Please help me reduce my AHI

Hello,

I've been using CPAP for several years now, and my AHI has always hovered around 4-5 AHI. My sleep clinic thinks this is fine but as I am still struggling with fatigue, I'd like to lower it and see if it helps.

I have tried a few masks over the years but the one I have the most joy with is the AirFit F20, which I'm currently using.

Please see my OSCAR report attached and let me now if you need any further information etc.

Thank you in advance!

Ch1lly wrote: ↑

Fri Mar 07, 2025 4:48 am

I've been using CPAP for several years now, and my AHI has always hovered around 4-5 AHI. My sleep clinic thinks this is fine but as I am still struggling with fatigue, I'd like to lower it and see if it helps.

Yep. Technically the reduction in AHI meets the sleep medicine community's definition of "effective CPAP therapy."

And yet people around here---people with actual sleep apnea problems who use a PAP machine every night will tell you that most of us don't feel at our best when the AHI is still hovering around 4-5 every night.

Since you are still struggling with fatigue, it is worth seeing what you can do that might get that AHI lower to see if that improves your daytime fatigue levels. And the obvious suggestions that many people might make would be to just bump your pressure up a bit (to 11 or 12 cm?) OR to switch to Auto mode with a pressure range of something like 8-12 to see where the machine wants to go. (Some folks would suggest using a pressure range of 8-20.)

But I think there's more going on than just the need to increase your pressure setting. And in order to make suggestions on how to do that, I think we do need a more complete picture of your situation, including some background information.

So here's a list of questions for you to answer:

1) Do you have any medical conditions other than obstructive sleep apnea? If so, what are they? And do you take any medication for them?

2) You are using a PR DreamStation Auto CPAP in CPAP mode. Are you aware of the fact that this machine was recalled a couple of years ago and if so, has the machine been replaced under the recall?

3) What do your sleep patterns look like? What I mean by that are the following things:

• Usual bedtime?
• Usual wake-up time?
• Usual time it takes you to fall asleep?
• How restless would you describe your sleep? Do you feel like you toss and turn for large periods of time on most nights? Do you feel like you have multiple wake during the night? If you wake up during the middle of the night, how much trouble do you have getting back to sleep?

4) What's your sleep hygiene look like? What I mean by that are the following things:

• Do you watch a lot of tv while in bed? Or use your cell phone to web-browse or watch videos while in bed?
• How much caffeine do you consume each day? How close to bedtime?
• How much alcohol do you consume each day? How close to bedtime?
• How close to bedtime is your last big meal or big snack?
• How irregular is your bedtime? How irregular is your wake-up time?
  
  Now to look at your data: The thing that jumps out at me is that there appears to be a whole lot of spikiness in the waveflow---even when looking at the whole night of data. That kind of spikiness in my own data indicates that I'm having trouble getting to sleep and staying asleep---as in it indicates a problem with my long-term, but now intermittent insomnia raising its ugly head.
  
  Here's a marked up version of the data you posted:
  
  The areas of breathing that I've put in blue boxes don't look like real, continuous sleep breathing. Rather, they look like you were very lightly asleep or awake or bouncing between a very like sleep and wake. And as a consequence, I'm not sure whether any of the events recorded during those times would have been flagged on an in-lab sleep test with EEG data about your sleep stages.
  
  The areas of breathing that I've put in red boxes appear to be real sleep breathing and/or transition to real sleep breathing. The events that I've boxed in black appear to be real events that bounced you out of sleep back into wake or kept you from transitioning fully to a real continuous sleep.
  
  In other words, based on this one night's worth of data, I would have to ask whether your remaining sleep problems are being caused by something other than obstructive sleep apnea. And the question is what might be causing your bad sleep if it's not sleep disordered breathing since the few times when you do get to sleep seem to be relatively uninterrupted by events.
  
  And all of that means looking at the set of questions I asked earlier.

Hi Robysue,

Firstly thank you for taking the time to reply to me, I'm grateful. In terms of pressure I have tried everything from 10-16 (all fixed pressures). I've answered your questions below each one in bold.

robysue1 wrote: ↑

Sat Mar 08, 2025 1:15 pm

Ch1lly wrote: ↑

Fri Mar 07, 2025 4:48 am

I've been using CPAP for several years now, and my AHI has always hovered around 4-5 AHI. My sleep clinic thinks this is fine but as I am still struggling with fatigue, I'd like to lower it and see if it helps.

Yep. Technically the reduction in AHI meets the sleep medicine community's definition of "effective CPAP therapy."

And yet people around here---people with actual sleep apnea problems who use a PAP machine every night will tell you that most of us don't feel at our best when the AHI is still hovering around 4-5 every night.

Since you are still struggling with fatigue, it is worth seeing what you can do that might get that AHI lower to see if that improves your daytime fatigue levels. And the obvious suggestions that many people might make would be to just bump your pressure up a bit (to 11 or 12 cm?) OR to switch to Auto mode with a pressure range of something like 8-12 to see where the machine wants to go. (Some folks would suggest using a pressure range of 8-20.)

But I think there's more going on than just the need to increase your pressure setting. And in order to make suggestions on how to do that, I think we do need a more complete picture of your situation, including some background information.

So here's a list of questions for you to answer:

1) Do you have any medical conditions other than obstructive sleep apnea? If so, what are they? And do you take any medication for them?

Unfortunately yes! Type 2 diabetes insulin/metformin controlled. I've also been diagnosed with Chronic Fatigue Syndrome, which might make my post for help seem silly....but I feel that if I don't get the Sleep Apnoea dialled in then I can't be sure it's just this causing my fatigue. I also suffer from anxiety and take an SSRI for it.

2) You are using a PR DreamStation Auto CPAP in CPAP mode. Are you aware of the fact that this machine was recalled a couple of years ago and if so, has the machine been replaced under the recall?

Yes it was replaced last year

3) What do your sleep patterns look like? What I mean by that are the following things:

• Usual bedtime? 10:30pm
• Usual wake-up time? 6:30am
• Usual time it takes you to fall asleep? Usually within 20 minutes
• How restless would you describe your sleep? Do you feel like you toss and turn for large periods of time on most nights? Do you feel like you have multiple wake during the night? If you wake up during the middle of the night, how much trouble do you have getting back to sleep? I do sometimes get restless legs. I also do recall waking up and turning several times in the night although it doesn't take me long to fall back to sleep

4) What's your sleep hygiene look like? What I mean by that are the following things:

• Do you watch a lot of tv while in bed? Or use your cell phone to web-browse or watch videos while in bed? Nothing in bed, but usually right up until bedtime
• How much caffeine do you consume each day? How close to bedtime? I have been caffeine free for 2+ years
• How much alcohol do you consume each day? How close to bedtime? I have been alcohol free for 2+ years
• How close to bedtime is your last big meal or big snack? 3-4 hours
• How irregular is your bedtime? How irregular is your wake-up time? My bedtime and wake up times are very consistent (kids lol)
  
  Now to look at your data: The thing that jumps out at me is that there appears to be a whole lot of spikiness in the waveflow---even when looking at the whole night of data. That kind of spikiness in my own data indicates that I'm having trouble getting to sleep and staying asleep---as in it indicates a problem with my long-term, but now intermittent insomnia raising its ugly head.
  
  Here's a marked up version of the data you posted:
  
  The areas of breathing that I've put in blue boxes don't look like real, continuous sleep breathing. Rather, they look like you were very lightly asleep or awake or bouncing between a very like sleep and wake. And as a consequence, I'm not sure whether any of the events recorded during those times would have been flagged on an in-lab sleep test with EEG data about your sleep stages.
  
  The areas of breathing that I've put in red boxes appear to be real sleep breathing and/or transition to real sleep breathing. The events that I've boxed in black appear to be real events that bounced you out of sleep back into wake or kept you from transitioning fully to a real continuous sleep.
  
  In other words, based on this one night's worth of data, I would have to ask whether your remaining sleep problems are being caused by something other than obstructive sleep apnea. And the question is what might be causing your bad sleep if it's not sleep disordered breathing since the few times when you do get to sleep seem to be relatively uninterrupted by events.
  
  And all of that means looking at the set of questions I asked earlier.

Shameless/desperate bump

Ch1lly.

It's midterms week and I'm a college professor. That's why I haven't responded sooner.

Ch1lly wrote: ↑

Sun Mar 09, 2025 2:59 am

Hi Robysue,

Firstly thank you for taking the time to reply to me, I'm grateful. In terms of pressure I have tried everything from 10-16 (all fixed pressures). I've answered your questions below each one in bold.

robysue1 wrote: ↑

Sat Mar 08, 2025 1:15 pm

Ch1lly wrote: ↑

Fri Mar 07, 2025 4:48 am

So here's a list of questions for you to answer:

1) Do you have any medical conditions other than obstructive sleep apnea? If so, what are they? And do you take any medication for them?

Unfortunately yes! Type 2 diabetes insulin/metformin controlled. I've also been diagnosed with Chronic Fatigue Syndrome, which might make my post for help seem silly....but I feel that if I don't get the Sleep Apnoea dialled in then I can't be sure it's just this causing my fatigue. I also suffer from anxiety and take an SSRI for it.

My heart goes out to you with the chronic fatigue syndrome diagnosis. My younger brother has dealt with the combination of chronic fatigue syndrome, sleep apnea for several years. And now he's also dealing with long covid.

I do think that with the chronic fatigue syndrome, some of your on-going issues may be that more than the sleep apnea not being treated as well as it could be. Has anything been suggested as a way of coping with the fatigue from the chronic fatigue syndrome beyond the usual "try to get a good night's sleep every night"?

3) What do your sleep patterns look like? What I mean by that are the following things:

• Usual bedtime? 10:30pm
• Usual wake-up time? 6:30am
• Usual time it takes you to fall asleep? Usually within 20 minutes

The data you posted makes it look like you are using a 30 minute ramp up period. It may be that the ramp is not doing you as much good as you think it is doing. Let's look at the one night of data that you posted (again):



Notice that your breathing pattern gets a lot more spikey right after that first H is scored while the machine is continuing to ramp up the pressure to your fixed pressure of 12.5 cm. That H was probably just a mis-scored sleep transition "event" that would not be scored on an in-lab sleep test. But perhaps because of the CPAP and the fatigue, you're a bit hyperaware of your breathing pattern and that natural slowing of the breath (in an effort to transition to real sleep) caught your brain's attention and caused you to arouse back to a more wakeful state where you became more restless. I say that because I see very little breathing at this level of zoom that looks like good quality sleep breathing in the sense of not being restless. The problem is not too many events; the problem is that it looks like almost the whole night is "sleep-wake-junk" breathing---i.e. the spikiness of the breathing makes it look like you never really got sound asleep. Rather, it sure looks like you were bouncing back and forth between very light sleep and wake for most of the night. And the patches where it looks like you almost settle down and start drifting into a sounder sleep---a sounder sleep that naturally involves shallower and slower breathing---something causes you to wake right back up and it's not always because of a flagged event.

If this were my data, I would zoom in on each of the hypopneas. I'm willing to bet that many of them follow a large inhalation or two, which would indicate that they are post arousal events that would not be scored on a sleep test. As post arousal events, they occurred when you were awake or (attempting) to transition back to (light) sleep. But again, I think your brain is reacting as if there's something wrong even though there's not. And so you wake back up and the SWJ pattern starts again and again all night long.

Any history of insomnia? If so, how have you managed it in the past?

How restless would you describe your sleep? Do you feel like you toss and turn for large periods of time on most nights? Do you feel like you have multiple wake during the night? If you wake up during the middle of the night, how much trouble do you have getting back to sleep? I do sometimes get restless legs. I also do recall waking up and turning several times in the night although it doesn't take me long to fall back to sleep

Were you more restless than usual on this night? Because the wave flow on this night does not look like the wave flow from someone who is sleeping well all night long with only a few wakes that they vaguely remember.

4) What's your sleep hygiene look like? What I mean by that are the following things:

• Do you watch a lot of tv while in bed? Or use your cell phone to web-browse or watch videos while in bed? Nothing in bed, but usually right up until bedtime
• How much caffeine do you consume each day? How close to bedtime? I have been caffeine free for 2+ years
• How much alcohol do you consume each day? How close to bedtime? I have been alcohol free for 2+ years
• How close to bedtime is your last big meal or big snack? 3-4 hours
• How irregular is your bedtime? How irregular is your wake-up time? My bedtime and wake up times are very consistent (kids lol)

So your sleep hygiene is pretty decent except for the tv/cell phone stuff right up to bedtime.

So that brings us back to: What (other than sleep apnea) might be causing your sleep to be so bad? Here's the thing: CPAP fixes sleep disordered breathing, but it doesn't fix bad sleep. The idea is that if the only thing disturbing a person's sleep is sleep disordered breathing, using a CPAP will allow the person to get good quality sleep because their sleep is no longer being disturbed by the sleep disordered breathing.

But if the bad sleep has multiple roots and CPAP only fixes one of them---the sleep disordered breathing---then the sleep can remain bad and daytime fatigue can remain a problem. So we're back to the same question: What else might be causing your bad sleep?

Are you, by chance, more anxious these days than you were before you started CPAP? And have you ever felt genuinely better on CPAP than you felt before you started using CPAP?

Hi Robysue,

I'm in touch with the CFS team, I have an appointment soon. I presume the most they can do is talk about pacing etc.

This chart is a typical night for me, and looking at some other days data it's actually one of the better ones! As far as I recall I don't remember a lot of these waking up events. I've added some zoomed-in looks at some of the events for your review.

No history of insomnia but I don't think this has ever been looked into. How do they even diagnose this?

My fatigue long pre-dates my sleep apnoea diagnosis and treatment. And to answer your question NO, I have never felt an improvement since starting CPAP.

My anxiety is up and down all the time and doesn't particularly seem to affect my sleep. Or at least I haven't noticed that even when my anxiety is very minimal, I still don't get refreshing sleep.....