 10 cm min and max wide open.
10 cm probably was over kill for non REM sleep stage but without that baseline pressure the machine couldn't get to where it needed to be on occasion in most likely REM sleep...up around 18 or so on occasion. Not all the time that high but occasionally.

So...up to you how much fine tuning you want to do...or even if you want to do anything.
RERAs, Flow Limitations and snores on your reports are probable signs of airway trying to collapse. The fact that your AHI is low means they don't grow up into some sort of apnea event.

So how is all this tied to maybe REM sleep...as we become adjusted to this therapy and sleep longer and better with less general awakenings then the chance of having more REM sleep occurs because when we have frequent awakenings (for whatever reason) we don't get the chance to have as many REM stages or have them last as long as they might when we don't get as much REM.

So it's very plausible that since you are sleeping better in general that the slight increase in whatever you might be seeing is tied to REM...might also be tied to supine sleeping with the same pressure needs explanation as above....or might even be a combination of supine and REM.

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archangle
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Re: Better Sleep = Increasing AHI ?

Post by archangle » Sat Oct 25, 2014 8:51 am

Crainnut wrote:And to clarify, the total AHI is now 1.78, just about the highest I've experienced since restarting therapy.
1.78 is sort of in the "don't care" range, especially if it's hypopneas. However, do go and look at the flow rate waveforms and see how long they last and how much your airflow is actually dropping. A lot of the times, when I look at the flow rate waveform for a hypopnea, I don't see what the machine is complaining about.

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Christine L
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Re: Better Sleep = Increasing AHI ?

Post by Christine L » Sat Oct 25, 2014 9:10 am

Crainnut wrote:And to clarify, the total AHI is now 1.78,
Should you be worrying about that? Gee. huh

Just look at the display in the morning and if it's that low, go on about your day.

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Re: Better Sleep = Increasing AHI ?

Post by Wulfman... » Sat Oct 25, 2014 12:32 pm

I guess it depends on why you're using an APAP to begin with. Do you want it configured to eliminate events and give you the best therapy ("numbers") or do you want it to ignore or not be able to pursue and squash those events......and give you "so-so" therapy.

Yes, those numbers you're seeing now are GOOD compared to the vast majority of users who just accept anything less then 5.0 and call it "good enough".

Lots of us can't tell the difference when we wake up whether we had a 0.5 night or a 1.5 or 2.5 night. But, sometimes the "psychological" factor of looking at the low numbers can also make us feel better about our therapy.

But, you were initially wondering about your numbers rising and seemed concerned about it.

I guess it all depends on what your goals are or what you're willing to settle for.


Den

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Crainnut
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Re: Better Sleep = Increasing AHI ?

Post by Crainnut » Sat Oct 25, 2014 10:34 pm

First, thank you all for your replies. I'm still learning and the feedback is helpful.

To go along with my theory of my AHI increasing as my sleep improves with PAP, last night was somewhat fragmented for a number of reasons and it showed up in the AHI reading. Dropped from the day before, 1.78 to 1.21. That is the trend I have been seeing which has been the opposite of what I've read here regarding the experience of other PAP users. When I sleep crappy my AHI goes down.

Den: I am trying to improve my quality of sleep AND quality of therapy. I'm willing to experiment a bit to improve upon both if possible. My sleep in recent years has been fair to poor at times and has undoubtedly impacted my health as it has that of so many others on this forum. My main concern right now is atrial fibrillation which is in check if I stay away from the things that seem to trigger an episode. I'm hoping this therapy will give me a bit of a cushion and keep me out of the ER.

Pugsy: I usually sleep on my back. I did something to my shoulders in July and it is painful to sleep on my side for any length of time. As far as the sleep study, I did one of those do-it-yourself oximetry sleep sessions to confirm O2 saturation levels drop overnight. Probable cause - OSA. I then did a do-it-yourself titration with an APAP machine for 7 days to estimate pressures. No brain state monitoring whatsoever.

The RERAs and hypopneas do appear clustered together and tend to occur during times when I feel like I'm dreaming. By the way, on PAP my dreams seem like they are in hi-definition.

In terms of pressures, the original settings were 5 ~ 12. I have slowly increased the base from 5 to 6.5 thinking that would improve things a bit. Going slow because I hate leaks. They wake me up. I also don't like a-flex and have disabled it so higher pressures might impact me more than others.

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Re: Better Sleep = Increasing AHI ?

Post by Wulfman... » Sat Oct 25, 2014 11:20 pm

Crainnut wrote:First, thank you all for your replies. I'm still learning and the feedback is helpful.

To go along with my theory of my AHI increasing as my sleep improves with PAP, last night was somewhat fragmented for a number of reasons and it showed up in the AHI reading. Dropped from the day before, 1.78 to 1.21. That is the trend I have been seeing which has been the opposite of what I've read here regarding the experience of other PAP users. When I sleep crappy my AHI goes down.

Den: I am trying to improve my quality of sleep AND quality of therapy. I'm willing to experiment a bit to improve upon both if possible. My sleep in recent years has been fair to poor at times and has undoubtedly impacted my health as it has that of so many others on this forum. My main concern right now is atrial fibrillation which is in check if I stay away from the things that seem to trigger an episode. I'm hoping this therapy will give me a bit of a cushion and keep me out of the ER.

Pugsy: I usually sleep on my back. I did something to my shoulders in July and it is painful to sleep on my side for any length of time. As far as the sleep study, I did one of those do-it-yourself oximetry sleep sessions to confirm O2 saturation levels drop overnight. Probable cause - OSA. I then did a do-it-yourself titration with an APAP machine for 7 days to estimate pressures. No brain state monitoring whatsoever.

The RERAs and hypopneas do appear clustered together and tend to occur during times when I feel like I'm dreaming. By the way, on PAP my dreams seem like they are in hi-definition.

In terms of pressures, the original settings were 5 ~ 12. I have slowly increased the base from 5 to 6.5 thinking that would improve things a bit. Going slow because I hate leaks. They wake me up. I also don't like a-flex and have disabled it so higher pressures might impact me more than others.
Since you mentioned Afib, I decided to do some searching. There have been many discussions here over the years. I was trying to remember if an APAP with a range of pressures was OK or if straight pressure was better. I didn't necessarily find any definitive answers, but did find some links if you're interested in some reading.

viewtopic/t34015/apnea-and-atrial-fib.html

viewtopic/t58165/APNEA-vs-ATRIAL-FIBRIL ... STING.html

viewtopic/t77254/What-came-1st--Sleep-a ... -AFib.html

viewtopic/t48708/Atrial-Fibrillation-st ... .html#wrap

In the back of my mind, I was thinking that pressure changes may have more of an effect or stress on the heart, but don't have any concrete facts or medical opinions to put forth on that.


Den

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Pugsy
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Re: Better Sleep = Increasing AHI ?

Post by Pugsy » Sat Oct 25, 2014 11:35 pm

When you have time sit down and compare what little clusters you might see with the typical time frames for normal REM sleep with good solid blocks of sleep.

This link has a normal hypnogram you can see or if you just Google hypnogram you can see lots of them.
http://en.wikipedia.org/wiki/Sleep

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