New user, high OAs followed by waking up

[Pugsy]

Pressure pulses are only used when the machine is having trouble distinguishing (it thinks) centrals from obstructives. So if it isn't using them with the flagged OAs it's pretty sure they are obstructive.

Thanks for doing the zoom in thing. I am not the best at analyzing flow rate at this level unless they are so obvious a blind man could figure it out so I am hoping one of the other forum members who is good at this sort of thing will chime in when they see it.

And yes, I understand a lot of insurance companies go for apap to figure out pressures and forgo the titration to save money.
Most of the time it works out well but sometimes it doesn't and they have to do the titration anyway.
Who is your insurance with?? Any chance it's Kaiser? That's what they do routinely but they will do titrations when things aren't easily fixed with apap figuring out the pressures.

Was your initial sleep study done in a lab or was it a home study? If it was a home study did you where a belt around your chest or did they just stick a pulse ox on your finger?
The sleep study showed AHI of 15....obviously you are having double that now and not getting any sleep to boot.

Do you take any medications...if so what?

I know you said you never changed sleeping position but what sleeping position is your normal position?

I think if it were me I would back way up and still use auto (apap) mode and go with the 7 cm minimum and open the max to 20 and see what happens.
Plus I would be making an appointment with the doctor for follow up (likely won't be immediate anyway) just in case we can't get lucky and get this stuff sorted out.

You still aren't getting any Flow Limitations and that's really odd because with this level of OA showing up there should be some FLs too.

At the back of my mind I am also worrying about the machine...it would not be impossible for it to be getting everything wrong...It's rare but it can happen.
Was this a brand new machine when you got it? Did you verify that hours of use were 0?

[Seiru]

Thanks for the questions!

1. My insurance is through Cigna, who has actually been good with paying 100% of things, but the process of getting to that point has been slow and frustrating. They work with another company called CareCentrix to deal with CPAP suppliers, which is super frustrating. I can always speak with my doctor to see if this experience with the machine could be used to request a titration study again.

2. I had a home sleep study last year that showed an 8 AHI. It had waist/chest bands, O2 monitor, some sort of breathing flow, etc. I think the only thing it lacked was EKG stuff. I was prescribed an oral appliance (which I felt did nothing for my fatigue), and was scheduled an in-office sleep study as a followup to check the efficacy of the oral appliance. The in office study with the oral appliance showed an AHI of 15. So, it was at the very most doing nothing, and at the very least possibly making things worse (difficult to tell which since it's comparing an in-office study AHI to a home study AHI).

3. No medications!

4. Sorry, I have no idea if the machine is new or not. I didn't see any data on it when I got it. I would assume completely brand new machines are somewhat rare? Seems like a lot of people return their machines, so there are probably a lot of refurbs floating around.

Thanks again. I think I'm going to try going back down to the 7 pressure it came with, and try to fall asleep with that again. I think I'll call my doctor tomorrow as well, to see what they recommend.

EDIT: Forgot sleeping position. I always fall asleep on my sides, sometimes I'll wake up slightly on my back.

EDIT 2: Not sure it matters, but I also don't have any of the big risk factors for sleep apnea. I'm pretty skinny, I'm only 29 years old. Never seen an ENT to really investigate what the structural issues could be that are causing the apnea, but maybe that's a future step.

[Pugsy]

DMEs will often dispense a "used" machine (returned to them for whatever reason) and pawn it off as new.
Prior therapy hours can be reset but the total machine run hours cannot and those will show up in a special section of the machine information on the LCD screen.

Do you have the provider/clinical manual....it should explain where the machine run hours are located (I forget exactly which menu) and you can compare those hours with your therapy hours.

I just ask because sometimes a machine might get returned for being buggered up and the DME puts it on the shelf and means to send it back but doesn't and it ends up going out to someone else still buggered up.
Your reports don't look "normal" to me. Not what I would expect to see with someone having that many OAs should be having some FLs as well and you aren't.
Is it you that is weird or the machine? Are those maybe centrals and the machine flagging incorrectly? I don't know but something just isn't right here and I don't know if it is the machine or you.

So the AHI with the oral appliance was 15....so maybe the oral appliance helped some and if you hadn't been using it the AHI might have been higher. I thought the AHI of 15 was without anything.

Let's see what happens if you start back with the basics and then tomorrow if things are still whacko I really think that your should be talking to your doctor and the machine supplier.
Maybe there is a sensor malfunction or something..it's rare but it can happen.

[Seiru]

Well the home sleep study (that was without an oral appliance, because I hadn't been diagnosed with OSA yet) showed an 8 AHI. So I don't believe the oral appliance was helping much, since when I used it my AHI was 15 (even ignoring the margin of error between a home sleep study and an in-office study).

[Seiru]

I checked the machine hours and they seem to match the therapy hours that I've used the machine for.

[Pugsy]

Okay...think I got it now.

How long ago was the in lab sleep study without anything that gave you AHI of 15?
And do you have the report....and what does it say about the oxygen levels?

[Seiru]

Haha, sorry, I think we keep misunderstanding each other. Here's the two sleep studies I've had, just for clarity:

1. October 2016, pre-OSA diagnosis. Home study, no oral appliance. Showed an AHI of 8.
2. April 2017. In-office study, wearing an oral appliance. Showed an AHI of 15.

I don't have the report, but I don't think my oxygen dropped below 90 for either of the studies. I can double check on that, if necessary.

[Pugsy]

Okay...I think I got it now. I just wanted to make sure that we had a picture of what the results were and also when.
Those are recent studies...unlikely that something significant has caused things to worsen unless you packed on a lot of weight in 3 months.
The oral appliance may have helped somewhat....we just don't know what the AHI would have been without it.
At any rate...things are looking much worse and some work needs to be done.
I can understand missing the pressure needed...they just came up with a wild ass guess as a starting point.
The problem is that you go from 7 starting to 14 and nothing gets improved at all. Something just isn't right here. Plus you don't have the FLs that I would expect to see with that many OAs....are those misidentified centrals...maybe. From the flow rate there look to be teeny tiny bumps which would indicate very minor air movement...they aren't totally flat.

I dunno what's going on ...I just know something isn't following the usual and customary stuff.

[Seiru]

Interesting. I'll be sure to keep trying every night (at least for a few hours) at a stable pressure for a while. I'll followup with my doctor as well to see if they have any ideas. I'm worried that at this point, they'll come back to me and say "Well, you're fiddling with your pressures so much, no wonder you can't get used to the therapy yet!"

[Pugsy]

I would like to see what apap mode with minimum of 7 (or 10) and max of 20 does.
I want to see just how much pressure the machine wants to use to kill those OAs.
I know 7 isn't going to be enough...but you are right...the doctor is going to say "you didn't do what I ask and now see what you did"
We already know 7 cm fixed isn't going to work..
Next logical step would be try apap mode...7 min and max set to 20.
Then the next logical step would be to raise the minimum based on what the prior night showed.
And the next logical step would be to raise it again.
That's what a titration does....keeps increasing the pressure until the desired results are obtained.

And if those are really OAs....you may need in the upper teens in terms of pressure if what happened last night is any indication.
And then you get to talk about bilevel and aerophagia.

[Seiru]

Got a new mask and some sleep data at 7cm. As expected, 7cm doesn't really do much at all. At least I'm getting better at falling asleep with the mask on.

I notice I'll sleep for anywhere between 5-15 minutes at a time, and wake up again. Which sort of lines up with the apneas on the graph. Here's the pics for the hell of it, maybe it shows something useful, I don't know.



And a closeup:



Haven't heard back from my doctor yet. I guess I'll try going back to APAP mode to see what happens? I'm a bit skeptical, it seems like APAP will take quite a while to get to a correct pressure if I set the min as 7 and max as 20. And I can only really handle so much sleep-wake-sleep-wake cycles before it gets too stressful and I take the mask off for the night.

[ajack]

set 7-10 for now, get use to that for a few days. Then worry about AHI and correct pressure.

[Pugsy]

The reason for the apap mode 7 minimum and 20 max was simply to see what the machine does and where it goes.
You could do 10 minimum and 20 max if you wish.
You could do 15 minimum and 20 max if you wish.
You could try fixed 20 if you wish.
I tend to suggest starting conservative and work up (which is what they do in a sleep lab titration) but you can work down if you wish.

I don't think that the slow response time is going to hurt the machine doing sufficient pressure increases fast enough but I do think that your frequent wake ups will affect the response time because the machine is unlikely to do anything while awake. I think you are waking up sooner than the machine can do what it needs and while awake there is no need to do anything.

If you can't stay asleep from whatever those events are then you need a real titration study to figure out exactly what type of events you are having and find a pressure that works.

[cpapdude1]

My idea is to put your machine on automatic and set the minimum at like 10 and max at 20.

That is the simplest and fastest way to solve your issue IN MY OPINION.

[ajack]

First I would want to keep the mask on for more than an hour or 2 a night. Watch tv with cpap to get use to it more. I'd set whatever pressure that would let me do that. I took a week to get use to the pressure wearing the mask all night, I woke every 1-3hrs, adjusted, swore and went back to sleep as best I could. As you are using the mask more, your body will get use to it.