APAP is helping, but still getting AI/HI and not fully reste

[PDouglas]

I've been doing a lot of work on my APAP, but I still can't get the AI/HI down & I want to feel more rested

My diagnosis is Obstructive Sleep Apnea Syndrome from a 3/12/2002 sleep study. Here are the pertinent sections of the report.

.







I felt good with my initial cpap, but not 100%. Years down the road, I received reports that I was still obstructing, got the AutoSetII and am finally getting data from it. Over the last 2+ months, the average AI has been 2.5, HI 9.3, with an AHI of 11.8. For the most part, the minimum pressure has been set at 11 and the maximum at 17. The resulting median pressure averaged 12.0 with a maximum of 15.8. I've addressed the leakage by replacing my mask. I feel better than previously, but far from well-rested. Here's my summary report:



Here's a detailed graph for typical single night:



Here's a detailed for one hour:



I haven't seen a correlation between leaks and events. When I have an event, the machine doesn't consistently raise the pressure. Sometimes the machine keeps the pressure constant or even lowers the pressure. I've had a few nights where I've set it in CPAP mode or used EPR. I make a point of sleeping on my side, rather than my back. I've tried using a netipot before bed to flush out my nasal passages. I've tried an antacid before bed to make sure that acid reflux isn't occurring. Even though I consistently wear my dental split (for teeth grinding), my jaw muscles feel like they've had a workout in the morning. Nothing that I've tried has produced results (either AI/HI or how I feel) that are statistically significant.

At this point, I see three options: 1) having a new sleep study done, 2) getting a new dental splint or device made just for sleep apnea that forces my jaw further forward, 3) waiting to see how I'm doing at the 6 month point.

Would you all have any ideas/suggestions?

Thank you!

[Pugsy]

When you tried straight CPAP mode what pressure did you choose? What were the AI and HI numbers when you tried CPAP? If you use or used EPR...at what setting?

How did you come to the APAP setting of 11 minimum?

Have you tried higher minimum?

[avi123]

Pat, in my opinion your treatment looks good. Resmed Autosets don't deal with hypopneas. I myself don't pay attention to them b/c I suffer strictly from OSA without underlying medical conditions such as heart failure issues, neuromuscular, COPD, etc. As the pressure in the Autosets rises above 10 cm h2o b/c of snoring and flow flattening, the obstructive apneas are already well controlled by then, but Central hypopneas might turn into full Central apneas in some people. But not in your case. Your events are mostly obstructives. Overall, the higher the pressure the greater the side effects and the leak. So you want to use the lowest pressure possible while keeping the airway open. As to the AHI, since it is calculated as AI plus HI then those hypos are raising it in your case. But you can see in your AHI graph that the the the AI comprises a one third of it and the rest is hypos. With the new mask your leak came down nicely.

[Sheriff Buford]

Pugs asked some good questions.... I'll be interested to see your replies are. You certainly look like your making progress. Give it time... keep monitoring your progress. You are headed in the right direction.

[Pugsy]

Pat, in my opinion your treatment looks good. Resmed Autosets don't deal with hypopneas. I myself don't pay attention to them b/c I suffer strictly from OSA without underlying medical conditions such as heart failure issues, neuromuscular, COPD, etc. Usually, as the pressure in the Autosets rises above 10 cm h2o Central hypopneas turn into full Central apneas. But not in your case. Your events are mostly obstructives. As to the AHI, since it is calculated as AI plus HI then those hypos are raising it in your case. With the new mask your leak came down nicely.

OMG Apples and oranges again. They can't be compared.

Even allowing for the S8 to aggressively score hyponeas, there are more of them than I would want to see.
The Autoset won't respond to them. That is why I asked about minimum pressure choices and straight cpap pressure choice and results. There are other ways to try to deal with them.

[avi123]

OMG Apples and oranges again. They can't be compared.

Even allowing for the S8 to aggressively score hyponeas, there are more of them than I would want to see.

\

The above is misleading information by someone who is not familiar with the Resmed Autoset:

In the Resmed Autoset:

When you are lying quietly awake, or when you
first go to sleep, or when you are dreaming, you
can have hypopneas (reductions in the depth of
breathing) which are nothing to do with the state of
the airway. For example if you sigh, which you do
every few minutes, you usually have a hypopnea
immediately afterwards. This can also happen if
you have just rolled over and are getting settled, or
if you are dreaming. And the annoying thing is that
when you are on CPAP, this tendency to have what
are called central hypopneas - hypopneas that are
nothing to do with the state of the airway - is
increased.

[cowlypso]

Hypopeas are a big deal. They can have a serious impact on your quality of life (and probably your health as well). Don't let anybody tell you that as long as you aren't having apneas you're okay. On my initial sleep study, my AHI was 15, and that was almost all hypopneas (1 apnea). I went in for the sleep study because I was absolutely and totally exhausted all the time. Now that I've started CPAP, my AHI is down to a usual of 0.3-0.6 each night, and I feel so much better.

I'm not sure what the answer is in your case, but I do know that you need to keep working at it and get that AHI down.

[avi123]

[quote="cowlypso"]Hypopeas are a big deal. They can have a serious impact on your quality of life (and probably your health as well). Don't let anybody tell you that as long as you aren't having apneas you're okay. On my initial sleep study, my AHI was 15, and that was almost all hypopneas (1 apnea). I went in for the sleep study because I was absolutely and totally exhausted all the time. Now that I've started CPAP, my AHI is down to a usual of 0.3-0.6 each night, and I feel so much better.

I'm not sure what the answer is in your case, but I do know that you need to keep working at it and get that AHI down.[/quote

Reply:

Hypopneas are a "big deal" in persons who suffer from Central Sleep Apnea Syndrome (CSAS). In these cases you need a PSG to distinguish between Central and Obstructive Hypopneas (you need astute techs for this). Most sleep clinics are not equipped to do it. As to the Resmed Autosets, not only that they do not distinguish but they don't react to any hypopneas. If they did then they would put the pressure to the max while the CPAPer is awake (see my above post).

[Pugsy]

The above is misleading information by someone who is not familiar with the Resmed Autoset:

In the Resmed Autoset:

When you are lying quietly awake, or when you first go to sleep, or when you are dreaming, you can have hypopneas (reductions in the depth of breathing) which are nothing to do with the state of the airway. For example if you sigh, which you do every few minutes, you usually have a hypopnea immediately afterwards. This can also happen if
you have just rolled over and are getting settled, or if you are dreaming. And the annoying thing is that when you are on CPAP, this tendency to have what are called central hypopneas - hypopneas that are nothing to do with the state of the airway - is increased.

Geez... are you saying that the OP hyponeas which BTW are all night long, are central in origin just by this one statement? The S8 doesn't score centrals. Just because these hyponeas occurred above 10 cm of pressure doesn't automatically classify them as central in origin. If this were an S9 report, maybe..but it isn't.

There is nothing misleading about my statement. You once again try to interject your own treatment (ineffective at that) into someone else's and give the impression that it is OK to have a high AHI just because you have deemed it acceptable for your own therapy.

I am not going to beat my head against the wall trying to explain anything to you.

[Pugsy]

To Pat:

I asked the questions that I did to try to get a little more background information. I am typing with one hand so I just can't go into a lengthy explanation behind the questions.

[robysue]

I myself don't pay attention to them (hyponeas) b/c I suffer strictly from OSA without underlying medical conditions such as heart failure issues, neuromuscular, COPD, etc

As to avi's idea that hypopneas don't matter and shouldn't be counted: Well, the sleep docs diagnosing us with OSA all believe hyponeas should be counted---or at least some hypopneas should be counted. Which ones should count still seems to be a bone of contention which is why we've got the confusing mess of the AASM Recommended Standard for hypopneas and the AASM Alternative Standard for hypopneas. See http://www.ncbi.nlm.nih.gov/pubmed/19238801 and http://www.journalsleep.org/ViewAbstract.aspx?pid=27368 for a scholarly discussion of how and when these two standards affect a patient's diagnosis of OSA as well as the formal definitions of the two standards:

AASM Recommend: A hypopnea requires at least a 30% reduction in airflow for at least 10 seconds AND a corresponding O2 desaturation of at least 4%. Such a hypopnea does NOT require an EEG arousal.

AASM Alternative: A hypopnea requires at least a 50% reduction in airflow for at least 10 seconds AND one or both of the following conditions: A EEG arousal OR an O2 desat of at least 3%.

And of course, under both standards, the disordered breathing has to occur during an epoch when the patient is ASLEEP according to the EEG evidence.

Note that under the AASM Alternate rules, if there's a reduction in airflow of at least 50% for at least 10 seconds that ends with an EEG arousal, then a hyponea with arousal CAN and SHOULD be scored---even if there is NO drop in O2 at all. And the whole reason that the Alternative standard has been adopted as a valid way to score hyponeas is that there is evidence that an excessive number of arousals from sleep disordered breathing can be just as harmful to the body as O2 desats are: The EEG arousals are associated with a number of physiological changes in the body that can loosely be described in layman's terms as "flight or fight". At this point, many (but not all) sleep doctors believe that these respiratory arousals (be they hyponeas with arousal or RERAs) need to be addressed by PAP therapy in the same way that OAs need to be addressed. But Medicare still insists on having a deep 4% O2 desat to be present for scoring a hypopnea. Hence one standard has to be used for Medicare and one standard can be used by docs who believe it is in their patients' best medical interests to deal with the "arousal" problem before their OSA progresses to the point where it is causing desats as well as arousals.

However the chosen sleep lab chooses to score the hypopneas, the associated sleep docs do believe the scored hypopneas should be counted in the definition that's used to diagnose a patient with OSA. And hence, those docs also believe eliminating or minimizing those hypopneas should be part of the strategy of xPAP therapy: Standard PSG protocol calls for the tech to attempt to eliminate all hypopneas as well as apneas; and the titration algorithm does tell the tech to increase the pressure when something like 3 hypopneas occur in a short period of time. And the manufacturers of other auto CPAP machines tend to agree with the sleep docs since their machines do respond (although sometimes slowly) to machine scored hypopneas.

Now the notion that hypops come in both central and obstructive varieties is indeed an issue that seems to not be well understood. But most labs are NOT set up to determine whether a given hypop is or is not obstructive in nature. Indeed, my understanding of the AASM standards is that unless labs have some specialized equipment, they are NOT supposed to try to classify hypops as central or standard. And my patient-level understanding of what I've read is that hypops are typically assumed to be obstructive simply because the patient is continuing to breath, albeit not very well, during a hypopnea. And in a lab PSG central apneas are scored only when there is no effort to breath as measured by the belts around the chest and abdomen. So in a PSG, patency of the airway is not determined solely from the flow data the way our xPAP machines do: In the lab, they use the belts---if there's effort to breath, then the airway is assumed to be obstructed; if there's no effort to breath, it doesn't matter if the airway is open or closed since the problem is central in nature---i.e. the brain is not sending the order to breath and that's the main reason there's no air going in/out of the lungs. On our xPAPs, determining an "closed" versus "open" airway apnea through FOT or PP is just a proxy measure for whether we're making an effort to breath or not.

[robysue]

In the Resmed Autoset:

When you are lying quietly awake, or when you
first go to sleep, or when you are dreaming, you
can have hypopneas (reductions in the depth of
breathing) which are nothing to do with the state of
the airway. For example if you sigh, which you do
every few minutes, you usually have a hypopnea
immediately afterwards. This can also happen if
you have just rolled over and are getting settled, or
if you are dreaming. And the annoying thing is that
when you are on CPAP, this tendency to have what
are called central hypopneas - hypopneas that are
nothing to do with the state of the airway - is
increased.

Avi,

The passage you quote from the Resmed literature is indeed part of Resmed's justification for the choice the Resmed engineers made in designing their Auto algorithm. And note that any irregular breathing that's done while you are "lying quietly awake" is by definition NOT sleep disordered breathing, but an xPAP machine has no EEG and cannot tell when we're awake and when we're alseep. So all full efficacy data machines will record a few false positives---i.e. "events" that occur when we are actually awake. And those false positives are NOT limited to hypopneas---some of us routinely hold our breath long enough when we're moving around in bed to have the machine score an apnea or two.

It is true: The Resmed machines simply do NOT respond to hypopneas by increasing the pressure.

But---the Resmed machines DO SCORE the hypopneas---regardless of whether the machine is running in FIXED mode or AUTO mode. And the Resmed S8 Elite and Resmed S8 Auto are known to be particularly aggressive in SCORING hypopneas---i.e. they'll flag lots of things that may or may not have been an actual hypopnea. But since the S8's don't record wave form data, it's impossible for a particular user to figure out just how many of the S8 scored hypopneas might be "real." There's been quite a bit discussion here from people switching from an S8 to an S9 and magically having their HI drop by 50% or more while using exactly the same settings they used on the S8.

And that aggressive scoring of hypopneas on the S8 may be the underlying reason the Resmed engineers chose to have their Auto algorithm ignore hypopneas: They may well have realized that as aggressive as the S8s scored hypopneas, there was a potential problem increasing the pressure too high for folks who may be prone to pressure-induced centrals.

But that is not the same as saying that hyponeas should not be treated: Resmed would claim that the treatment for the hypopnea problem is to make sure that the patient is properly titrated and that the minimum Pressure setting in APAP range is high enough to be therapeutic for the patient much of the time. And other manufacturers of Auto machines do have algorithms that respond to hypopneas. These machines, however, are also much more conservative in scoring hypopneas than the Resmed S8's are.

And in any case, if the pressure range for an Auto is appropriately set, the min pressure setting should provide enough pressure to take care of many (or most) of the patient's respiratory problems and the max pressure setting should prevent the machine from increasing the pressure so high as to induce centrals. That's why so many of us who prefer running in Auto also use a very tight Auto range. The purpose of Auto is to allow us to have slightly lower pressures most of the night, but still have enough pressure to properly manage our OSA during the rough spots.

[HoseCrusher]

So, which came first... the chicken or the egg.

Does the hypopnea cause the arousal? If yes, then this would be "significant."

However, if the arousal resulted in a hypopnea, then the significance would drop off.

In the first case blowing air may help. In the second case it won't necessarily help.

[avi123]

In the Resmed Autoset:

When you are lying quietly awake, or when you
first go to sleep, or when you are dreaming, you
can have hypopneas (reductions in the depth of
breathing) which are nothing to do with the state of
the airway. For example if you sigh, which you do
every few minutes, you usually have a hypopnea
immediately afterwards. This can also happen if
you have just rolled over and are getting settled, or
if you are dreaming. And the annoying thing is that
when you are on CPAP, this tendency to have what
are called central hypopneas - hypopneas that are
nothing to do with the state of the airway - is
increased.

Avi,

The passage you quote from the Resmed literature is indeed part of Resmed's justification for the choice the Resmed engineers made in designing their Auto algorithm. And note that any irregular breathing that's done while you are "lying quietly awake" is by definition NOT sleep disordered breathing, but an xPAP machine has no EEG and cannot tell when we're awake and when we're alseep. So all full efficacy data machines will record a few false positives---i.e. "events" that occur when we are actually awake. And those false positives are NOT limited to hypopneas---some of us routinely hold our breath long enough when we're moving around in bed to have the machine score an apnea or two.

It is true: The Resmed machines simply do NOT respond to hypopneas by increasing the pressure.

But---the Resmed machines DO SCORE the hypopneas---regardless of whether the machine is running in FIXED mode or AUTO mode. And the Resmed S8 Elite and Resmed S8 Auto are known to be particularly aggressive in SCORING hypopneas---i.e. they'll flag lots of things that may or may not have been an actual hypopnea. But since the S8's don't record wave form data, it's impossible for a particular user to figure out just how many of the S8 scored hypopneas might be "real." There's been quite a bit discussion here from people switching from an S8 to an S9 and magically having their HI drop by 50% or more while using exactly the same settings they used on the S8.

And that aggressive scoring of hypopneas on the S8 may be the underlying reason the Resmed engineers chose to have their Auto algorithm ignore hypopneas: They may well have realized that as aggressive as the S8s scored hypopneas, there was a potential problem increasing the pressure too high for folks who may be prone to pressure-induced centrals.

But that is not the same as saying that hyponeas should not be treated: Resmed would claim that the treatment for the hypopnea problem is to make sure that the patient is properly titrated and that the minimum Pressure setting in APAP range is high enough to be therapeutic for the patient much of the time. And other manufacturers of Auto machines do have algorithms that respond to hypopneas. These machines, however, are also much more conservative in scoring hypopneas than the Resmed S8's are.

And in any case, if the pressure range for an Auto is appropriately set, the min pressure setting should provide enough pressure to take care of many (or most) of the patient's respiratory problems and the max pressure setting should prevent the machine from increasing the pressure so high as to induce centrals. That's why so many of us who prefer running in Auto also use a very tight Auto range. The purpose of Auto is to allow us to have slightly lower pressures most of the night, but still have enough pressure to properly manage our OSA during the rough spots.

Reply:

You're running around the bush with what Resmed SHOULD have done and what sleep doctors should know and how we should manage our OSA despite the facts that:

1) The chief designer of Resmed Autosets says, clearly, NOT to pay attention to hypopneas registered on these Autoset machines, all of them since 2002, (except for CSAS patients) b/c these hypopneas have nothing to do with the state the airway. So who should I listen to? Please note that I am not talking about the importance of knowing the hypopneas, or the pressure range set-ups that you use, etc. I am referring only to Hypopneas indicated by the Resmed's Autoset machines, since 2002!

2) Since the AHI is composed of the Apnea Index plus the Hypopnea Index and since the AHI value of the OP's graph shows that only about 1/4 of the AHI is AI and the rest is hypopnea and b/c Resmed's scientists say to ignore the hypopneas on Resmeds Autosets, what's wrong with the OP's AHI of .........? Why the OP should go thru hoops and loops as you do?

3) If you make an automatic CPAP device similar to the Resmed's Autosets but that responds to hypopneas , as you mentioned above to be your wish, you would push the pressure up to the maximum while the CPAPer is awake.

[PDouglas]

Thank you for your responses.

• Concerning the hypopneas, I might not be so concerned about them (or even the apneas) if I felt better. I'm not working now and haven't for some time. I had a couple of interviews a month ago. I wrote down the time of the last one, but didn't put it into Outlook. Then I couldn't find the piece of paper I wrote it on and relied on my memory. I found the paper just as I was ready to walk out the door. They were expecting me 3 hours before that. Arrr.
• Concerning the minimum pressure setting, I reviewed the detailed graphs with a wider pressure range. The pressure was rarely below 11. Reviewing the detailed graphs indicates that the pressure is rarely down at 11 and that lower pressure isn't associated with more events. I don't know how it can report that the median pressure is 12.0.
• Here's the CPAP/EPR results:
  • 6/28 13.0 cm EPR off: AI=3.5, HI=12.8
  • 6/29 12.0 cm EPR off: AI=4.1, HI= 7.6
  • 6/30 14.0 cm EPR off: AI=1.2, HI= 7.9
  • 7/01 14.0 cm EPR off: AI=1.7, HI= 9.7
  • 7/02 14.0 cm EPR off: AI=3.5, HI= 8.5
  • 7/03 14.0 cm EPR off: AI=2.9, HI=11.3
  • 7/04 14.0 cm EPR 3: AI=0.7, HI= 6.4
  • 7/05 14.0 cm EPR 2: AI=2.9, HI= 7.1
  • 7/06 14.0 cm EPR 2: AI=3.7, HI= 8.0
  • 7/07 14.0 cm EPR 1: AI=3.3, HI= 7.3
  • 7/08 through 7/13 on auto: AI=2.9, HI=8.6 (for comparison purposes)
  • 5/05 through 7/13 (entire period, including nights w/ excessive leak, also for comparison purposes): AI=2.5, HI=9.3
  It's hard to know how to interpret the CPAP/EPR data. When I raised the CPAP pressure to 14 on 6/30, I thought I had found a sweet spot. Good results on 7.1, but poor results on 7/2 & 7.3. Then I read about complex apnea and how higher pressures can cause central apneas. I also took a second look at my sleep study & found that the predominant disturbance w/ CPAP was central, rather than obstructive. Note that without the CPAP, the predominant disturbance was obstructive, hence the diagnosis of obstructive sleep apnea. Concerned that the remaining events were central, I tried full time EPR. Once again, I thought I had found a sweet spot w/ an EPR of 3 on 7/4. The detailed graph showed that the lower, exhalation pressure stayed at 13.2, rather than dropping a full 3 cm. I don't understand why the exhalation pressure didn't drop further. The next night, I tried it again at an EPR of 3, but something felt wrong, as if it was anticipating my breaths. Even when I lowered the EPR to 2, the exhalation pressure varied between 2.2 and 1.8 cm below the set pressure of 14. I stayed on an EPR of 2 for 2 nights and then lowered the EPR to 1 cm for a night. Neither of those produced good results. I noticed one odd thing with the EPR: the ratio of apneas to hypopneas increased. AI/HI ran at 0.27 over the entire time period. With the EPR, it was somewhere between 0.4 and 0.5. Looking at the detailed graphs, it seemed like the apneas were a little longer than typical. I wondered if some of the "hypopneas" went over the 10 seconds and were recorded as apneas.

Pugsy, do I need to try it in CPAP mode with pressures of 14+? Should I try adding EPR again?

Thank you!