AHI is around 27, Clear Air Apnea is high

[GLeas]

Hi all! Just getting started in the CPAP world, and I started using SleepyHead software 10 days ago. As I'm slowly starting to understand what the terms and graphs mean, one thing I notice is that my Clear Air apnea (Central apnea?) reading is over half my total AHI value. My AHI is around 27 with the CA reading around 15 usually. I know that's a high AHI, but should I be concerned about the high Clear Air reading? I know 10 days is a small sample size but the readings have been pretty consistent over that time frame. I contacted my DME about this, and since she hasn't heard of SleepyHead software, she says not to worry about it. I'm beginning to wonder if I should start seeing a real sleep specialist for this and not just my ENT. Anyway, I'm curious as to what the people who are living with sleep disturbances think about this. Thanks in advance!

[BlackSpinner]

That AHI is what gets people on cpap so it is much too high even without the CAs.
You need to contact your dr / DME immediately.

[Pugsy]

Even if a person hasn't heard of SleepyHead an AHI of 27 with the machine being used isn't good to see.
What machine brand and model are you using (please add it to your equipment profile as I have added mine so we don't have to ask every time)?
What pressure settings are you using? Did you have a sleep study where they used the machine and supposedly found the optimal pressure?
Using any sort of exhale relief? If so at what setting?
How is your sleep quality while on the machine? Lots of wake ups for whatever reason?
How is the leak line looking?

[icipher]

I started off with a bipap, and i remember the first two or three nights i had an AHI of like 30, all hypopnea and clear airway. Eventually my body adjusted and i was fine. perhaps you're going through an adjustment, but i would definitely still contact your sleep doc.

[GLeas]

That AHI is what gets people on cpap so it is much too high even without the CAs.
You need to contact your dr / DME immediately.

Will do, thanks for the reply!

[GLeas]

Even if a person hasn't heard of SleepyHead an AHI of 27 with the machine being used isn't good to see.
What machine brand and model are you using (please add it to your equipment profile as I have added mine so we don't have to ask every time)?
What pressure settings are you using? Did you have a sleep study where they used the machine and supposedly found the optimal pressure?
Using any sort of exhale relief? If so at what setting?
How is your sleep quality while on the machine? Lots of wake ups for whatever reason?
How is the leak line looking?

I've filled out my equipment profile, and it's an APAP machine set for between 6 & 15. I did have a sleep study done, but because of some insurance snafu they didn't titrate the ideal pressure. That's why my doc prescribed the auto machine. As far as exhale relief goes, my machine has A-flex and it's set at 1 now. I've no idea what that's for though. My sleep quality hasn't changed much at all after around 2 weeks. I wake fully about 5 times per night, but partially many more times than that. The leak line looks pretty low (the one on the bottom of the graph). I wonder if I should wait to see if I get better over time, or if I should make an appt now (that might be 4 weeks from now anyway!). Thanks for your time...

[Pugsy]

It wouldn't hurt to make the appointment for follow up now because most likely they won't have an opening for 4 week or longer

In the meantime you report lots of awakenings during the night and often awake breathing gets flagged by mistake and most often as Clear Airway (centrals). So I wouldn't panic over those at the moment. If you had said you go to sleep and stay soundly asleep then we would have a different discussion.

Often when using the APAP machine to titrate to an optimal pressure they set the machine starting out low for comfort and expect the machine to get to where it needs to be really quickly and it doesn't always work that way. A setting of 6 starting out may simply take too long to get to where the pressure needs to be to do the best job of preventing the apnea events.

Now some of your awakenings might just be the "newness" of all this stuff being plastered on your face but some of them might be events themselves causing awakenings.

Can you post an image of a typical night's report from SleepyHead? Don't know how?
viewtopic.php?f=1&t=81072&p=737779#p737779
I don't need to see all the graphs on the right...you can turn off the AHI graph as it is redundant information.
So on the left side...see the AHI bar graphs and times for sleep and wake.
On the right...Events graph, flow rate graph, pressure graph and leak graph. You can manipulate the sizes of the graphs and get all 4 on one screen image. Just hover mouse on the bottom line of a graph till you see the short double line then click and drag to resize.

I suspect that you probably just need a little more minimum pressure and then the obstructive component of the AHI will reduce and if those centrals are arousal centrals..they should reduce too.
If they don't..then we talk about something else but let's cross that bridge if we need to.

[GLeas]

It wouldn't hurt to make the appointment for follow up now because most likely they won't have an opening for 4 week or longer

In the meantime you report lots of awakenings during the night and often awake breathing gets flagged by mistake and most often as Clear Airway (centrals). So I wouldn't panic over those at the moment. If you had said you go to sleep and stay soundly asleep then we would have a different discussion.

Often when using the APAP machine to titrate to an optimal pressure they set the machine starting out low for comfort and expect the machine to get to where it needs to be really quickly and it doesn't always work that way. A setting of 6 starting out may simply take too long to get to where the pressure needs to be to do the best job of preventing the apnea events.

Now some of your awakenings might just be the "newness" of all this stuff being plastered on your face but some of them might be events themselves causing awakenings.

Can you post an image of a typical night's report from SleepyHead? Don't know how?
viewtopic.php?f=1&t=81072&p=737779#p737779
I don't need to see all the graphs on the right...you can turn off the AHI graph as it is redundant information.
So on the left side...see the AHI bar graphs and times for sleep and wake.
On the right...Events graph, flow rate graph, pressure graph and leak graph. You can manipulate the sizes of the graphs and get all 4 on one screen image. Just hover mouse on the bottom line of a graph till you see the short double line then click and drag to resize.

I suspect that you probably just need a little more minimum pressure and then the obstructive component of the AHI will reduce and if those centrals are arousal centrals..they should reduce too.
If they don't..then we talk about something else but let's cross that bridge if we need to.

[Pugsy]

Did your initial diagnostic sleep study mention any centrals to speak of? If you don't have a copy of that report...get one.

Make the appointment for follow up...let's see how far out they are. A sleep specialist if your ENT isn't well versed in sleep apnea therapy and treatment.

Are you wanting/willing to try to do some changes yourself or do you wish to get with your doctor first?
This isn't working obviously.
It's impossible to know with any certainty exactly what is going on here.
Is it simply sub optimal pressure allowing way too many obstructive apneas and arousals and thus those centrals being related to arousals or awake breathing or multiple sleep onset centrals? Or is this an indication that pressure itself is triggering the centrals?
A titration study would/should have spotted it if they were related to pressure but we don't have that to help us out.

The centrals are a concern in these numbers.
But it is also obvious that the minimum pressure is sorely sub optimal. All I know to offer is treat the obvious first and see what happens. The obvious is the obstructive apneas...more minimum pressure is needed. You might get lucky and have the centrals dissipate if they are post arousal centrals.
How much more minimum pressure? I don't know but I suspect at least 10 cm but I wouldn't suggest making that big of a jump. Instead I would go up slowly (if you are comfortable doing this while awaiting the follow up appointment)...like maybe 7 cm for a couple of nights..then maybe 8 or 9 and see what happens.

If you aren't comfortable increasing the minimum pressure on your own then push for an immediate follow up appointment.
No amount of "wait and see" and "give it time" is going to fix this.

[GLeas]

Did your initial diagnostic sleep study mention any centrals to speak of? If you don't have a copy of that report...get one.

Make the appointment for follow up...let's see how far out they are. A sleep specialist if your ENT isn't well versed in sleep apnea therapy and treatment.

Are you wanting/willing to try to do some changes yourself or do you wish to get with your doctor first?
This isn't working obviously.
It's impossible to know with any certainty exactly what is going on here.
Is it simply sub optimal pressure allowing way too many obstructive apneas and arousals and thus those centrals being related to arousals or awake breathing or multiple sleep onset centrals? Or is this an indication that pressure itself is triggering the centrals?
A titration study would/should have spotted it if they were related to pressure but we don't have that to help us out.

The centrals are a concern in these numbers.
But it is also obvious that the minimum pressure is sorely sub optimal. All I know to offer is treat the obvious first and see what happens. The obvious is the obstructive apneas...more minimum pressure is needed. You might get lucky and have the centrals dissipate if they are post arousal centrals.
How much more minimum pressure? I don't know but I suspect at least 10 cm but I wouldn't suggest making that big of a jump. Instead I would go up slowly (if you are comfortable doing this while awaiting the follow up appointment)...like maybe 7 cm for a couple of nights..then maybe 8 or 9 and see what happens.

If you aren't comfortable increasing the minimum pressure on your own then push for an immediate follow up appointment.
No amount of "wait and see" and "give it time" is going to fix this.

Thanks for spending the time going over these graphs and info, I appreciate it! You mention that the minimum pressure is very low. Can you tell me how you know this? I'd love to be able to interpret these (and other) graphs... Is it even possible for me to raise the minimum pressure from the menu of the machine, or is that something for the DME to do? I want to be as directly involved with my therapy as I can, and I don't mind making adjustments on my own (with the advice of more experienced users in this forum of course!)... Thanks again for your help!

[Pugsy]

It's easy to see the pressure you start out the night at because it shows on the pressure graph.
It starts at 5 it looks like. Then it goes all over the place up to 15 for a good part of the time.

Yes, you could change it yourself. It isn't rocket science but if a person doesn't feel comfortable or understand why....I don't recommend that people go doing things that they aren't comfortable doing.

http://www.apneaboard.com/pr-system-one ... structions
This link explains how and there is also a little video at the bottom of the page.

Increasing the pressure can sometimes actually cause more centrals in a small percentage of people using cpap therapy.
I don't know if you are one of those people or not. All I know is that the minimum is preventing the obstructive apneas or hyponeas very well and there's a chance that if the OAs and hyponeas are better controlled that the centrals might go away or greatly reduce if the centrals are post arousal centrals.

Best I can offer is what I would do in this situation if it were my report...and I wouldn't totally discount bringing the doctor into it either. I would make the appointment as it is unlikely they can get you in tomorrow...and try more minimum pressure and I would limit the maximum pressure just in case those higher pressures are triggering the centrals...then work my way up as needed after looking at the reports. I would start with modest pressures and not expect an overnight miracle but instead be prepared for further adjustment. If you weren't having so meany centrals I wouldn't worry so much about the maximum..but you are so they can't be totally ignored.
If it were me..I would try minimum of 8 cm and limit the max to 12...and then see what the reports show.

[DoriC]

If you look at the Statistics section your minimum pressure is 10 which means that almost immediately your pressure goes up to that # from 5 to try and keep your airway open, your Median pressure(Avg) is 12.40 which means that half the night you were at that pressure and your 95% pressure is 15 which means that for 95% of the night you were at OR BELOW that pressure. So Pugsy is suggesting a reasonable conservative recommendation to increase your min pressure to at least 8 so if you need 10cms the machine won't have that far to go to reach it like it would if you started at 5cm. I believe she's suggesting a max limit of 12cms to possibly prevent pressure induced CAs. That's my layman's explanation, hope I didn't confuse you.

[Todzo]

So looking at the beginning of your night I see a lot of events. They seem to pretty much go away when the pressure is brought up to about 9.5 cm/H2O. But then the machine tries dropping pressure and then things really take off and eventually become a fight that never gets won.

There are basically two kinds of events. Hypercapnic and hypocapnic. The first is most likely to come from obstruction that is not prevented by the pressure of CPAP So you stop or reduce breathing and your carbon dioxide levels go up. As well an arousal occurs which fractures your sleep. As well your stress hormone levels go up.

You might say your body strangled you and you got mad about that!

So with the higher levels of stress hormone in your system you tend to breath more.

Any pressure from your CPAP will tend you to breath more.

A few more events occur which further raise stress hormone levels. At a certain point many events start to occur, you are breathing much more (in general you can “see” how much you are breathing by how wide the Flow Rate waveform is).

Years ago I started training to breath more eucapnically. One of the things that became vary obvious to me is that my over breathing first resulted in a stuffy nose. So I believe that as you breath more you also bring more stuffiness into you nose and likely inflammation into your airway.

Each event of any kind (obstructive or otherwise) raises the stress hormone level and along with it the tendency to over breath. The tendency to “over shoot” during the “recovery time” from apnea or hypotnea becomes great – and the tendency to over breath becomes chronic (long term potentiated). You literally come to times when you absolutely need to stop breathing to recover enough carbon dioxide in your blood to facilitate proper circulation and oxygen transport. So you have a time of not breathing even though your airway is clear. You have a hypocapnic central apnea (often seen in the eyes of the software as a “clear airway” event or “CA”).

Between the high pressures from your machine trying to overcome the increased obstruction and your own CPAP pressure and stress hormone induced over breathing stemming from too many stress hormones and likely some circulatory upsets caused by the rapid cycling of your blood chemistry everybody is fighting everyone and things apparently do not get quited down until sometime near morning.

I think that Pugsy is correct to guide you to use a higher initial pressure.

If I were you I would be spending some quality time with the machine for the next month. Take an hour a day. Much of the time with simple distraction such as reading, TV, or music. Some of the time in bed practicing to breath quietly using the same amount of air you would if the machine were not present. Also in bed work out leak issues and hose management issues as you move between all your positions.

[Pugsy]

Are you using the ramp feature?
Looks like part of that starting point of 5 might be ramp but it doesn't increase like ramp normally shows an increase.
The pressure settings look like either 5 or 6 to 15...this is shown in little letters above the AHI event categories on the left side.
Where it says "Mode"...
Also your pressure graph looks a bit strange. I don't see the normal pressure probes that we normally see. How much of the night do you think you might have been asleep?
Go to Preferences...then appearance tab and remove check mark for "use pixmap caching" for next report images.

[GLeas]

If you look at the Statistics section your minimum pressure is 10 which means that almost immediately your pressure goes up to that # from 5 to try and keep your airway open, your Median pressure(Avg) is 12.40 which means that half the night you were at that pressure and your 95% pressure is 15 which means that for 95% of the night you were at OR BELOW that pressure. So Pugsy is suggesting a reasonable conservative recommendation to increase your min pressure to at least 8 so if you need 10cms the machine won't have that far to go to reach it like it would if you started at 5cm. I believe she's suggesting a max limit of 12cms to possibly prevent pressure induced CAs. That's my layman's explanation, hope I didn't confuse you.

Thanks for the clear explanation. While I understand the technical concepts, it's good to have it explained in more common sense terms. I've taken Pugsy's advice and raised the minimum pressure to 8 cm H20, but I haven't touched the max pressure yet. I'll change one variable at a time, then evaluate the results. Thanks again!