Help needed from England

[summer]

Hello,

I'm new to the forum, and would be very grateful for some advice, I have been recently diagnosed with sleep apnea and I am currently using a APAP Trend II Hoffrichter machine to titrate, my mask is Fisher & Pakel Flexifit HC431. I have the machine set up with a min of 7.5 and max of 10.

I cannot seem to get a consistent therapy, feel awful and its getting me down!! I got my new mask on the 6th Dec, prior to that my AHI were averaging 8, but with the new mask things started well 5.0AHI, 4.9AHI, 5.7AHI, 3.3AHI, 7.3AHI, the following night I upped minimum to 8, but got 9.9AHI!!, then next night reduced min back to 7.5, got 6.4AHI, and then 9.4AHI, 3.0AHI (GOOD), but last night 9.5AHI!!

Results for Friday night (AHI 3.0) and last nights (AHI 9.5) were so different. I have a higher number of Hypopneas than all the other put together.

Friday(per hr) Saturday (per hr)
AHI 3.0 9.5
CSA 0.3 1.5
MSA 0.0 0.6
OSA 0.2 0.4
HYP 2.5 7.0
Airway constriction 3.2 6.3
Snore 0 0

90% events < 9.5 9.5
Leaks 4 4

I do not have the resp flow data

There are 4 screen shots of data Friday night part 1 & part 2 , Saturday part 1 & part 2







Do not know what to do!!

Thank you for your help.

[napstress]

Welcome, summer! Even though you mentioned your equipment in your post, it would be good to post it permanently at the foot of your post so you don't have to keep repeating yourself each time it's relevant to a new post you want to make. To do this, you can go to the User Control Panel>Profile>Edit equipment. After choosing from the drop-down boxes, be sure to select to display the items as Text rather than Image b/c many items look pretty similar. The Text format makes it easier for people to know exactly what you have.

That said, I am not familiar with your machine and equipment. Hopefully someone who is will chime in. In the meantime...

You mentioned the pressure levels at which you had set the machine. Was this based on titration study results?

Am I understanding you correctly that you attribute your inconsistent AHI to the new mask you started using a couple of weeks ago? How long have you been on CPAP therapy altogether?

It's good that you feel comfortable tweaking your pressure. I've heard that, for best results, one should stay at a new pressure configuration for a week or two before trying another. Apparently it takes the body a while to adjust each time.

Tidbit: Higher pressure ranges tend to result in higher CAs, which are included in the overall AHI number. That might explain that one night when your increasing your minimum resulted in an AHI of 9.9. However, I'm not sure if that factoid is true for both increasing the minimum and increasing the maximum. It's definitely true for increasing the maximum.

My SWAG (Serious, Wild-Ass Guess) on the sharp difference between Fri and Sat nights is that maybe you slept more on your back on Sat. Does your sleep study say that you had more events supine than on your sides or stomach? This is quite common and can remain true even under therapy.

Good luck!

[2 B Sleeping Soundly]

Summer,

Welcome to our little world of all things about sleep and hoses (well most of the time)

Unlike Napstress I can't even come up with a SWAG to help you, but agree with her that it sounds like it could be a positional type of thing. Was your last mask also a FF mask? The reason I ask is that like Napstress said most of the time it can take a week or two for the body to adjust to a change we undertake to our therapy, so maybe the mask change has increased leaks somehow, changed how you sleep ( on your back/side), even your head position on your pillow with different masks can have a different effects to your therapy.

Just more thoughts I know, but something to think on until more of the seasoned people here (I'm still a newbie) respond.

Hang in there it will get better and you have come to a great place for support and increasing your education about what we all share in our hose head world.

John

[Pugsy]

Welcome to the forum.

Your current machine won't be shown in the equipment drop down list but your mask should be.
Current machine is apparently a trial anyway. It is an APAP and the report generated is very similar to a report from my APAP.

First thing...you can't change something for just a single night and expect a huge difference and increasing the minimum from 7.5 to 8 is really not that much of a change and the increase in AHI for that night probably would have happened anyway. Just a bad night.

You don't seem to be having many centrals or mixed apneas...this is good because they aren't treated with pressure increases anyway.

The bulk of your events are Hyponeas and Obstructive Apneas which are treated with pressure. Along with those airway constriction numbers which on my machine report are called Flow Limitations (a baby Hyponea).

From the pattern of your events it appears that these could be coming along in REM sleep or if you happen to be sleeping on your back. You have times when the events are well treated and time when they aren't well treated..so something is making the events occur more and more difficult to treat.
Sleep position and REM stage sleep are the primary culprits when we see this occur.

If you don't ever sleep on your back, you can eliminate that culprit. If you do sleep on your back you can try sleeping on your side to see if it helps reduce the events. If they are REM stage sleep events the only thing to do is increase the minimum pressure because we have no control over REM.

If this were my report I would increase pressure to 9 or maybe 10 minimum but go up in stages (easier to adjust to it and also watch the reports). I would increase the max pressure to 12 right now if you have it at 10...

[summer1000]

Thank you all so very much, I will reply to you one by one as below (feel tired, fribomyalogia today etc, but its at least it sunny here in Oxfordshire!) and I have some more questions at the bottom of the post.

Dear napstress;

1) no the pressure levels were not based on a titration study, they are being used to find out what my titration figure is.
2) no in fact the new mask is better, and generally I'm having lower AHI's, it just so inconsistent at the moment, some days the trend is leveling ang
d going down then others it just goes back up for several days.
3) My sleep study I hardly slept on my side, all of it was on my back.

Dear 2B sleeping Soundly,

1) Yes my last mask was a FF (Hoffrichter), I also had higher AHI with old mask but bizarrely less leaks!! I now understand that I need to take it slower and give each change a week or so and then make a judgement with the help of my clinician as to what to do. I just need to feel at the very least that I'M going in the right direction and it feels I'm not!.

2) I do agree that the head position may being make a difference, I note that with the flexifit the more I tighten the mask my perception is that my head/chin tends to be pulled downwards and backwards, not sure whether some nights I'm over tightening compared to other nights.


Dear Pugsy,

Your astute observations that some times my events are well treated within a single night (in fact I can have one night with lower AHI and the following night an AHI 3 times more) I can see that now. I was hoping not to have to increase the pressures as I don't like the higher pressures they are just uncomfortable and can wake me up. Its just odd that I can have few hours with hardly any events, then get a truck load!.
I think I spending the majority of the time on my back, I find it very awkward to lie on my side with the face mask and tubing, and I if I do, I am holding the mask as I doing it as I'm worried that I will get leaks and cause a rum away effect.(You've got me thinking,prior to apap treatment I did spend quite a bit of time on my side!!).

1) I think what learned so far is that I tend more events at the beginning (11 to 2.30) and toward the end of my sleep (4 - 6.00), although this is by no means consistent. Also I seems to get clusters.

2)I think I'm spending all my time on my back, as I have not woken up during the night on my side. I will only try to sleep on my side when I partially awake and then I holding the mask as its tends to be tugged by the bed sheets.

3)That it my be more events are happening during REM


Questions;

1) Sleeping on my side, how do you guys stop the mask moving or causing a leaks?
2) I worried about increasing the min pressure, as I do have more hypopneas than anything else and that I have read that the Hypopneas could be central based, and I am getting central clusters. Is it just a question of upping the min pressure and see what happens after a week.
3) Why do think there is such a difference between days, one day at 9.5AHI next day 3.0? When I had a 3.0 AHI on Friday night I thought ok, if can I get a 3.0AHI with the current pressures no need to change anything from now on. Are these night just one offs and therefore I still need to increase pressures.

There seems to be so many variables.

Thank you for all taking the time to listen.

[Pugsy]

1) Sleeping on my side, how do you guys stop the mask moving or causing a leaks?

It sure can be problematic. Have you investigated using a different pillow? Something that allows for sleeping on your side without adding pressure from the bed pillow to mask? There are various "CPAP" pillows out there with cut outs in the foam to allow for the mask to sort of rest in a hole and not have so much pressure on it. If you Google CPAP pillow you will see tons of various modifications. I use a buckwheat hull pillow myself. I can shove the little hulls around and make a nest for my mask. Though I do use a nasal pillow mask and the nest doesn't need to be large.

2) I worried about increasing the min pressure, as I do have more hypopneas than anything else and that I have read that the Hypopneas could be central based, and I am getting central clusters. Is it just a question of upping the min pressure and see what happens after a week.

Hyponeas are just as easily obstructive in nature...and probably more times than not they are obstructive. If yours happened to be central in nature I would also expect higher centrals than you are having. If they were central in nature your maximum pressure would be of more concern than the minimum pressure though because you are already spending a good deal of the time at your maximum or very near it. Minimum pressure needs to be high enough to give the machine a good running head start to prevent whatever is causing those events in the cluster. I happen to be a "worse in REM" person and I have clusters like you have if I drop my minimum just 0.5 cm. The machine just can't get to where it needs to be fast enough to be effective. That little 0.5 cm makes a difference in AHI like yours to consistently seeing AHI less than 3.

You can try sleeping on your side. Many people are able to limit the pressure variations and needs by doing this. If it doesn't seem to help then consider increasing the minimum but go up in small stages because it will be much easier to adjust to..and watch the reports as you increase in small stages. Who knows you might only need 8.5 minimum..

Whatever you choose to do remember that we sleep differently every night and you simply cannot judge a change based on one night results. Even now I might have an AHI of 1 tonight and tomorrow night see near AHI of 5. When I first started therapy 2 1/2 years ago I saw such fluctuations often, even with zero changes in any of my settings. There is some truth to the "give it time" thing.

Make one change at a time and allow several nights to see how that change may or may not affect therapy. Your reports are not horrible by any means. I do think you are probably very close to having optimal settings and at least optimal therapy on paper. I noticed significant change in how I felt when I broke up my clusters which looked a lot like yours with similar AHI reporting. The other night I did an experiment that resulted in the return of the clusters and I sure felt them.

A great AHI does not guarantee that we feel those good numbers though but it is a place to start. Get the AHI consistently under 5 and then evaluate how you feel. Other things can make us feel less than optimal.

If you are worse sleeping on your back and can limit being on your back you may not need to do anything other than stay off your back. If those clusters are REM stage sleep related you probably just need a small increase in the minimum pressure to break up those clusters. You will have random events no matter what you do. All I would do is try to break up the clusters if it was me.

[chunkyfrog]

I have a flexi fit 432, which is very similar to your mask, and I use my medium soft bed pillow to help CONTROL leaks,
rolling the side of my face into the pillow enough to secure the 'down' side to my face, nice and snug.
The 'up' side is held on by the headgear and inflation of the cushion.
The vents on these masks are positioned to make them difficult to block.

[napstress]

Sleeping on my side, how do you guys stop the mask moving or causing a leaks?

For more about pillows for side sleepers using full-face masks, you can Search this forum for "bed pillows." That will direct you to contour pillows for sale and to forum users who fashioned their own.

I will only try to sleep on my side when I partially awake and then I holding the mask as its tends to be tugged by the bed sheets.

To keep your hose from dragging across you when you're sleeping, you can position your machine so it's at the head of your bed, instead of to the side. For more about hose hangers, you can Search this forum for "hose hangers." That will direct you to hose hangers for sale or to forum users who fashioned their own.

We're rather a creative lot.

Good luck and trust Pugsy.

[summer1]

Hi everyone,

Thank you all again for your replies, I left the setting the same last night and got an AHI of 8.2.

Thank you Pugsy wow! a very informative response, one thing I am noticing from last nights results (apart from being completely spaced!) is that there are single and a cluster of Hypopneas that machine does not respond to. It seems that the machine just ignores them and remains at 7.5 pressure, although others it responds to. However the machine does respond always to airway constrictions. Why is that?.
I have also noticed that the machine as you have said seems slow to respond either responding during or at the end of the event but not getting rid of it. It does look like I can change the reaction speed of the machine, there is a parameter called pressure steepness (settings of 1 to 5), I 'm currently set to 3, I have read that 5 is the most aggressive/quickest to react, do you or any of you have that facility?, I tempted to changes this.

Thank you Chunkyfrog, I tried you suggestion and rolled my face into pillow, I think I need more practice and perhaps softer pillow or one of those CPAP pillow that you all have mentioned, but its good to know that it can be done!

Thank you napstress, I think I will try a softer pillow, and as my bed is a metal frame bed, I think I will feed tube over the head board, so that tube now enter from above (swivel mask tub upward).

Thank you for all the great advice!!

[Pugsy]

ne thing I am noticing from last nights results (apart from being completely spaced!) is that there are single and a cluster of Hypopneas that machine does not respond to. It seems that the machine just ignores them and remains at 7.5 pressure, although others it responds to. However the machine does respond always to airway constrictions. Why is that?.

I don't know why the machine doesn't respond to some Hyponeas and will respond to others unless the ones that it doesn't respond to don't meet whatever criteria your machines algorithm has for initiating pressure increases. It is quite possible that they are central in nature and APAPs don't respond to events unless obstructive precursors are present or it could just be that the machine was unsure. Since centrals won't have the normally seen collapse of airway precursors, then it has nothing to respond to.
In theory, this would be the likely explanation but in reality there may be other factors involved.

Also remember that while these machines do a bang up job, they really have some limitations and not perfect.

I have also noticed that the machine as you have said seems slow to respond either responding during or at the end of the event but not getting rid of it. It does look like I can change the reaction speed of the machine, there is a parameter called pressure steepness (settings of 1 to 5), I 'm currently set to 3, I have read that 5 is the most aggressive/quickest to react, do you or any of you have that facility?, I tempted to changes this.

This is not a feature that is found on the machines we use here. Is this feature something that is easy and up front for patient to be able to alter? Or is it deep within the machine and alters the event definitions so that the machine is more aggressive?
Pressure steepness is not a feature that is common on machines used here. As long as it doesn't have to do with altering event definitions and machine sensitivity (Devilbiss machines will allow that) then I would at least give it a try.

Again, make one change at a time and give it a few days UNLESS the change brought about significantly horrible results.

[summer1]

Hi Pugsy,

Thank you for your reply, yes I know how to alter the steepness setting, it is really something that the clinician should do, and I will probably wait until I next see him.(I think I'm frustrated, its just everything takes so long!). I believe it does not change the event definition only how quickly it reacts to them.

By the way , I will up the maximum pressure tonight to 12, with a view to next week to increasing the min pressure to 8.

Thanks again

Merry Christmas to you and a Happy New Year.

[Pugsy]

I think minimum pressure is more critical than maximum pressure. Maximum pressure setting doesn't really impact the time needed from the starting pressure needed to get to effective pressure unless you are maxed out for the majority of the time and the machine doesn't get back down to minimum pressure much.
So just keep that in mind.

Try to be patient. I know it is hard..we want to make a change and see an immediate result. I want the same thing. Still do after all this time on the machine. I just have to keep telling myself....give it a bit of time.