New CPAP User. Huge Spike in AHI (<100) after 5 nights.

After having issues with daytime drowsiness my doctor had me take an at-home sleep study on 5/22/2024. I was found to have 559 obstructive apneas, 1 central apnea, 0 mixed apneas, and 130 hypopneas. There was no Cheyne-Stokes breathing. These events resulted in an apnea/hypopnea index (AHI) of 92.5 events/hour. The mean SpO2 was 89% and the SpO2 dropped as low as 75%. I was prescribed a CPAP machine and used it for the first time on 6/26/2024. I had some issues adjusting to sleeping with the machine, but I had a noticeable improvement on how I felt during the day.

Everything seemed to be going smoothly for the first 5 nights, then my AHI went from less than 5 to over 100 in just a few days. I didn't make any changes to settings that correlate with the jump in AHI. I did make some adjustments to my mask (tightened the straps) but have since tried everything to get it back to how it was in the beginning. I've even tried tying an ACE bandage around my head to make sure my mouth isn't accidentally opening when I'm asleep (that had no impact on my AHI but I only managed to use the CPAP machine for 4 hours that night).

Unfortunately, I didn't realize there was an SD card slot until yesterday. So I only have summary data for all nights except for last night. I am going to reach out to my CPAP supplier and their tech but they have been slow and unresponsive. It took over a month to get the machine. After seeing how knowledgeable the people in this forum are, I'm hoping by posting my data someone could offer insight into what's going on. Thanks in advance. Please let me know if there's anything else you need from me.

Here is my overview: (notice the spike in AHI starting 7/1)


Here is last night's daily details: (the only night I had an SD card installed)


Here's another screenshot of last night's details that include all of the graphs on the right


Thanks for your time!
Greg

WOW....what a mess.

Can you upload to SleepHQ last night's report?

Just the free version is sufficient for what we want to see.

BTW the image with all the various graphs shown is really not all that informative. Making so many graphs means that the graphs are teeny tiny and it's really hard to evaluate.....and besides not really needed.

My apologies regarding the last image-- I'll make sure to share only the relevant data in future posts. Here is the SleepHQ link for last night.

Some nosy questions.
1....sleeping position? Primary or all over the place.
2....do you take any meds of any kind, if so, what?
3....would you say you slept much last night or was it a really restless night?
4....any other physical or mental health issues going on?
5....what altitude do you sleep at?

Now...right now all that I can think of to try to see if we can improve on the mess you see....Reducing or eliminating EPR.
Can you try doing without EPR and turn it off (or alternately we can set it to ramp only if you need it to fall asleep) or maybe just reduce it.

Assuming you actually slept last night then for some reason you seem to have developed treatment emergent central sleep apnea. Now what to do about it.....choices are really limited with this machine but you might get lucky.
If you didn't sleep...then you have a different problem.

EPR use on SOME people (certainly a minimal number of people) can trigger central apneas.
I don't know if you are one of those people or not but it's a fairly easy question to at least get an answer.

So for tonight.....turn EPR off (or if you need ramp to fall asleep then set it to ramp only and set the ramp for a suitable amount of time for you to sleep.....or maybe use AutoRamp) and make no other real changes in therapy settings.

Only want to see if EPR is a factor or not with these centrals....and go from there.
Don't go changing the pressure settings or anything else....just EPR off or if you need ramp you can set EPR for ramp only and not use ramp any longer than necessary.

Remember mainly one change at a time....EPR only change for now. Want to see if you still get centrals when asleep with EPR off.

And answer the nosy questions. Might be some clues in those answers.

Thanks for your advice! I just turned off EPR and will report back tomorrow.

To answer your questions:
1....sleeping position? Primary or all over the place.
90% on my sides (primarily right side) and 10% on my back.
2....do you take any meds of any kind, if so, what?
Yes. I've struggled with insomnia for as long as I can remember. I've been on sleeping meds for a decade. I've tried just about every major medication out there. After a lot of trial and error, I found that 12.5mg of Ambien CR and 50mg Trazodone work best for me. I've been on this combo/dosage for 3 years.
3....would you say you slept much last night or was it a really restless night?
Last night was definitely a rough night. I went to bed super early since I was so tired and felt like I had a really restless night. My purely anecdotal rating of last night's sleep quality would be a 3/10.
4....any other physical or mental health issues going on?
Only insomnia
5....what altitude do you sleep at?
4,500 ft

Thanks again for your time and help!

Thank you for answering my nosy questions.
History is always helpful. You would be surprised as to how many people don't answer at all or maybe answer 1 and not do any others. It's why I try to keep the nosy question list rather short....that way I have more of a chance of getting answers.
I was looking for anything that might make a person more apt to have central apneas pop up.
Not much there except maybe the altitude but centrals just from altitude usually don't rear their ugly head until maybe 7K or more. Note....just a guess on my part from what people say when they come here and I have no time to go googling.

I am crossing all my fingers and toes that the "No EPR" trick works a miracle.
I have seen it with small miracles (like where the central index was maybe 20 per hour)....yours would be a huge miracle if it works. Cross your fingers and toes as well.....this is pretty much my only item in my little bag of tricks in your situation....though maybe we might think about fixed pressure instead of auto adjusting....I have seen that little miracle as well.

But miracles can and do happen. I don't see a lot of them but I do see them.

Sorry for the delay. Yesterday was a super busy day and I didn't get a chance to upload all the data and write a post. The results are looking better!!! When I looked at the July 8th data I thought a miracle happened. Unfortunately, July 9th wasn't as good but still better than most of my other (elevated) nights. I'm feeling optimistic. Thanks again SO SO much for your help, Pugsy!

So a few notes about the data from 7/8:
I got up to go to the bathroom at around 11pm, disconnected the hose from my mask, but forgot to turn off the machine. During the initial set up of my CPAP machine, the tech recommended that I turn off SmartStop while I get used to the machine...so that setting is been off. I was so tired when I got back into bed that I am almost positive that I forgot to put my mask back on. I woke up at 2am and realized the machine wasn't plugged into my mask (and had somehow turned off on it's own). I plugged it back into my mask and the SmartStart feature kicked in after a few breaths. I finished the rest of the night without any noticeable issues. Even with the 2 hours of missing data and the 1 hour of data where the mask wasn't connected to my face, I still managed to have the mask on for 5 hours. I'm not sure how the hour of it running disconnected from my mask affected my AHI but I assume it was not good. That being said, my AHI was 26.17 for the night...a 74.8% reduction in my previous night's AHI!

I didn't make any changes from the 8th to the 9th (other than not having a mishap by forgetting to plug the mask back in) so I'm not sure why my AHI went up.

Since learning about SleepHQ, I've purchased the O2Ring (which just came today). I will have that for tonight's data. I also purchased a Wifi SD card so I can automate my data transfer.

Here is my overview: (notice the drop in AHI on 7/8 after I disabled EPR)


7/8 SleepHQ Link


7/9 SleepHQ Link


Thanks again for your time. Let me know if anyone has additional insights or ideas. Otherwise, I will post more data as I collect it.

Well crap.....not the miracle I was hoping for. Not even remotely.
Plus the possibly improved night is full of compromised data so we don't know if we can trust it to even be maybe improved a little.
Last night (the more ugly night) really didn't show any improvement to speak of.

I got a few chores to attend to...plus I am going to email a friend of mine and gets his opinion.
I will go through the SleepyHQ in detail later when I have my chores done.

I have an awake experiment I need you to try when you have time.
I want you to find at least 30 minutes while awake and no desire or need to sleep...and use the machine at current settings...for 30 minutes. An hour would be even better.

More later....Hubby is antsy and since the chores involve his honey to do list I gotta be a part of the chores.

No rush! I will do that test asap and upload the results.

GregBot wrote: ↑

Wed Jul 10, 2024 8:51 am

Thanks again for your time. Let me know if anyone has additional insights or ideas. Otherwise, I will post more data as I collect it.

Zoom into the awake breathing... say, at the very beginning of your session. Does it really look like that? Are you really breathing in that uneven way, normally? The pattern is ongoing from the very start, the episodes just get long enough to qualify as CA's as you drift off, looks like.

You should contact your sleep doctor IMO, not your DME/tech... this looks like complex apnea, the kind you need an ASV machine for. Either your machine is very broken or it's the wrong machine for you IMO. This is very different from your initial sleep study data... that's why I'm having a hard time believing the machine at this point... but the graphs don't look broken, just wild. Can you correlate any medication changes to the AHI rise?

Did you get that awake experiment done yet?
I wanted to see if you got a bunch of flags while awake or not.
Trying to verify if the machine is working properly or not.

I think you are most likely going to need to get with your doctor about what is going on but wanted to see what it shows while awake.

At this point (assuming the next experiment of trying a fixed pressure doesn't provide us with the miracle we want) I don't know if your machine is whacko and needs to be replace or if you simply have developed complex sleep apnea just from the cpap therapy and need a different type of machine.

I haven't had a chance to do the awake experiment. I will do that as soon as possible. The charts from last night are below (my AHI is down to 17). My SleepHQ O2 Ring came yesterday so last night was the first night with O2 data included. Here's a link to last night's data in SleepHQ

Summary data from 6/26/24-7/10/24



7/10 Sleep details data


@vandownbytheriver-- There haven't been any changes in medication, so there is no correlation regarding meds.

Thanks again for your time and help. I will try to get that awake experiment done ASAP. My doctor wanted me to have 30 nights on the machine before a follow-up appointment. Do you think this data is concerning enough to warrant an earlier appointment?

GregBot wrote: ↑

Thu Jul 11, 2024 2:09 pm

Do you think this data is concerning enough to warrant an earlier appointment?

No.... not at this point. Even the really ugly stuff the doctor would very likely want to give it some time even if it was truly full blown CPAP treatment emergent central sleep apnea.
The reason he would want to "give it some time" is because treatment emergent central apneas will sometimes go away on their own without doing anything. Insurance would require it also most likely before they would want to shell out the big bucks for the ASV machine (which can treat both central apneas and obstructive apneas).

But don't go cancelling that appt.

Last night was better and some of the flagged centrals you weren't asleep when they got flagged but then some of them it looks like you were asleep. At least last night it wasn't a solid block of centrals.

Questions....how well do you think you slept last night? How are you feeling today?
Were you for sure asleep during the really ugly time frame of about 10:30 to 12:15?

Next experiment....lets back up and start with the basics and see what happens.
Still in auto mode set your minimum pressure to 7 and your maximum pressure to 7, still no EPR.
Let's see what happens with going back to the basics. Do it tonight or tomorrow night...your choice but don't wait long.

When you get a chance do the awake experiment but your last night's report pretty much points to the machine not malfunctioning and making up crap. You have some nice normal breathing without centrals that happened which means it can happen again.

We can try a handful of little things to see if it helps or hurts the situation ....while waiting for that 30 day follow up appt.

In the meantime....continue to try to optimize your sleep quality itself. The more soundly you sleep the less SWJ false flagging we will see and makes for easier and more accurate evaluation of things when we don't have a lot of awake/arousal breathing going on.