Can't seem to break 4 AHI barrier

I'm 4 nights into my APAP (brand new). Sleep study sheet said I had 18 AHI events/hour. Prescribed 5-15cm on my Resmed Airsense 10 Autoset with a Airfit N30i mask (pillow). My main complaint for getting a sleep study was for pretty bad snoring, and some sleepness/hard to get up in the morning. 6'1 tall and 190 pounds, BMI is ~23, in my early 40s.

Machine came set with autoramp and 4 set as default, but I couldn't get air so I set it to 6cm min the first few nights. I also turned ramp off. Here was my chart from Thursday:
Using Oscar v1.1.1, I saw my average pressure was around 7.7 for the week, so I set it to min 7cm last night, and bumped EPR to 3. Here was the chart for that:
Wife says the snoring is gone, and I sleep very well 4 days into this. Feeling pretty good, no dry mouth like before. But oscar shows a lot of CAs? I understand a lot are false, like I woke up at 5am this morning to help my youngest. So I saw a few CAs as I was falling back asleep. But I don't recall waking up prior to that. Mask seems to fit good, no nose soreness or anything.

Any comments to a newbie on why I'm not seeing lower numbers for AHI? Appreciate all of your input and help.

If the CAs/central apneas are false flagging...they indicate poor sleep quality...being awake often and you may or may not remember being awake. You can't fix centrals with more pressure.
If they are indeed mainly related to poor sleep and are awake events being flagged by mistake you have to try to fix whatever is causing the poor sleep.

Now if you are sleeping soundly and sure these are asleep flagged centrals you can try turning off EPR or using it only during ramp if you need it to fall asleep because sometimes EPR (exhale relief) causes centrals.
You can go here and watch the videos and help you learn how to spot awake/arousal vs asleep flagged events
http://freecpapadvice.com/sleepyhead-free-software

4 days in--and you are looking like a CHAMP.
Pat yourself on the back.
The rest will come.
It almost never goes as fast as you'd like.

Thanks for the good feedback. I drilled down into the CAs and I can't be for sure if they are flat or not. Pretty close. I did turn EPR to be on during ramp only. Here was the chart after the change:
The AHI is definitely down but the leaks went up? MyAir score was slightly down due to the leaks, and I did wake up like 2-3 times. Not sure if this was related to epr being off after ramp was done. How's this compare to the original graphs?

I'm still going through the oscar how-to videos and am learning a lot, thanks for the tips.

Did those leaks wake you up much?
Did you wake up with dry mouth much?

The leaks are either mask moving around or mouth breathing. We can't really tell just by looking at the leak graph.

The AHI went down because the number of centrals went down and that's why we tried EPR being off...sometimes using EPR actually causes centrals in some people. At some point you might try adding in EPR if you want to with going up 1 setting at a time and see if the centrals return in large numbers or not. That's up to you.

If you want to zoom in on one of those flagged events and post it if you can't tell if it is arousal or asleep...we can take a look.
Do about a 3 minute segment and have the actual flag more to the last third of the graph so we can see the breathing prior to the flag.

I am betting most are awake related...we see at least 2 breaks in therapy where we know you were awake.
I am thinking you didn't sleep so solid last night...had probably a lot of little wake ups and might have been from the leaks and maybe something else. The leaks could be causing awakenings that you may or may not remember.

I'm with chunky frog: you're doing great! I am especially impressed by your good use of Oscar and your problem-solving cast of mind.

Having EPR at 3 did knock your flow limitations down some; then again, turning it off knocked your CAs down some. And on the third hand, some of the clusters of CAs close to start/stop times in the earlier charts look as though they may have occurred while you were awake or partly awake.

I think it would make sense to stick with your current settings, at least for a few nights, and see what happens (including how you feel during the night and during the day).

If the CAs are SWJ (sleep-wake junk) they may settle down as you adapt to the new experience and sleep better. If they are treatment-emergent, again they may settle down if your apneic threshold adapts. (With PAP, you may be washing out just enough CO2 to mess with the "breathe-now" signal to your brain.)

About the leaks: it's hard to tell, but a fair amount of the leaking looks like mouth leaks to me. Can you tell if air is escaping from your mouth?

Pugsy wrote: ↑

Sun Jul 19, 2020 2:23 pm

Did those leaks wake you up much?
Did you wake up with dry mouth much?

The leaks are either mask moving around or mouth breathing. We can't really tell just by looking at the leak graph.

The AHI went down because the number of centrals went down and that's why we tried EPR being off...sometimes using EPR actually causes centrals in some people. At some point you might try adding in EPR if you want to with going up 1 setting at a time and see if the centrals return in large numbers or not. That's up to you.

If you want to zoom in on one of those flagged events and post it if you can't tell if it is arousal or asleep...we can take a look.
Do about a 3 minute segment and have the actual flag more to the last third of the graph so we can see the breathing prior to the flag.

I am betting most are awake related...we see at least 2 breaks in therapy where we know you were awake.
I am thinking you didn't sleep so solid last night...had probably a lot of little wake ups and might have been from the leaks and maybe something else. The leaks could be causing awakenings that you may or may not remember.

I do recall waking up a little bit more last night. A couple times I did notice dry mouth. The piece from the previous graph of me waking was me going to get a drink of water because of that.

Here is the 3 minute zoom graph where I'm pretty certain I"m asleep. I don't recall any waking at 2am. Only 4am and 5:30am do I remember sitting being up. Real CA you think?

You are correct, this was my most unsteady night of the whole first week (other than the very very first night!). Felt very off this night, but my chart showed 0 OAs and fewer CAs. Maybe I just need to run a few nights with same setting, or maybe I'll try just a 1 EPR to compare. Thoughts? (and I appreciate your time!!)

Miss Emerita wrote: ↑

Sun Jul 19, 2020 2:25 pm

I'm with chunky frog: you're doing great! I am especially impressed by your good use of Oscar and your problem-solving cast of mind.

Having EPR at 3 did knock your flow limitations down some; then again, turning it off knocked your CAs down some. And on the third hand, some of the clusters of CAs close to start/stop times in the earlier charts look as though they may have occurred while you were awake or partly awake.

I think it would make sense to stick with your current settings, at least for a few nights, and see what happens (including how you feel during the night and during the day).

If the CAs are SWJ (sleep-wake junk) they may settle down as you adapt to the new experience and sleep better. If they are treatment-emergent, again they may settle down if your apneic threshold adapts. (With PAP, you may be washing out just enough CO2 to mess with the "breathe-now" signal to your brain.)

About the leaks: it's hard to tell, but a fair amount of the leaking looks like mouth leaks to me. Can you tell if air is escaping from your mouth?

I appreciate the kind words and support! I tried to read a lot here before getting the machine last week.

On your leak question: When I'm awake, I don't feel any air escaping, seems solid. I vaguely recall waking up from time to time to a slight escape. I'm mainly a back sleeper, but I remember going from side to another side for about 1/3 of the night. Some dry mouth here or there, and it does seem to vary from very little on some times, to more so on others (intermittent, if that makes sense).

Here's a section of my last night chart right before I woke up at 4am. Seems like a large leak going on and that I was starting to take up on this one? I got out of bed and recall some dry mouth around this time at 4am.
I probably just need more time under my belt to adjust. But appreciate comments on what I may or may not be doing right, and any fine tuning that could tighten the numbers.

chunkyfrog wrote: ↑

Sun Jul 19, 2020 1:14 am

4 days in--and you are looking like a CHAMP.
Pat yourself on the back.
The rest will come.
It almost never goes as fast as you'd like.

Thanks!! Appreciate the support. It's so neat being able to see such details to help fine tune the response to the machine.

As a side note, this forum did help me make sure my APAP came with a SD card from my DME. When I went in to pick it up, it had none, so I kindly asked for one, which they provided.

Another interesting story: I missed reading ahead time to check the hours on the machine.

I specifically asked them if it was new, and the reply was yes, brand new. After my first night, I found how to view the machine hours in "About", and it was at 399 hours. I called DME back and they had an excuse about a warehouse mix up, but were nice enough swap it out same day for one with 0 hours. Hmmmmmm.

I'll definitely take my time and remember it takes a while to get used to these to settle in.

captain556 wrote: ↑

Sun Jul 19, 2020 7:52 pm

Here is the 3 minute zoom graph where I'm pretty certain I"m asleep. I don't recall any waking at 2am. Only 4am and 5:30am do I remember sitting being up. Real CA you think?

Arousal related flagged CA/central. See that little bit of irregular breathing that happened right before the flat line and the flag?
That's arousal breathing...you may or may not remember being awake or half awake but you weren't asleep. It was very brief and maybe it was a turning over in bed hold your breath kind of thing. That's not a real asleep CA/central.

We can and will have very brief arousals that we don't remember because we weren't awake long enough to form a memory of being awake.

You do need more time and experience. Heck when I first started cpap it took me 3 months for my brain to quite waking me up just to tell me I had something weird stuck on my face at least a dozen times a night...and those were the arousals I remembered. There were probably a lot more.

When/if you wake up try to figure out why.
Also realize that it is normal to wake up after a REM sleep stage cycle has completed. Most of the time we don't remember it but sometimes we are awake long enough to remember being woke up and not have any idea why...and it could be simply a normal awakening after REM.
Google "sleep stages" and take a look at the normal hypnograms.....it's normal to wake up after REM and we have 3 to 5 REM cycles a night depending on how long we sleep.

About mouth leaks.

1. Tongue position. Try putting the tip of your tongue behind your upper front teeth. Then position the main part of your tongue up against your upper palate. Finally, give a little suck or swallow to create a bit of suction. You should now be able to open your mouth while breathing entirely through your nose. Practice this during the day, and see if you can get it grooved in deeply enough to help while you are asleep at night. For some people, this is really all it takes to avoid mouth leaks.

2. Collar. If your jaw tends to drop down during the night, pulling your mouth open, then a soft cervical collar, or a firmer snore collar, can be a big boon. More here:
http://www.apneaboard.com/wiki/index.php...cal_Collar

3. Tape. Some people (including me) rely on tape to keep the lips from opening. (I can't rely entirely on the tongue thing.) When the lips open, all too often that eventually leads to a noisy and disruptive mouth leak. To see whether tape would be feasible for you, I recommend that you invest in a box of Somnifix strips. They are very gentle on the skin but hold very well. Be sure to curl your lips inward per instructions before placing the strip. If these work for you, then you can experiment with lower-cost options.

Note about tape: Some people avoid it, for two reasons. (1) If you suddenly need to vomit in the night, the tape could lead to your aspirating some vomitus, which would be bad. However, you can sacrifice one strip to see for yourself how well you can pull you mouth open in an emergency using only your jaw muscles. (2) If there is a power failure and your machine goes off while you're sleeping, you won't be able to do the natural thing and open your mouth to breathe. As for that, out of an abundance of caution, I've put a circuit alarm in a plug on the same circuit as my machine. It will wake me up immediately if I lose power to the machine.

4. Chin strap. Many people find that most chin straps are counterproductive, because they tend to pull the jaw back, which makes it harder to keep the mouth closed. But I've heard good reports on the Knightsbridge Dual Band strap; the bands are attached to a cap so that they pull up rather than back.

Miss Emerita wrote: ↑

Mon Jul 20, 2020 10:05 am

About mouth leaks.

1. Tongue position. Try putting the tip of your tongue behind your upper front teeth. Then position the main part of your tongue up against your upper palate. Finally, give a little suck or swallow to create a bit of suction. You should now be able to open your mouth while breathing entirely through your nose. Practice this during the day, and see if you can get it grooved in deeply enough to help while you are asleep at night. For some people, this is really all it takes to avoid mouth leaks.

Thanks for the wonderful info. 1 seems to be helping. Is using a full facemask a solution as well? My n30i mask seems to be going less on leaks now.

I tried a f30i one night, but got 25% leaks. Found out I received a large and not standard frame, and my sizing shows standard. Was going to try it again once I get the right size.

I'm 3 AHI average right now on day 10 with the N30i, so I think I am getting it to work better. Seems to be sleep wake junk so far.

Sounds like things are settling down well -- glad to hear it. Yes, another approach for mouth leaks would be to use a full-face mask, and when you get the right size, it'll be well worth trying. The theoretical problem is that the larger the perimeter of contact with your face, the more opportunities for leaks. But plenty of people use FFMs with great success.

When you get the f30i, watch some fitting videos and try fine-tuning the fit lying down in your favored sleeping positions (side, back, whatever). Be sure to change the setting on your machine for mask type. Just so you know, there are mask liners that can help with comfort and leaks. Just google "cpap mask liners" and you'll see some options.

Miss Emerita wrote: ↑

Fri Jul 24, 2020 10:14 am

Sounds like things are settling down well -- glad to hear it. Yes, another approach for mouth leaks would be to use a full-face mask, and when you get the right size, it'll be well worth trying. The theoretical problem is that the larger the perimeter of contact with your face, the more opportunities for leaks. But plenty of people use FFMs with great success.

When you get the f30i, watch some fitting videos and try fine-tuning the fit lying down in your favored sleeping positions (side, back, whatever). Be sure to change the setting on your machine for mask type. Just so you know, there are mask liners that can help with comfort and leaks. Just google "cpap mask liners" and you'll see some options.

So I kept getting mouth leaks last week with the N30i (wife told me there were times where I had mouth open with "that weird noise") so I tabled the N30i, and went with the F30i with a medium cushion. First few days were dicey, couldn't fall sleep at times and AHI would be anywhere from 2-8 AHI depending on how long I was awake.

It seems a lot of those were CAs when I was just laying there so probably false awake stuff. Things seem to have settled down, here was last nights report, 10 days since I posted the first graphs:
I only recall waking once with what seemed to be a slight leak, so I turned the machine off and on again to get back to ramp pressure. Woke of feeling good and rested and not like I was fighting the mask or machine.

I've been running with EPR 2 on RAMP ONLY, and that's seems to be great. I also noticed I never got near 15 unless there were serious leaks so I reduced the max pressure down a bit to the mid 13's to see how that does. I'll run with the above settings for a few more days to see if it's consistent. Looking better? And thanks again for all the tips and advice so far, it really helps a newbie.

Great to hear you're feeling rested! I'm glad to see the CAs have settled down, and it sounds as though you've found a mask that works for you. I'd say keep on keepin' on!

If you had reported feeling sleepy and unrefreshed during the day, we could give thought to addressing the FLs with gradual introduction of EPR throughout the night. But as long as you are feeling good, I'd say don't change a thing.