AHI 14 after 4 months – How Improve?

Happy Holidays to all,

I have an opinion question or two for all the wonderful folks here. I post occasionally here but am more of a silent read only type, so first a bit of history -

I have been on xPAP since August, so about 4 and a-half months now. During titration they discovered that normal CPAP gave me centrals, so I am on BiPAP. I’m 34, 140 lbs. I have an 11 month old who still gets me up at least once a night so that may have something to do with it, who knows.

I started out with a nasal mask and tried several of those – ComfortGel, Fusion, ComfortClassic, Softgel, and Activa. I tried one nasal pillow, the Swift FX, and absolutely loved it – well, as much as one can anyways. If I could I would use the Swift FX. Sadly, apparently I’m a mouth breather as when using the nasal I would always wake up with a very dry mouth no matter where I had the humidifier set, and I know air was escaping through my mouth, as when I would be falling asleep puffs would leak out and wake me up. A chinstrap was both uncomfortable and didn’t help at all, since even if my teeth were clenched tightly, I’d still get the puffs. So I switched to full face and have gone through about all the full face masks there are because of either leakage or causing sores on the bridge of my nose. I’ve tried the Quattro, the Liberty, the Hybrid, the ComfortFull 2, ComfortfulGel Full, The Forma, the F&P 431, and the Zzz Probasics. Right now I switch between the F&P 431 and the Zzz Probasics. I was able to try all these masks thanks to my DME and cpap.com. I’m 99% compliant. 0% leaks.

I may order another Swift FX as a Xmas present for myself as it was so comfortable and try and learn how to not have mouth leaks if that’s even possible.

Anyways, I was started at a pressure of 11/7. AHI average 16 or so. After a couple months they have me do a second sleep study because the AHI is still high, and upped my pressure to 16/9. That pressure was too high for me to take. I had to strap the masks on so tight to prevent leaks it was very uncomfortable and the pressure alone I just couldn’t adjust to. So they dropped me down to 12/8, which is what I am now. During titration, those were the top 3 pressure settings that had my AHI under 10, though they never did get it fewer than 5. It’s weird that in titration they can get it lower than 10 but never at home… nor did they say I mouth breathed during my first titration when I had a nasal mask on but evidence points contrary to that… anyway.
So I went for a follow-up yesterday and my AHI is still in the 12-16 range. The doctor says let’s wait and see another month a half, maybe my body will adjust to it, so I am supposed to back in late January but no changes for now.

So here’s the question(s) –

1. How likely will there be much improvement? Since day one while use at home AHI has never been lower than 12. Usually in the 14 – 16 range. A lot higher with the 16/11 pressure. I don’t see why waiting another month and a half will do anything.

2. Since normal CPAP causes me centrals, would an APAP machine be of any benefit to me over a BiPAP? The doctor told me no.

3. What’s the next step for someone who’s AHI is still high on BiPAP? Is it an Auto BiPAP, if there is such a thing? Or is it the one that has a timing sequence in it, that shoots a very high pressure after so long if it doesn’t detect a breath? Would Oxygen be of any benefit whatsoever? Whichever the best next step is, how do I talk my doctor into it since he seems to be dragging his feet?

4. My doctor said something that bugged me yesterday which makes me worry about his plans (if any) on what to do in a month a half if things haven’t changed: “Sometimes you have to compromise on the benefits and get the best you can since the higher pressure didn’t work for you.” This makes me feel like he is saying that since I couldn’t take the 16/9 pressure that he’s basically given up on me he’ll leave me at 12/8 no matter what AHI that turns out to be.

5. Does anyone know any good sleep doctors in Annapolis, MD? Because mine is affiliated with the diagnostic center I got referred to in Annapolis, and is actually located in Virginia except for a single day a month where he comes to the diagnostic center in Maryland for appointments. I’d actually like a doctor who I could see except for one Thursday out of a month…

Thanks

Mask2sleep wrote:3. What’s the next step for someone who’s AHI is still high on BiPAP? Is it an Auto BiPAP, if there is such a thing? Or is it the one that has a timing sequence in it, that shoots a very high pressure after so long if it doesn’t detect a breath? Would Oxygen be of any benefit whatsoever? Whichever the best next step is, how do I talk my doctor into it since he seems to be dragging his feet?

Yes there is an Auto BiPAP... whether it's right for you... I don't know.

I know this suggestion is counter intuitive but have you tried lower pressure? Higher pressure can induce centrals. This topic is covered extensivly on this site.

I also have a Bipap that and was prescribed 13/9. My AHI was always above 10 at this pressure. First I tried raising the pressure and the AHI got worse. Then I lowered it and the AHI got better.

I am now running my Bipap in CPAP mode. Pressure is fixed at 9.6 -- my AHI is consistantly below 5. Last night is was 3.5. I also use the F&P Forma mask which is comfortable and has 0 leakage. As a baseline comparison you could consider 1 night running straight CPAP pressure of 10 or Bipap 10/10. See what impact this has on your AHI and adjust from there.

Mask2sleep wrote:What’s the next step for someone who’s AHI is still high on BiPAP? Is it an Auto BiPAP, if there is such a thing? Or is it the one that has a timing sequence in it, that shoots a very high pressure after so long if it doesn’t detect a breath? Would Oxygen be of any benefit whatsoever? Whichever the best next step is, how do I talk my doctor into it since he seems to be dragging his feet?

Hi,

Yes, there are auto BiPAPs. For me, auto mode didn't work--I woke up feeling like a zombie despite having a low AHI. Everybody is different, I guess. From there, you can move to a S/T machine and then an ASV machine. Those are very expensive, so insurance companies are reluctant to provide them unless you really need one. You might really need one. The only way you are probably going to find out is by getting a 2nd opinion. I'd take the time and expense to get evaluated at major sleep clinic or a cardiac care center. You want some real pros, not some guy who comes out once a month.

If it is pressure that you need, and you cannot find a mask that you can live with, then you might be looking at a surgical option. A trache will probably fix the problem. The question is if the xPAP treatment that you end up with good enough? If not, then you might have to look at this as an option. In my case, I was pretty much out of options. It was either dealing with a pressure of 20, or getting a trache. That gave me all the motivation that I needed. I still ended up accumulating a pretty large mask graveyard before I tried and liked the Swift LT. Funny thing is that I don't even notice the pressure when using the Swift LT, whereas the full face and nasal masks feel like a wind tunnel to me.

As far as O2 goes, are you still having oxygen desaturations? If so, O2 might help. If your O2 doesn't drop, then it probably isn't going to help you. You can purchase a decent consumer grade recording Oximeter for around $100. That would give you a very quick answer to that question. For example, without CPAP, my O2 levels dropped into the high 60s. With my BiPAP running, I never drop below 94%. I run the Oximeter every 60 or 90 days just to confirm that I am still doing OK.

-john-

Well, certainly nobody could say you haven't tried to find a mask that works for you! As to using nasal pillows, Is your mouth breathing due to a deviated septum or nasal issues? Do you mouth breathe during the day too? Just yesterday I read someone's story on here of how getting their nose issues resolved surgically significantly dropped their pressure need. Of course there's always mouth taping, however, if those passageways are inadequate, I would want my mouth to be a recourse.

Something else that's been discussed before is the MMA procedure. It's a pretty radical surgery, so I'd need the docs to absolutely prove to me it was indicated in my case. My brother works with a guy who had it done, and he said it was really hard to go through but it changed his life. Seems to me if other efforts fail it would be beneficial to know based on appropriate scans if your airways are compromised at any point so you can make decisions based on facts.

Your doctor certainly doesn't foster confidence or hope in his patients. This waiting game sounds like a stall before saying they don't know what to do. If he can't even suggest what the next steps might be, I don't see how he is going to be of any benefit to you.

That beautiful baby is quite a motivation to get the sleep thing right. You're gonna need the rest to keep up with her soon.

1. Without using the software you are flying blind.

2. As a known mouthbreather, you must stop all air being expelled from your mouth for treatment to work.

3. Despite what's said here to the contrary, mask vent rate matters. Any mask rate that exceeds 40 LPM isn't good enough for me.
I set the high leak limit for the masks I buy at 38 LPM @ 15cm of water pressure, if the mask is higher than that I don't use it, PERIOD!

Once more without correct data, you are playing a guessing game, and losing.

With Encore software, the dailies will tell the tale. Jim