Worrying session last night - hypopneas increased tenfold!

I've been on PAP for almost 4 months now and I thought I was beginning to understand it all pretty well....but last night's results have left me totally flummoxed! My AHI shot up suddenly to ten times my average and I have no idea why!! I show below a typical night's charts, followed by last night's.





My history (I'll try to keep it brief)....my PSG at the local hospital last September yielded an AHI of 25.2 (OA 2.8, H 15.3, CA 4.. However, that included some particularly bad supine sleeping which I never normally do....but with all the wires and tubes there, I did! So I really compare my new figures (with PAP) against their non-supine findings of 21 AHI (OA 0.8, H 15.3, CA 3.2). Either way, the main culprit is clearly hypopneas.

The UK's 'National Health Service' will kindly provide me with PAP equipment and guidance/monitoring for free....but sadly not for many months! So I bought my own ResMed Airsense 10 Autoset and paid for some (remote) initial guidance from ResMed's own clinic in London.

They quickly set me up at 4-10 in APAP mode and after the first few days I now rarely go over an AHI of 1 - the 14 week average AHI is 0.8 (OA 0.2, H 0.5, CA 0.1). This includes use of both P10 nasal pillows and F20 FFM (after a few days of the pillows I give my sore nostrils a rest - then after a few days of the FFM I give the sore bridge of my nose a rest). It also includes use of a Chin Strap AND more recently a Soft Cervical Collar.

I also bought a 'Wellue SleepU' oximeter as an extra tool, because I thought drops in oxygen should show a good correlation with at least some of the events marked by the AirSense....but it doesn't! It usually shows NO correlation at all....but occasionally it does really well!

I study my data in Oscar every day and have read up on Sleep Apnea avidly since I was diagnosed with it. I decided just a week ago to follow ResMed's "CPAP Titration Protocol" as explained by 'CPAP friend' (https://www.youtube.com/watch?v=-IIZdru6vus) by upping my minimum pressure from 4 to 5. So far, that hasn't caused any obvious change in AHI.

However, last night I switched from pillows to FFM and my AHI went through the roof to 4.9 (OA 0.4, H 4.5, CA 0). A change to FFM has never done anything like that before, so I can't understand what happened. Hence my first post on here, as I have seen how much you people know about this subject.

In case they are relevant, I should mention a few things:

1. I have been noticing some weird Flow Rate waveforms lately (see example below) which are labelled in the Oscar Guide as "Palatal Prolapse". That's why I started wearing the Soft Cervical Collar a few days ago, to see if they would go away - but they haven't. Is there some side effect to wearing one - especially in conjunction with a FFM - of which I am unaware?



2. It is clear from the charts that my Pressure stayed at the max almost the whole night - but is that a cause or effect? I usually suffer from a small amount of aerophagia but today I am feeling it more - no doubt due to the consistently-high pressure.

3. My wife noticed that I was snoring again last night for the first time since I started PAP (though not as loudly as I used to). Looking at the Snore chart in Oscar, which is usually virtually empty, I can see what she means!

4. Despite all the above, I slept quite well!

So, my plea is simple....does anyone know why my hypopneas increased to 10 times their normal figure last night, please?

Might be positional? Are you a full-time back-sleeper? Or occasionally? Supine sleeping is hell on AHI.... when I went in for my titration I was adjudicated 13cm... then they asked me to go on my back. Supine the pressures went from 13 up to 18!

Relaxing your jaw and tucking your chin may help, it did help me. Also, your ring and machine's clocks may be skewed, check the time on both, the ring's PC utility has a clock sync in Settings... your machine may get cellphone time, or it may not.

Did you notice the tremendous difference in your leak rate?
The leak - and pressure - grew at the end of the night of 20th, and are much higher on all of the 21st, than they on most of the hours of the 21st.

I'd check all the connections in the system - humidifier seal, hose all mask parts, filter door etc.

Your not above the leak redline most of the time, but the difference between the two nights is noticeable.

Hi BigWing,

I've just finished a long response to another UK poster, so I need to be brief – I have relatives coming.

1. Just to put things in perspective, the staff at the sleep medicine department you attend would be delighted with an average AHI of 5 or under – because that is the clinical goal they work to. If, on some days, you are doing less that a tenth of that, they will be delighted.

2. You are clearly responding to your diagnosis and self-funded treatment with gusto. To which the response always is: don't be changing too many 'variables' all at once.

It is in the nature of obstructive sleep apnea that, even without you changing anything, results will vary – sometimes quite a lot – inside of any five days. And best practice is: to change one thing at a time – and only one thing at a time – and give it time to show that it is working – and then decide what to do next. Including possibly nothing – see above when I say that for medical professionals, under 5 is a result.

3. The other common response, I predict, from any of us experienced posters will be: there may be reason to come back later to leaks and choice of mask and 'positional hypopnea', but the variable which stands out most right now is pressure range.

I won't go into the details as to 'why the pressure of 4 cm is subjectively 'no pressure at all'. But I can tell you that for many patients the clinical effect is 'no effect at all'. And for you, that raising the minimum to, say, 6 or 7 is the first place to start. In my opinion.

Remember: (a) make one small change (b) try that for at least three days (c) evaluate ... and (d) if necessary, go back to (a).

As to maximum pressure: if you are using an auto machine, you can leave the maximum setting at 20 (ex-factory default), and the machine can safely decide if you ever need to go there.

4. You mention that you have had a sleep study or PSG – what kind was that?

Via a WatchPat? Via three-channels, with a clip on your finger, a tube round your chest, and prongs up your nose? Which?

And you mention that a machine will not be supplied for several months – so because of that, you have bought your own.

5. Is the machine that you have bought the same brand the hospital has standardised on?

The reason it matters is that, if the brand you have bought is different from the brand the sleep medicine department has standardised on, then communication will be tricky.

The software sold by ResMed for use with their range of machines will not work with the range of machines made by Philips Respironics. And vice versa: the software sold by Philips Respironics for use with their range of machines will not work with the range of machines made by ResMed.

Few SMDs keep both. And the NHS does not use OSCAR.

6. In general, the staff at NHS sleep medicine departments are not comfortable with patients making adjustments on their own initiative. If you use the search function (this page, above and left), you can find out what I have said before about UK law and the 'duty of care'.

The staff at the SMD I am a patient with let me do what I do, because they know that: I know what I am doing. You may have to negotiate your own laissez-faire arrangement.

That's all for now. And I was trying to be brief, honest.

And btw, I know I haven't added my location to my profile. I keep meaning to. It's in Gloucestershire, UK.

I really appreciate the responses and I will address each one later, but first I must share my news....I think I have solved the mystery....

I realised right from the start that what was unique (for me) about my really bad night was the use of an FFM together with a Soft Cervical Collar (SCC). But I really couldn't see how the SCC could have caused it.

I only tried the SCC because I read (https://www.apneaboard.com/wiki/index.p ... cal_Collar) that "Flow restrictions caused by chin tucking can be eliminated by wearing a loose-fitting soft cervical collar", but in my first few days of use (which happened to coincide with my use of nasal pillows) I could see no improvement.

I then happened to switch to the FFM to give my nostrils a rest, and that's when I suddenly got a tenfold increase in hypopnea.

In the absence of any other clues to the possible cause for this, I slept last night with the exact same setup except without the SCC....and that fixed it! When I awoke after 3.5 hours to go to the loo, my PAP showed ZERO events.

Feeling the need for further evidence, I reinstalled the SCC and got back in bed. Within 15 minutes, I had 5 events (i.e. an AHI of 20!) and my snoring had returned (according to the Oscar charts). Not a huge experiment but....Voila!?

It's starting to look like I may have Palatal Prolapse after all, but I am now trying to discover if using an SCC is known to be bad in that case....and why it should matter so much which type of mask you wear.

I'd welcome more input from anyone familiar with Palatal Prolapse.

vandownbytheriver wrote: ↑

Fri Mar 22, 2024 8:45 pm

Are you a full-time back-sleeper?

As I mentioned, I almost never sleep supine (I think because when I have tried it makes me wake with a snort as soon as I start falling asleep).

Relaxing your jaw and tucking your chin may help, it did help me.

Do you mean reducing the separation between chin and chest?! I thought lifting the chin was meant to reduce obstructions?

your ring and machine's clocks may be skewed

The 2 clocks seem to drift apart each day, though only by 10 seconds at most. But I synchronise the 2 sets of charts each night anyway by a distinctive sniff and arm shake as soon as I get into bed (part of a technique I have developed to also monitor when I wake and which side I am sleeping on - I can elucidate if there is any interest).

BigWing wrote: ↑

Sat Mar 23, 2024 5:33 am

I really appreciate the responses and I will address each one later, but first I must share my news....I think I have solved the mystery....

I realised right from the start that what was unique (for me) about my really bad night was the use of an FFM together with a Soft Cervical Collar (SCC). But I really couldn't see how the SCC could have caused it.

I only tried the SCC because I read (https://www.apneaboard.com/wiki/index.p ... cal_Collar) that "Flow restrictions caused by chin tucking can be eliminated by wearing a loose-fitting soft cervical collar", but in my first few days of use (which happened to coincide with my use of nasal pillows) I could see no improvement.

In my case I've found that chin tucking is actually good for my AHI. It promotes moving the jaw forward. I've been chin tucking for years to combat a radiculopathy in my C4-C5 neck. I have a pretty severe overbite and moving the jaw forward opens the airway. A chinstrap (Knightsbridge dual) tended to force my jaw clenched, which also forced it back. AHI goes up! Jason (poly-something technologist) has recommended chin tucking in his videos.

I then happened to switch to the FFM to give my nostrils a rest, and that's when I suddenly got a tenfold increase in hypopnea.

In the absence of any other clues to the possible cause for this, I slept last night with the exact same setup except without the SCC....and that fixed it! When I awoke after 3.5 hours to go to the loo, my PAP showed ZERO events.

Feeling the need for further evidence, I reinstalled the SCC and got back in bed. Within 15 minutes, I had 5 events (i.e. an AHI of 20!) and my snoring had returned (according to the Oscar charts). Not a huge experiment but....Voila!?

Sounding like my experience with the chin strap.

It's starting to look like I may have Palatal Prolapse after all, but I am now trying to discover if using an SCC is known to be bad in that case....and why it should matter so much which type of mask you wear.

I'd welcome more input from anyone familiar with Palatal Prolapse.

I thought I had PP too... my ENT said 'tongue'. Now I believe him... I'm experimenting with an over-the-counter MAD device and my AHI's and APAP pressures have dropped dramatically. Going to consult with a sleep dentist soon. I'd imagine that positive affects from an MAD would rule out PP... see my thread on my use of SnoreMD... the effect for me was dramatic. You should consult with an ENT, of course DISE (which I have not done) would be the gold standard in diagnosis.

BigWing wrote: ↑

Sat Mar 23, 2024 6:05 am

vandownbytheriver wrote: ↑

Fri Mar 22, 2024 8:45 pm

(snip)
Relaxing your jaw and tucking your chin may help, it did help me.

Do you mean reducing the separation between chin and chest?! I thought lifting the chin was meant to reduce obstructions?

Let's just say Apnea Board has misinfo running around too. Does moving your lower jaw forward help your AHI? Very much yes for me. Does tucking your chin allow you to relax your jaw and let it fall forward? Again, very much so for me... since I have an over-bite, the cushion or chin-strap tends to force my jaw back, exactly opposite of what I want. Experimenting with an MAD right now... seeing positive results... going to consult with a sleep dentist soon.

your ring and machine's clocks may be skewed

The 2 clocks seem to drift apart each day, though only by 10 seconds at most. But I synchronise the 2 sets of charts each night anyway by a distinctive sniff and arm shake as soon as I get into bed (part of a technique I have developed to also monitor when I wake and which side I am sleeping on - I can elucidate if there is any interest).

Good idea... I've done that myself... too lazy to carry it through to telling sides apart yet. I refer to it as 'hillbilly EEG'. The Movement graph on the O2Ring is not appreciated near enough.