One year later... Increasing pressure not helping

Hi, I know the first question is going to be "can you post some sleepyhead data". I guess I could, but I'm not sure it would help. Overall, my AHI is pretty good, usually between 1 and 2, occasionally under 1 or over 2, but not frequently.

Over the past few months, I have increased my minimum pressure from 10.0 up now to 11.5 by 0.5 each time. I've let each pressure settle for at least a month before the next step. I can't say I really see any response to what I have been doing. There may be a sweet spot for me at 11.0, but it may have been a coincidence. The average AHI there for 38 days was 1.01. At 11.5 for the past 2 months it has been 1.40. At each step, when I look at the Sleepyhead data, the 95% pressure on the SleepyHead overview has gone up by exactly the amount of the step. In other words, I increase the min, and the machine then adjusts the pressure up about the amount I step it. I guess I'm going to go back down now to 11.0. I was hoping to optimize things and get the AHI even lower. I have the pressure relief at C-Flex x2, and I am considering reducing that as well. SleepyHead reports that I have CA=0.3, H=0.38, and OA=0.73, so not an overwhelming number of centrals. Most of my events are relatively short - 20 seconds, preceded by a deep breath.

Any suggestions, or am I as optimized as I can get?

A year in, improvements have been very subtle for me. One issue I have is that I get overwhelmed with complex cognitive issues and have little patience. I also have some anxiety related symptoms, like occasional chest pains, and some GI issues that flare up. Most of this has eased up somewhat over the last year, but not completely. It does seem like I can deal with stress better than I could when I was untreated. I use a Swift FX mask, which doesn't seem to give me too many hastles, leaks and mouth breathing sometimes, but not too bad.

Thanks for your time,
Jim

Mouth breathing and leaks, STOP your treatment from working and make the data readings corrupt. Jim

Good point. The amount of leaking I get is minimal and does not really coincide with my events. I get a little noise from the leaks once in a while and occasionally a bit of a dry mouth. Not really a big deal.

I think that for some people there comes a point where more pressure simply doesn't reduce the AHI or change it much.
I know that I once did an experiment on my apap after using 10 minimum and 20 maximum for about 6 months and my AHI was averaging in the 1 to 2 range like yours. Back then our machines didn't tell us if we had any centrals or not.
So I decided to try more minimum pressure to see if I noticed any changes in either the AHI or my sleep quality or how I felt. So I increased my pressure 0.5 cm at a time (leaving it for 1 week with each change) up to where I was using 13.5 cm minimum.
So took me several weeks to get to that point. I discovered that nothing changed....the AHI was still pretty much the same with only the normal variances that we can expect....my sleep quality and hours of sleep didn't change...and I didn't feel any better or worse at any point along the path up to 13.5 cm minimum.

I wasn't unhappy with the way I felt at 10 cm minimum but just did the experiment to see if more pressure would do anything in my situation. It really didn't so I went back to 10 cm and decided that I had come to a point that this was pretty much a plateau of sorts and yeah...this was as good as it was going to get.

I have on occasion has an AHI of 0.0 and other than giving me a chance to pat myself on the back at little extra it didn't do anything either in terms of how I slept or how I felt.
My end goal has never been a perfect 0.0 math score...my goals have always been good quality sleep and feeling better during the day and as long as the AHI is "acceptable" then I am good.
Now if I noticed some HUGE improvement in how I felt with one of those nice low less than 1.0 AHI nights then I might have worked harder to see more nights like that but I just never did so I saw no sense in chasing something that really didn't seem to make any difference overall.

Even people who don't have OSA will have an occasional apnea event of some kind from time to time.
Total eradication of all apnea events is really an unrealistic goal and it doesn't guarantee that we feel any better.
Now I do notice a bit of a difference when the AHI is over 3.0 and there are clusters of events. For that reason I try to keep the clusters from happening.

jim22,

First I want to say that I agree with what Pugsy has said.

But I also want to address a few things you wrote in particular:

jim22 wrote: Over the past few months, I have increased my minimum pressure from 10.0 up now to 11.5 by 0.5 each time. I've let each pressure settle for at least a month before the next step. I can't say I really see any response to what I have been doing. There may be a sweet spot for me at 11.0, but it may have been a coincidence. The average AHI there for 38 days was 1.01. At 11.5 for the past 2 months it has been 1.40. At each step, when I look at the Sleepyhead data, the 95% pressure on the SleepyHead overview has gone up by exactly the amount of the step. In other words, I increase the min, and the machine then adjusts the pressure up about the amount I step it.

It's important to understand what you're trying to optimize when you are tweaking the pressure settings. And if the variable that you're trying to optimize is not changing all that much, it's time to look at whether the increased pressure setting is doing anything positive at all.

Every once in a great while, I've increased my very tightly controled max IPAP setting---on the grounds that when my max IPAP = 8 (as usual), I spend 50% or more of the night with IPAP = 8 on most nights, and conventional wisdom is that spending that much time at your max usually indicates the need for more pressure. So I've done the experiments: If I increase my max IPAP to 9, I spend a lot of time with IPAP = 9 and the AHI is still about the same---usually between 1 and 2.5. When I've increased the max IPAP to 10, same thing. When I've increased the max IPAP to as much as 12 or 13cm, the 95% continues to go up, although the median IPAP tends to stay below 11. And there's no real change in AHI. And I feel worse than when I keep my max IPAP = 8 because the more time I spend with IPAP > 8 (and EPAP > 6), the more aerophagia I get.

In my case it became quite clear that what was driving the pressure increases when I opened up my max pressure setting was mostly flow limitations. And yet, the overall Flow Limitation Index on my PR System One remained about the same. In other words, my particular flow limitations are not eliminated by additional pressure. It's possible that they're caused by problems in my nose rather than my upper airway being very slightly compromised. At any rate, the Flow Limitation Index is never extremely high---it's typically runs between 2 and 4 (and is higher on bad allergy nights). And since the allowing the machine to increase the pressure above my usual max IPAP = 8, max EPAP = 6 does lead to aerophagia and additional problems with tossing and turning, it's clear that increasing my pressure settings in an effort to reduce and/or eliminate my flow limitations and reduce my already decent AHI a bit further does not work.

In your case, I think it would be useful if you looked at what triggers the pressure increases. Chances are your breathing was already close to optimal with a min pressure setting of 11cm and the pressure increases are due to the small handful of events or flow limitations or snoring that's going to happen regardless of whether you're using 11cm or 13.5cm for your min pressure setting.

I guess I'm going to go back down now to 11.0. I was hoping to optimize things and get the AHI even lower. I have the pressure relief at C-Flex x2, and I am considering reducing that as well. SleepyHead reports that I have CA=0.3, H=0.38, and OA=0.73, so not an overwhelming number of centrals. Most of my events are relatively short - 20 seconds, preceded by a deep breath.

At this point I think you should be concentrating more on what makes you sleep the best (subjectively) instead of trying to reduce that already very good AHI.

It's also worth pointing out that when an event is preceded by a deep breath, it's possible that the deep breath may be evidence of a spontaneous arousal and that the event is a post arousal central that is misscored as an OA.

A year in, improvements have been very subtle for me. One issue I have is that I get overwhelmed with complex cognitive issues and have little patience. I also have some anxiety related symptoms, like occasional chest pains, and some GI issues that flare up. Most of this has eased up somewhat over the last year, but not completely. It does seem like I can deal with stress better than I could when I was untreated.

It's important to understand that CPAP only fixes sleep disordered breathing, which means that the symptoms that are resolved are the symptoms that are due to untreated OSA and nothing else. And CPAP data you provide says that the CPAP is doing its job. So the questions become:

1) How well are you sleeping? By this I mean all of the following: How long do you sleep each night? What's the overall quality of the sleep? Are you waking up a large number of times? Do you have a lot of trouble getting to sleep? Staying asleep? Waking up too early in the morning? Do you feel like you get enough deep sleep? Do you think you are dreaming an appropriate amount? All of this is important because if you are not sleeping well (in spite of the CPAP), then the bad sleep itself could be causing your residual problems.

2) Are the residual issues that you are experiencing due to anxiety or other medical problems instead of just OSA? It sounds like you have some other potential medical issues (anxiety, possible GI issues, little patience, etc.). For example, it is possible that you have an anxiety problem that goes beyond "anxiety due to untreated OSA", and that would explain why the anxiety issues have not completely resolved themselves even though your CPAP is doing its job of keeping the OSA under control. If you have not had a full physical exam with your PCP in a while, that may be the starting place for trying to resolve the continuing issues that you're dealing with.