Desperately need to help lowering AHI

[morecaffeine]

Hi!



First of all, thank you to this whole community and shoutout to Pugsy. 

I don't know you yet, but you’re past comments and the rest of the community have been 10x more helpful than my own doctor. Would love to buy you a coffee! (can you DM me your email address?)

Okay, now on to my struggles...

I took at-home sleep test (ApneaLink Air) last month after constant fatigue and waking up feeling exhausted. I had also recently bought the Oura ring which tracks sleep quality. Was constantly getting low scores saying my sleep quality is bad. Turns out, I was diagnosed with Obstructive Sleep Apnea w/ significant oxygen desaturations.

A little about me:

-Mid-twenties male

-Exercise daily, average build, good sleep hygiene
-Non-drinker & non-smoker
-Have some nasal congestion sometimes before bed.

At home sleep test (ApneaLink Air) Results:
—> Without therapy my AHI averaged at 17.5 

—> Doctor suggested APAP therapy at 5-20 cwp with heated humidity.



After my at-home sleep test, went in for in-lab sleep test. I wore nasal mask at 9 pressure and felt better than usual after.

So the next day I went out and bought a cpap machine (airsense 10 with n30i) and have been struggling to use it successfully.

Most days, I still wake up and feel drained & fatigued. My AHI score is always poor.

In desperation to feel better, I've been experimenting with my pressure settings and masks, with little to no success.

 Some nights are better than others obviously, but since I've turned the pressure up, I've noticed a tiny improvement in AHI but I do remove my mask 'in my sleep' sometimes (as you'll see below).

I just learned about Oscar (thanks to this community) and set it up last night. 

I recorded a screen share video here ( https://www.loom.com/share/d76bd79ea43c ... c04a9b0dc7 ) and went through my Oscar results. I don't know how to analyze or interpret this yet so hopefully, I captured everything important!

Does anyone know how I can get my AHI down? Or what Im doing wrong?

Thanks in advance!

[Pugsy]

viewtopic/t158560/How-to-post-images-for-review.html

please read above thread and post a screen shot of the detailed report in the format mentioned and examples shown.

I couldn't see how to zoom in on the detailed report on the video to see hours of use...and I see a big gap in therapy but couldn't check times either.

I did see a lot of central apneas flagged (CAs on the OSCAR report) which makes me wonder what is going on.
Changing the pressures isn't going to do a darn thing for centrals. So quit doing that for now.

How is your overall sleep quality? Waking often? How many hours of real sleep are you getting...don't count awake time laying in bed with mask and machine on.
The second segment on the report you did share was rather short and had a lot of centrals...were you awake or asleep that last segment?

Watch the videos here...especially the last one.
http://freecpapadvice.com/sleepyhead-free-software
We need to figure out if the centrals flagged are real asleep centrals or arousal/awake related false positives.

[morecaffeine]

Thanks Pugsy.



Here are some images:

Overview tab:

https://imgur.com/a/LczZk2v

https://imgur.com/a/n4JfUGz



( Zoomed in around 7am during second segment ):

https://imgur.com/a/rJFXNfq




Overall sleep quality:


I’d say its okay. I fall and stay asleep easily, but it's definitely not refreshing or restorative sleep (likely due to apneas / these interruptions). I get 6-7 hours of actual sleep per night, not including laying in bed awake.

Second segment:


I was sleeping. I’d woken up from my alarm and realized I took the mast off unknowingly (i’ve done this a few nights now since increasing my pressure).

So I put it back on and went back sleep for a few hours.

[Pugsy]

Not quite zoomed in enough on the segment with centrals.
But from this overview...looks more like awake/arousal breathing to me.

Need a more zoomed in image.
Go to the events graph tab on the left under AHI and above Statistics...click on events tab and then click on CA event tab.
You will see a list of CAs/centrals and the time they were flagged.
Scroll down the list until you see the CA flagged just before 06:58:00...click on that CA flagged event.
The graphs on the right side will change scale...that scale is what we need to see.

Do the same thing for the CA flagged at around 06:04: or whatever is the first CA flagged after 06:00:00 ...I can't see exactly what time...but I want same level of zooming in on the first CA flagged after 06:00:00.
The event you highlighted and clicked on should be sort of in the middle of the graph...that's what I want.

[morecaffeine]

Oops. Thanks for these detailed instructions.

Here are more zoomed in pics.

8/16 Clear Airway event at 6:58am (3 pics):

https://imgur.com/a/NkRwLO4




8/16 Clear Airway event at 6:11am (3 pics):

https://imgur.com/a/XlL3H3S


~~~~

Also, some good news, I went through the resources you shared yesterday and learned more about these CA events

I lowered my pressure settings and my AHI improved a little! I also managed to keep the mask on all night. Results below.

8/17 Overview:

https://imgur.com/a/Y5t3xAv

I zoomed into some CA events too. I had 28 total CA events last night with a full night of therapy. Which is less than Aug 16th where I had 32 events, from an only partial night of therapy. Below are some zoomed pics of these CA events too.

8/17 Clear Airway Event at 6:51am:

https://imgur.com/a/PlPiCRs

https://imgur.com/a/okzm70v

https://imgur.com/a/3WUqqZt




8/17 Clear Airway Event at 6:04am:

https://imgur.com/a/S7oo46z

https://imgur.com/a/obSzpD1

https://imgur.com/a/ilsYlOc


[Pugsy]

8/17 Clear Airway Event at 6:51am:

https://imgur.com/a/PlPiCRs

https://imgur.com/a/okzm70v

https://imgur.com/a/3WUqqZt

When evaluating zoom in flow rate we don't need all those other graphs. You are creating extra work for yourself.
The first one (top) of the 3...is all we need. The other zoomed in graphs are useless.

https://imgur.com/a/PlPiCRs .....looks more arousal related. Probably in the process of waking up.

But not as clear cut arousal as this one below.
This one
https://imgur.com/a/S7oo46z
Most definitely arousal/awake related.

[morecaffeine]

How do you know when they are arousal-related, Pugsy?

I tried tightening my mask straps yesterday to reduce leak, and changed the pressure setting from 5 to 9, which I learned is what they used during my in-lab pap titration test. I achieved a 2 AHI during my test...

But last night 9.28 AHI with 73 CA events, 11 Obstructive events, and 1 Cheyne Stokes Respiration.

See here: https://imgur.com/a/GknZGAn

I did stay in bed way after my alarm clock went off (around 5.30am) which appears to have been mostly interrupted sleep.

But is there something I should be doing differently with my therapy/setup? I feel exhausted whenever my AHI is like this and I need energy for work

[morecaffeine]

Pugsy, I've been reading your past comments about central and wanted to clarify something.

During my in-lab sleep study, I only had one central.

https://imgur.com/a/SNJD2Lv

In that image of my in-lab sleep study, you will see I had quite a few 'arousals' though.

But during my at-home sleep study, centrals made up 2.2 of my 4.5 Apnea index.

Details: https://imgur.com/a/64Eod5h

But last night with therapy I had 73 central evenbs, according to oscar (as shown above)

[zrob]

Pugsy helped me by suggesting a lower PS. I think I was at 8 and had lots on centrals on my first night. I went down to 4 and now I range from 0.5-3 AHI a night.

[Pugsy]

How do you know when they are arousal-related, Pugsy?

You learn how to spot arousal/awake flow rate from asleep flow rate.
http://freecpapadvice.com/sleepyhead-free-software

Some people who don't have a problem with central apneas when not on cpap can end up with problems once on CPAP.
Sometimes it is related to higher pressures...sometimes related to any pressure....I have seen as little as 5 cm pressure trigger centrals. It's called treatment emergent central sleep apnea.

Your centrals do seem to increase significantly when your pressure hits the max of 9 cm...don't have too many when the pressure is around 7 cm.
I am unsure of your centrals are awake/arousal related mostly....or primarily related to cpap pressures.
I do think you need to make your medical care team aware of your results though. The prolonged CSR event and the fact there are just more centrals than we want to see or can pooh pooh off and blame all of them on arousal/awake breathing.

Now the doctor may want to just give things time to see if the centrals reduce on their own but he does need to be aware of them.
If it were my report...I would reduce the max to 7 and see what happens...while "giving it time".
The reason docs "give it time" is that sometimes people who do have treatment emergent central apnea will have it fade away with time on cpap. That and insurance usually requires it before they want to pay for a different machine that can deal with central apneas as well as obstructive apneas.