I don't get it! AHI still high

[mellocello2003]

There are numerous posts about this particular question but none seem to be applicable to me.

I have a Respironics Auto PAP and use a Fisher and Paykel nasal pillow mask. I've never quite been able to get my AHI down into acceptable levels (below 5) where I feel great every day. Occasionally, there are a few glorious days where I feel optimistic that I've finally figured out what works best, but the very next day I feel terrible once again.

All throughout, my AHI has never really been reasonable.

I'm guessing that my current high AHI woes are related to me opening my mouth despite wearing a chin strap. I'll be taping my mouth shut tonight to see if it improves the situation, as well as moving the chin strap a bit closer to my head (I was wearing the headgear portion a bit further back towards the back of my head which could have been pulling my chin back, reducing the size of my airway and leading to more apneas).

I've tried a Fisher and Paykel "FlexiFit" full face mask, but that bruised the bridge of my nose, and seems to be leaky (if I look at the LPM chart).

To try to help you guys help me the most, here are some specific questions:
1. Is it reasonable for my AHI to be this high? Based on what I've read, the CA's are generally misread by CPAP machines, but OA's and Hypopneas are often correct.
2. How do I get the most out of interpreting my EncoreViewer results?
3. Should I look into a different full face mask or try to continue futzing with a chin strap and nasal pillow?

I've also attached a few nights of data from EncoreViewer.

I appreciate everyone's help in advance.
http://postimg.org/image/ejhpf8co7
http://postimg.org/image/ykhg4g10n
http://postimg.org/image/jpapms09x

[Pugsy]

Welcome to the forum.

I don't see any huge really bad leaks on those leak reports...if you are mouth breathing you aren't doing very much of it. The leak line varies a little but so does your pressure and we expect more vent with more pressure.
If that was my leak line I wouldn't do anything about it unless the leak is maybe waking you up often.
I wouldn't be doing a chin strap nor looking for a different mask...your leak line is well within acceptable limits.
Your large leak number is somewhere around 85 to 90 L/min.

Your minimum pressure is not optimal. It is making the machine start out too low so it takes too long for it to get to where it needs to be to effectively prevent the events...so while it is climbing (it goes up slowly) events materialize and fade away while the machine is trying to increase to where it is needed.

Please look at this thread.
viewtopic.php?f=1&t=39869&st=0&sk=t&sd=a

You need more minimum pressure so that the airway is help open a little better to prevent the collapse of the tissues and when it does happen the machine can get to where it is needed more quickly.
So if you are comfortable changing the minimum...increase it by 1 cm (it will be an easier adjustment) and watch your reports for a few nights...then another 1 cm for a few more nights...then maybe another 1 cm.
Look for the snores and flow limitations to start reducing and the OAs and hyponeas should also start reducing in number.
I suspect 2 or 3 cm more minimum will make a pretty big difference in the clutter we see on your report.
There's enough "clutter" with the snores and flow limitations that it's likely your sleep quality is not optimal.

If you aren't comfortable changing your pressure yourself then get with your medical care team and tell them things aren't optimal.

I wouldn't do anything with the maximum just yet. Sometimes when we get a better minimum preventing happenings the need for the machine to play catchup with the higher pressure is eliminated. If you get to 9 or 10 minimum and the max is still being reached and flat lined often...then increase the maximum a couple of cm to see where it is wanting to go.

[mellocello2003]

Wow - that's an amazing response. I'll try that tonight and keep you guys informed.

Thank you so much!

[porete]

I agree with Pugsy; originally, my machine was set from 4-14. However, I started feeling like my cpap wasn't working well and my AHI was well over 5. I noticed from my Sleepyhead data that my machine was averaging about 9 minimum. I decided to change my min. pressure to 8 and my AHI average went down to the 1 -3 range. I felt much better in the daytime and my energy level went back to normal. I would strongly advise changing the pressure and see if you improve.

[mellocello2003]

Looking a whole lot better. THANK YOU SO MUCH!!

Should I try to up the pressure another .5cm to further reduce the OA events? Or would I run risk of increasing the CA's?

I'm still wearing the chin strap, but will not wear it tonight since it's a pain.

See below

[mellocello2003]

Also, what kind of leak line would you be seeing if I really did need a chin strap?

Thanks again so much.

[Pugsy]

I would watch the reports for a few nights before increasing another 0.5 cm...see if things will go a little lower anyway.
I have found that there's some night to night variance anyway. Let your body get used to the changes now and see if things settle down a little more.
This report is awesome good as it is...especially compared to the previous reports. See what I mean about the pressure stabilizing once it doesn't have to play catch up?

Mouth leaks are usually seen as large clumps or spikes pushing above the baseline vent leak line.
Your leak line is nice and level. The brief little spikes that you see flagged as large leak are obviously mask reseating or mask removal...no big deal.
Here's an example of mine below...probably a little mouth breathing going on. See the humps? It still doesn't get to 90 L/min where my large leak territory starts. So the leak line is still within acceptable parameters...it doesn't wake me up and if it is mouth breathing...it sure isn't enough to impact therapy pressure.
How do I determine likely mouth leaks? Mainly because I use a nasal pillow mask that never moves. So there is just one other place for air to leak from . Not all mouth breathing means that a person is losing enough air to lessen the effectiveness of the therapy pressure. I have woke up in the middle of the night with lips barely parted and only a tiny bit of air escaping.

I don't see you needing to go to any extra measures to keep your mouth closed based on the leak lines...
Here's one of my reports shown in Encore so you can get the same idea what someone else's might look like.
I have a really bad leak example but Photobucket is acting squirrelly and not letting me access old photos.

[mellocello2003]

OK. Well, I tried without the chin strap, and the following odd behavior occurred (I feel terrible again today).

Leak lines are a bit shaky, but nothing terrible (like you imply). Certainly more shaky than without the chin strap. Also, my wife noticed that I was sleeping with my mouth open.

Back to the chin strap? Or increase the base pressure? Again, thank you so much for the help so far. This is really the way to solve sleep apnea - short iterations, good data, and caring people.

[Pugsy]

Your obstructive apneas increased a little...those likely played a factor into feeling less than ideal today.
Your leaks are NOT excessive and no where near where the machine can't compensate for leaks.
You had one short lived large leak spike at the 7 hour mark...that little spike didn't mess up the entire night...it only messed up that little few minutes where you had the large leak.
Now if you woke up multiple times during the night because of mouth leaks...well maybe use the chin strap but it isn't needed for bad leaks but it might benefit things in the less sleep disruptions category.

You have in front of you 2 reports...one looks darn near perfect and the other looks like a poor quality sleep night.
Pressures are the same...we can and will have this sort of variance without any change in pressure.
You might leave things alone and tonight have a report that looks like the darn near perfect report.
We don't have a crystal ball so that we can look to see if tonight we might need a little more minimum or not. Or heck maybe it wasn't pressure and maybe it was something else.
We really can't be changing pressures every day base on last night's report...we never know if last night was a fluke...or was the near perfect night a fluke?
We do know that you can get a near perfect report at this pressure...which way will it go if you left things alone for 1 week?
We don't know until that week goes by and you get to look at the 7 reports and see if you had more good nights or more not so good nights. It really is about trends and patterns.

When I first started bilevel pressure self titration (long story as to why which I won't go into now) but I picked a pressure and it wasn't close enough for me so I selected a little higher pressure combination and I got a spectacular report and the very next night I got a pretty ugly report....but I knew that the pressures I selected gave me at least one good night.
If I remember right the AHI was like 1.2 or somewhere in that range...and the ugly night was over 5.0. Pretty big change and the bulk of it was obstructive. Over the next 7 days I stuck to the setting that I got the first good report with and I think I had 3 good nights with AHI 1 to 2 and 4 nights with AHI over 4.0.
I have always been one who wanted to use the least amount of pressure as I can get by with...so I decided that since I did repeat the "good" nights that I would keep those settings for another week and see what happens. I think I had 4 good nights and 3 bad nights that second week. Then the 3rd week about the same 4 good and 3 not so good but the not so good AHI started coming down a little and the good nights also gave me a couple of nights with AHI less than 1.0.
So for 6 weeks I left the settings alone..didn't change anything then I went back and compared the overall average AHI for the first 3 weeks to the overall average for the second 3 weeks and you know what...the average was reduced by 50% without me changing anything...
At the end of 6 weeks my weekly AHI average was around 1.4...more good nights and only a rare not so good night.

Granted my AHI wasn't horribly high on a "bad" night but it was enough that knee jerk reaction is to try to do something to "fix" it. I resisted the urge because I knew that I could have good nights too....
That was nearly 18 months ago and it remains true to this day. I have mostly "good" nights and some "really good" nights and occasionally I have a not so good night with AHI 5 to 6.

That said...another 0.5 cm minimum increase isn't going to hurt anything and you might find you feel better with that added security. Some people have said that they actually feel better with a 1 or 2 cm higher pressure than the reports might indicate that is what was doing a good job. Example reports show a nice low AHI at 8 cm but they actually feel better using 9.5 maybe.

If you are more comfortable using a chin strap and like the added security..then by all means use it but it isn't a critical need just looking at the leak line itself. It is very possible that the minor mouth breathing you might be doing without the chin strap is a disruptive factor to your sleep and that in itself is unwanted.

Were you using a chin strap on the "good" night? I had the impression that you weren't using one and thought you had to because of bad leak. If you have been using a chin strap for a while and last night you didn't use the chin strap...that change in routine itself could have impacted the quality of your sleep.
Last night's report with the added CAs....points to just a crappy night in general. I bet those CAs are from minor arousals that you may or may not remember and that means your sleep was likely fragmented and fragmented sleep pretty much guarantees feeling yucky the next day. It isn't totally the AHI that might be a little higher...it's also the fractured sleep that likely goes along with things.

So make a decision what you want to accomplish with your experiments...set your experiment parameters and stick with them for a week...then evaluate. Using or not using a chin strap is part of the parameters. Remember science 101 when doing experiments...keep your variables to a minimum and repeat your experiment several times so you can gauge reproducibility of the results. It's unfortunate that we simply don't sleep the same each night so we have that variable every night....so limit the other variables as best you can.

You can try a little more minimum..won't hurt and continue trying without a chin strap if you wish.
You can also revisit the lower minimum later if you want to. Just try to resist the urge to change things on a daily basis because you are trying to fix last night's results thinking that is what you might have tonight...and what you might have tonight probably is not going to be what you had last night. because we just don't sleep exactly the same each night.
You are in the tweaking stage where you are just doing a bit of fine tuning. The first big jump in pressure gave you a remarkable result..now you have to be patient and see how things are going to trend. Tiny tweaks and lots of patience are needed now.

[mellocello2003]

Excellent. Thank you. The good night was using a chin strap. This is also the first time I haven't used a chin strap in a while, and I was thinking that it was my body "rebounding" to the lack of a chin strap.

So, here's what I'll do.

I'll go back to using the chin strap (despite it not being necessary), and get to a point where I'm actually in a nice AHI range for a long period of time (i.e., months).

Then, perhaps on some long weekend, I'll try getting rid of the chin strap, and attempt to reach a similar minima over a range of a few months.

Unfortunately, things are rather hectic at work, so I simply can't take the risk of attempting a long-term trend without my chin strap (despite it rather clearly being related to my body reacting to change).

[Pugsy]

Sounds like a good plan.

Keep us posted though.

[mellocello2003]

OK, it's been a few more days, and I have some more results. My AHI has been hopping around between 4 and 5, and occasionally 6 and change. In general, I'm feeling better, but I do know that I should be able to get things down to an average of 3 or less (at least in theory). I also have soreness/redness between my nostrils, and a sense that my nostrils are getting bigger and bigger as a result of using the nasal pillow. I may be wearing it too tight?

A few questions:
- I'm currently using A-Flex set to 1. Should I switch completely to Auto CPAP and get rid of the A-Flex? I know that people find just straight Auto CPAP without the flex, although less comfortable, yields better AHI.
- I'm using an Opus 360 nasal pillow - do you recommend other nasal pillows? My nose has a slightly longer "extension" in between the nostrils, and that's what's pushing up against the pillow and getting red and sore.
- Due to the fact that my AHI was still hovering around 4.5, I tried tuning my machine up another 0.5 to disastrous results (my AHI spiked to 6.9). My only assumption is that the machine really does need the ability to hover around 9, and by pushing it up 0.5, it (obviously) had nowhere to go but up.

Here's the night where my AHI spiked to 6.9


and here's last night


Any thoughts or insights very much appreciated!

[Pugsy]

I also have soreness/redness between my nostrils, and a sense that my nostrils are getting bigger and bigger as a result of using the nasal pillow. I may be wearing it too tight?

Yep, too tight highly possible.
Maybe consider a different nasal pillow mask at some point. Also, maybe try going up a size in nasal pillow. Don't freak out thinking larger will make your nostrils larger. It won't unless you have it so tight it is pulled into the nostril.

I'm currently using A-Flex set to 1. Should I switch completely to Auto CPAP and get rid of the A-Flex? I know that people find just straight Auto CPAP without the flex, although less comfortable, yields better AHI.

Some people might do better with AFlex off..Some people might do worse with AFlex off.
The reduction in pressure afforded by the Flex options is not very much of a reduction. Nothing like the equivalent setting on a Resmed machine with EPR. That setting of 1 isn't much of a reduction but you can turn if off and try it.

I think your main problem is still just the minimum pressure not quite being optimal at times during the night.
Parts of the night things are fine but parts of the night they aren't. The machine wants to go higher but it takes too long to get to where it needs to be.
Might be sleeping position that needs more pressure...like supine.
Also might be REM stage sleep sometimes needing more pressure.
Might be a little bit of both.

I don't think changing AFlex is going to do what you think it is going to do but go ahead and just turn it off (set to 0) and give it a try. I don't think it will really impact the AHI all that much and if it isn't as comfortable to breathe with it off...your sleep may be more disturbed from the comfort aspect of things with turning it off and not feeling comfortable.

[mellocello2003]

Could you forward me a description of, or describe to me, the algorithm being used by the auto pap to increase pressure based on apnea events? I still don't entirely understand why I would get such a proliferation of apnea events at a higher pressure level (when I increased the pressure by 0.5). In the night where my AHI was higher, you can see a number of OA events occurring around hour 3, the machine increasing pressure, and the events continuing. Should it have further increased pressure? Were the events still not prevalent enough for it to increase pressure? Is the phillips auto pap algorithm not "reactive" enough for my body?

On second look, it seems as though the machine is "probing" pressures to see which ones yield the lowest AHI. It increased the pressure way up front within hour 1.

Thanks so much again.

[Pugsy]

Could you forward me a description of, or describe to me, the algorithm being used by the auto pap to increase pressure based on apnea events?

I don't have any idea what the official algorithm says....sorry.

I still don't entirely understand why I would get such a proliferation of apnea events at a higher pressure level (when I increased the pressure by 0.5). In the night where my AHI was higher, you can see a number of OA events occurring around hour 3, the machine increasing pressure, and the events continuing. Should it have further increased pressure? Were the events still not prevalent enough for it to increase pressure? Is the phillips auto pap algorithm not "reactive" enough for my body?

None of the APAP machines will respond with a large and very quick higher pressure as in a large increase in the blink of an eye. They simply don't work that way.
Also they don't respond to an event once it has materialized (none of them do). APAP machines are designed to prevent apneas from ever happening in the first place. They are designed to respond to event precursors or warnings signs that a collapse might be in the making. Were you thinking that the machine actually blows a sudden burst of pressure that blows the airway back open and moves the airway tissues back out of the airway? APAPs don't work that way. They don't act like ventilators.
The whole idea behind cpap/apap therapy is for the pressure to hold the airway open well enough that airway tissues collapses are prevented from ever happening in the first place.

In some situations we simply need more pressure at some times during the night and at other times we don't. Supine sleeping and REM stage sleep are the most common culprits...we can have more events and those events can need more pressure to hold the airway open so that the collapse is prevented.
I know a guy who needed 18 cm pressure when he was on his back...and 9 cm when he was sleeping on his side.
He opted to make a special effort to stay off his back.
I don't know why your pressure needs vary with any certainty. You could try staying totally on your side to see if that impacts the pressures needed. If it is REM related there isn't anything you can do to prevent those pressure needs because we can't control REM.

So cpap/apap therapy is a preventive measure....supply enough pressure to keep the airway open and limit the chances of the tissue collapsing. If you happen to have a sudden quick collapse of the airway without any of the normal event warning signs (snores and flow limitations are what the machine looks for) we call that a frank apnea because it just happens out of the blue without any warning. The machine can't prevent those short of using a much higher pressure all the time.

Yes, your machine does "probe" to test things out and if it senses something it doesn't like then it increases the pressure.
What it looks for and responds to are snores and flow limitations because those are common signs that the airway tissue is collapsing. It does't wait till an event has come and gone to decide what pressure to use the next time...

It takes a few minutes for your machine to respond and increase the pressure...it can't go from 9 cm to 12 cm in 30 seconds...not even 2 minutes.
If the minimum is not optimal then it simply takes too long for the machine to get up to where it is needed to better hold the airway open so the event comes and goes while the event is still trucking on upwards.
Setting the minimum pressure to a level where the machine can do a better job holding the airway open in the first place and shortening the distance to where it might need to go so it can hopefully get there soon enough is what we have to do with APAP machines.

Or you can use a higher pressure all night long in cpap mode and the higher pressure would hopefully prevent the collapse.

I don't know about you but I don't want to use 16 all night when I can use 12 most of the night and let the machine spend an hour or whatever up around 16 or 18cm.

It's a common misunderstanding for people to think that APAP mode automatically can find the precise pressure needed in the blink of an eye. They simply can't move that quickly.
This is why setting 4 to 20 can be a disaster...works great if the highest pressure you ever need is 8 or 9...totally ineffective if you need 12 or higher.