Therapy Much Worse After 1 Year

[jcs]

Hi there,

I've posted a few times on this forum, and the responses have been very helpful. I could use another set (or sets) of eyes on these screenshots and some advice.

Basically I've been concerned that my therapy has been degrading over the last 6-8 months or so. I've suspected that something may be wrong with my machine, but maybe it's just me.

Screen Shot 2020-08-02 at 9.00.58 AM.png (361.15 KiB) Viewed 568 times

This is from one year ago, shortly after I restarted CPAP therapy. This is pretty typical from that time period. AHI in the 1-2 range, flow rate was pretty steady, not too many events.. usually just some hypopneas, very few CA/OA events.

Screen Shot 2020-08-02 at 9.01.52 AM.png (367.95 KiB) Viewed 568 times

The second graph is what I see now. High variability in flow rate, lots of events. Quite a few CA/OA events and breathing not detected episodes for multiple minutes.

Screen Shot 2020-08-02 at 9.08.52 AM.png (84.05 KiB) Viewed 568 times

If you look at the year's worth of AHI data it sure looks to me like things started to get worse around February of this year. I spoke with a sleep Dr. in May who increased my pressure from 8 to 9, but it hasn't helped. I spoke with her again last week, and she recommended switching to a full-face mask. I'm willing to give it a try, but I am concerned that there's a problem with my machine itself. Is that possible?

While googling I found this thread (viewtopic/t114731/Breathing-not-detected.html?start=15) which describes a very similar situation with the same mask/machine. I've also anecdotally thought that my AHI may be worse when dehydrated, but it's not been consistent. Any help/advice would be appreciated. Thank you.

[Julie]

Hi, is there a reason you're not on an auto machine (which would also allow plain cpap if necessary)?

Have you gained weight (even a little) over the time you mentioned?

Taking any new meds?

[jcs]

Hi Julie,

Thank you for your reply. I don't think there's any reason I'm not on an auto machine. I was given this one 3.5 years ago, and I think the initial sleep study recommended CPAP.

RE: weight gain, I've actually lost about 20lbs since I took a break from weight lifting earlier this year. Mostly muscle and water weight I think, but I'm sure I've lost 1"+ on my waist. I would guess my neck circumference has also gotten significantly smaller.

No new medications.

[Miss Emerita]

Hello jcs. There's some clustering to your events, which makes me wonder whether you have started tucking your chin toward your chest at night. That's something that can set you up for obstructive events. There's more on the subject here:

http://www.apneaboard.com/wiki/index.ph ... cal_Collar

I believe the Dr. Dakota and Eliminator collars are currently unavailable.

It would be a simple experiment to see whether a collar changes the picture.

[Julie]

Losing weight could explain some of the leakage as your face has changed. I wonder if a 'liner' from Padacheek.com might help with that... they're known to do it and the owner-designer is/was a member here.

[jcs]

Thank you for your replies.

RE: chin-tucking, maybe? I'll give one a try!

RE: leakage, maybe? The dreamstation usually tells me my mask fit is 100%. Does the leak rate look bad?

Could you take a look at this section?

Screen Shot 2020-08-05 at 5.06.33 AM.png (399.68 KiB) Viewed 440 times

I am so distressed by these "Breathing Not Detected" sections. I noticed that at 23:51 the leak rate starts to increase while the flow rate decreases.

Here is the end of that section, zoomed in:

Screen Shot 2020-08-05 at 5.07.35 AM.png (385.78 KiB) Viewed 440 times

I am just grasping at straws here, but I have a few theories:
1. I am mouth breathing during this period
2. It's some sort of positional thing where the hose gets crimped (this past night I slept with the hose over the headboard, so I think that's out as a possibility)
3. I have the large leak threshold set incorrectly for my pressure (9.0) and this is a positional thing where the mask is basically nearly off, and the machine can't detect my breathing as a result. Why DreamMapper does not classify this as a large leak is beyond me, but I do see a non-zero "number of disconnects" without me actually taking the mask off or anything...
4. There's something wrong with the machine (Anecdotally, I did have 3 nights in a row with AHIs around 10. I took the pollen/ultra-fine filter out, and they were both visibly dirty. I replaced the ultra-fine and rinsed the pollen filter and the next couple nights were better.. 2-3 AHI range.)

Looking back on a year's worth of data, i did not have a single BND event until 1/18/20:

Screen Shot 2020-08-05 at 5.08.27 AM.png (401.09 KiB) Viewed 440 times

I think it's unlikely that I removed my mask and just let the machine run for an hour between 2 and 3am. My wife would not be happy

Since then these type of events have become more and more common. I've replaced seals, filters, masks, headgear, etc.

Any advice would be appreciated!

[Julie]

Have you left off the whole left side of the report for a reason?

[jcs]

Hi Julie, thanks for your reply. Sorry, I was only trying (incorrectly) to show what I thought was the relevant part of the screen. I've updated the attachments to include the whole software interface. Sorry about that

[Pugsy]

3. I have the large leak threshold set incorrectly for my pressure (9.0) and this is a positional thing where the mask is basically nearly off, and the machine can't detect my breathing as a result. Why DreamMapper does not classify this as a large leak is beyond me, but I do see a non-zero "number of disconnects" without me actually taking the mask off or anything...

You can't really set the leak threshold thing.....that's something the machine does on its own and if it doesn't register a large leak then DreamMapper won't either.

Go into the clinical set up menu area and make sure
Auto On is set to "ON"
Auto Off is set to "ON"
and see if you get any more further BND sections without disconnects.

Your total leak number (that top line on the leak graph) is probably just below large leak territory which is why you aren't showing large leaks.

[jcs]

Hi Pugsy, thanks for your reply.

I checked the provider interface and Auto ON is ON as expected, but Auto OFF is OFF.

Can you explain why I should turn auto OFF to ON?

RE: the OSCAR leak rate, I think I manually set the max leak to 60 based on someone's advice previously. My hope is that this value is just inaccurate and all of my issues are due to poor mask fit..

[Pugsy]

I want to see if the machine turns itself off when the BND is happening. That's why I want the Auto Off to be turned on.
Your setting the threshold to 60 only affects the software reporting. It doesn't affect the machine large leak reporting at all.
The machine will report a large leak IF it senses a large leak no matter what the software is set to....that LL line on the events graph...that's large leak and the machine isn't flagging it. Now logic would make us think that if your mask isn't on your face enough for BND to be flagged that we would assume a really big leak but your pressure isn't all that high and maybe it is just below the LL line per the machine.

At this point I am questioning the sensors in the machine...and that's why I wanted to see if the machine shuts itself off after a minute with BND not detected or not.
It should shut itself off after a minute if it doesn't think you are attached and with auto on set to on then once it senses your breathing it should turn itself back on.

[jcs]

Just for kicks I did a little experiment. I put the mask on and breathed through my nose for a few minutes. Then I intentionally breathed through my mouth for a few minutes, and finished up with a bit more normal nose breathing. It looks like the machine tried to "pulse" me 8 times before giving up and classifying that section BND.

Screen Shot 2020-08-05 at 1.00.25 PM.png (374.1 KiB) Viewed 395 times

It used to be that opening my mouth and trying to talk or breathe with my mask on was very uncomfortable. It felt like the air from the CPAP was rushing in my nose and out my mouth. Perhaps now my anatomy has changed such that there is a very good seal between my nose and whatever else when mouth-breathing... it's not really that uncomfortable. In fact during this experiment I could sometimes feel pressure on my eardrum but my mouth/throat felt fine.

I will try the experiment again with AUTO OFF turned ON. I expect it will work.

One small point of anecdotal evidence is that I used to use the AUTO ON feature regularly, but I've switched to using the button on the machine. It feels like it takes longer for the AUTO ON feature to work, but I may just be misremembering.

[jcs]

The AUTO OFF feature seems to work. I turned the machine ON and let it just go... turned off after ~90 seconds.

Maybe it's not the machine, and I just need a full-face mask/more pressure?

[jcs]

I made a small change. I actually loosened the headgear slightly, and though the leaks are much worse, I am not seeing any BND sections. I think it's possible that I had the headgear too tight, compressing the mask too much. I'm not sure if the Dreamwear mask needs to really inflate, but it felt more comfortable while I was awake...

Screen Shot 2020-08-08 at 5.20.57 AM.png (485.53 KiB) Viewed 340 times

Obviously this much leak is bad. Does the high leak explain the huge variability in flow rate and tidal volume?

The variations are so spiky and frequent.. concerning. Mouth breathing??

For reference, here is a night from earlier this year, before I lost weight:

Screen Shot 2020-08-08 at 5.32.24 AM.png (476.63 KiB) Viewed 340 times

Can this dramatic change be explained by mask fit?

Is there a point where a new sleep study is every warranted? e.g. body weight change of +/- 10%?