Huge jump in AHI - Altitude-related?

apneasaurus · Post by **apneasaurus** » Mon Sep 30, 2019 7:44 am

Hi all,

I've been using a Resmed Airsense 10 for the past couple of years without much in the way of issues.

However, I just recently moved somewhere at somewhat significant altitude - ~5,300 feet, and my AHI has shot way up since getting here (not to mention that I'm always exhausted during the day now...) Just this past night, I had an AHI of 53

I've been here for a month now, and its only gotten worse the longer I've been here - my first couple of nights sleep here were actually comparable AHI-wise to what I would get at sea level, but things have seriously taken a turn for the worse since my first week.

I've got my machine set to APAP mode between 13cm and 20cm of pressure to try and give the machine some range in which to work - previously, at sea level, I was generally around 14-17 in APAP mode or ~16 in CPAP mode to minimize AHIs (got down to <2/night at one point). Humidity at level 5, and hose temp at 74 degrees (neither of which I've changed since moving).

Other notes - I don't drink, but I do smoke cigarettes (10/day), which hasn't changed since I moved up here. Regular morning coffee drinker, but that morning cup is all I do. I'm significantly overweight (hence the apnea!), but have come down in weight by over 100 lbs in the past 4 years or so - 6 ft. and 325 right now, but I started this journey at 440 lbs.

Any ideas about what might be happening here? I've got SleepyHead software installed and can post screenshots of particularly rough nights (like last night!) if you think that would help. Really appreciate all the insight and advice over the years from you guys - lurking here put me way ahead of the curve when I got started on all this!

Pugsy · Post by **Pugsy** » Mon Sep 30, 2019 7:51 am

Welcome to the forum.

Post a screenshot of last night please.

D.H. · Post by **D.H.** » Mon Sep 30, 2019 8:30 am

Most CPAPs have automatic altitude compensation to at least 7500 feet (approx 2300 meters). This means that the it will deliver the same pressure that it did at sea level. The motor will work harder than it did at sea level to do this.

The first thing to do is to verify that your machine does have automatic altitude compensation. If it has manual altitude compensation, you'll need to make the adjustment yourself (and undo it when you visit the place you used to live).

If that's not the problem, remember that you're in a completely different environment. Any environmental factor could be at issue.

Also, all that altitude compensation does is delver the same pressure as it did before. A different altitude might mean that your underlying pressure needs are different.

Pugsy · Post by **Pugsy** » Mon Sep 30, 2019 8:42 am

D.H. wrote: ↑
Mon Sep 30, 2019 8:30 am
The first thing to do is to verify that your machine does have automatic altitude compensation. If it has manual altitude compensation, you'll need to make the adjustment yourself (and undo it when you visit the place you used to live).

The ResMed AirSense 10 machines all have automatic altitude adjustment. Did you miss the part about what machine was being used?
Or did you not know that all ResMed machines made within last 15 years have automatic altitude adjustments?

apneasaurus · Post by **apneasaurus** » Mon Sep 30, 2019 8:52 am

Thanks for your responses!

Screenshots of last night's sleep / this afternoon's nap here:

https://imgur.com/a/if4VFg4

I tried to capture every page of graphs + the full session data on the left-hand side of the screen (you can see that in "Page5"

On the machine adjusting for altitude - I've got a Resmed AirSense 10, and they're supposed to auto-adjust for altitude.

Any and all ideas welcome...just want to get to the bottom of this!

chunkyfrog · Post by **chunkyfrog** » Mon Sep 30, 2019 9:02 am

It might be helpful if you shared the altitude of your old location vs new.
Or not.
Oh, I see you did--my bad.

Pugsy · Post by **Pugsy** » Mon Sep 30, 2019 9:03 am

Well...more OAs and hyponeas than centrals (ClearAirway with this software).
Unusual but not impossible. I was expecting centrals caused by the higher altitude.

Please review this thread for graph formatting .
viewtopic/t158560/How-to-post-images-for-review.html
We don't need all those graphs and what we do need is easily seen on one image. Less work for you but no need to redo this one.
I can see what I need to see in this one for the time being.

Your pressure is maxing out at 20 cm and not getting the job done and if those are indeed obstructive in nature and not central...you most likely are going to need a different machine.
It pretty much is immediately going to the max and staying there. Increasing the minimum isn't going to change much.

Some questions for you.

What is your normal sleeping position?
What medications do you take? Any change recently?
How long have you been at this altitude?

Can you get me a screen shot of a detailed report prior to the move where your AHI was within acceptable limits?

apneasaurus · Post by **apneasaurus** » Mon Sep 30, 2019 9:39 am

Pugsy wrote: ↑
Mon Sep 30, 2019 9:03 am
Well...more OAs and hyponeas than centrals (ClearAirway with this software).
Unusual but not impossible. I was expecting centrals caused by the higher altitude.

Please review this thread for graph formatting .
viewtopic/t158560/How-to-post-images-for-review.html
We don't need all those graphs and what we do need is easily seen on one image. Less work for you but no need to redo this one.
I can see what I need to see in this one for the time being.

Your pressure is maxing out at 20 cm and not getting the job done and if those are indeed obstructive in nature and not central...you most likely are going to need a different machine.
It pretty much is immediately going to the max and staying there. Increasing the minimum isn't going to change much.

Some questions for you.

What is your normal sleeping position?
What medications do you take? Any change recently?
How long have you been at this altitude?

Can you get me a screen shot of a detailed report prior to the move where your AHI was within acceptable limits?

Wow...thank you for your quick and detailed response!

Per your questions - answers below:

1) Normal sleeping position is on my back - it's always been the most comfortable because of the full face mask...

2) Medications: Prozac (for depression) and Methylphenidate (prescribed off-label to help treat the depression). No med changes in the past year - before Prozac / Methylphenidate, I was on Parnate which worked really well for the depression but ended up giving me awful insomnia ~1 year in.

3) Been at this altitude (~5,300 ft) for 33 days now - was at sea level before.

Properly formatted screenshot(s) (I couldn't get rid of the Event Breakdown chart) of a decent night's sleep at sea level below:

https://imgur.com/a/FAl4Y1F

Thanks again!

Pugsy · Post by **Pugsy** » Mon Sep 30, 2019 10:07 am

To get rid of the pie chart you have to go into Preferences/Appearance tab and remove the check mark for "show pie chart".
Sometimes it sticks and sometimes it doesn't. Not a big deal. I can see what I want to see.

I just did a quick bit of research on higher altitudes making OSA worse. It is more common than I thought.
I knew it was really common for central sleep apnea to worsen or pop up entirely new when going to higher altitudes but wasn't aware of the OSA also worsening.

Your OSA was barely treated acceptably even at sea level and you probably would have benefited from a bilevel machine that could go above 20 cm.

I don't know that there is a whole lot you can do with your current machine.....you could try turning EPR off and see if a constant 20 cm pressure makes much of a change or not. In other words....minimum to equal maximum and that would be 20 or got to cpap mode at 20 cm. Or if that is too much to handle reduce EPR to as low as you can comfortably deal with and see if it helps reduce the apnea events.
When we use EPR we are effectively reducing the pressure during exhale and if we are to believe your machine....you need more pressure and not less. I don't hold much hope of the minor change by reducing or turning off EPR making that much of a difference but I suppose nothing is impossible. Worth trying just in case a miracle happens.

There is some evidence that adding the medication Diamox to cpap OSA users whose OSA has worsened at altitude has helped reduce the OSA.

Sleep position can also make a huge difference and if at all possible I would suggest that you try sleeping on your side. I know it's a bit of a challenge with full face masks but it can be done. Meaning sometimes the pressure needs when we are side sleeping can be markedly lower and if you are one of those people then your current machine might be able to handle the situation.

How come the full face mask use? Can you normally breathe through your nose just fine or is it chronically congested and you can't get it clear enough to use a nasal interface mask?
What full face mask are you using? Some of the newer full face masks make it easier to side sleep and/or even sleep on your stomach?

You really need to be getting with a sleep doctor about this new development though. While waiting for the appointment you could try side sleeping or reducing or turning EPR off and see if you get lucky but as it stands right now the machine is unlikely going to be able to deliver what you need in terms of pressure to adequately reduce your OSA to acceptable levels.

apneasaurus · Post by **apneasaurus** » Mon Sep 30, 2019 10:44 am

Pugsy wrote: ↑
Mon Sep 30, 2019 10:07 am
To get rid of the pie chart you have to go into Preferences/Appearance tab and remove the check mark for "show pie chart".
Sometimes it sticks and sometimes it doesn't. Not a big deal. I can see what I want to see.

I just did a quick bit of research on higher altitudes making OSA worse. It is more common than I thought.
I knew it was really common for central sleep apnea to worsen or pop up entirely new when going to higher altitudes but wasn't aware of the OSA also worsening.

Your OSA was barely treated acceptably even at sea level and you probably would have benefited from a bilevel machine that could go above 20 cm.

I don't know that there is a whole lot you can do with your current machine.....you could try turning EPR off and see if a constant 20 cm pressure makes much of a change or not. In other words....minimum to equal maximum and that would be 20 or got to cpap mode at 20 cm. Or if that is too much to handle reduce EPR to as low as you can comfortably deal with and see if it helps reduce the apnea events.
When we use EPR we are effectively reducing the pressure during exhale and if we are to believe your machine....you need more pressure and not less. I don't hold much hope of the minor change by reducing or turning off EPR making that much of a difference but I suppose nothing is impossible. Worth trying just in case a miracle happens.

There is some evidence that adding the medication Diamox to cpap OSA users whose OSA has worsened at altitude has helped reduce the OSA.

Sleep position can also make a huge difference and if at all possible I would suggest that you try sleeping on your side. I know it's a bit of a challenge with full face masks but it can be done. Meaning sometimes the pressure needs when we are side sleeping can be markedly lower and if you are one of those people then your current machine might be able to handle the situation.

How come the full face mask use? Can you normally breathe through your nose just fine or is it chronically congested and you can't get it clear enough to use a nasal interface mask?
What full face mask are you using? Some of the newer full face masks make it easier to side sleep and/or even sleep on your stomach?

You really need to be getting with a sleep doctor about this new development though. While waiting for the appointment you could try side sleeping or reducing or turning EPR off and see if you get lucky but as it stands right now the machine is unlikely going to be able to deliver what you need in terms of pressure to adequately reduce your OSA to acceptable levels.

Again, I really appreciate how detailed you are with your responses!

I hear you on sleeping on my side - I will do so tonight and report back with the data my machine produces. I'll try that with my current APAP settings, and then make further adjustments as the results come in (going to straight 20cm CPAP, turning off EPR, etc).

On why the full-face mask...it's what I was given originally, I wasn't ever given the option of nasal pillows or anything else (didn't even know they existed way back then!). I can't complain though - got used to it pretty quickly and it doesn't bother me much. I do have nasal congestion more often than not (probably a result of my cigarette habit), so it's probably a good thing they started me on the full-face from the get go. I use this full-face mask (link below) in size Medium:

https://helpmedicalsupplies.com/product ... h-headgear

If making adjustments over the next few days doesn't yield any improvement, then I'll definitely be making an appointment with my sleep doctor. 53 AHI is no joke!

Thanks again for all your help - will be back in this thread with results from tonight's side-sleeping experiment...

Pugsy · Post by **Pugsy** » Mon Sep 30, 2019 11:06 am

If you want to try a nasal interface mask you might think about it.
Sometimes people need less pressure with a nasal mask than they need with a full face mask. I know people using 2 to 3 cm less pressure with a nasal mask than they used with a full face mask and getting better results in terms of AHI reduction.
Not to mention comfort and opening up easier sleeping positions.

TropicalDiver · Post by **TropicalDiver** » Mon Sep 30, 2019 12:03 pm

I just wanted to reiterate what Pugsy said. Before the move to altitude, your AHI was OK but your machine was pretty much maxed out (at 20 much of the night). Altitude or other changes pushed it over the edge -- it is running at 20 and still can't keep up.

She has given you some strategies that might help lower your apneas without going to a bi level machine (typically support pressures to 25). I would schedule the sleep doc appointment now -- it will likely be some time before your appointment. If things are resolved before then, great then you can cancel (or not). (I think she even phrased her ideas as things you could try while waiting for the appointment...)

As you said, your treated AHI is no joke. And poorly treated apnea (severe) is one of only several significant risk factors you have increasing the likelihood of a stroke or cardiac event. If I was your friend or family member, I would be strongly encouraging you to be seen ASAP.

palerider · Post by **palerider** » Mon Sep 30, 2019 1:35 pm

D.H. wrote: ↑
Mon Sep 30, 2019 8:30 am

The first thing to do is to verify that your machine does have automatic altitude compensation. If it has manual altitude compensation, you'll need to make the adjustment yourself (and undo it when you visit the place you used to live).

No it's not.

The first thing to do is put dh on the for list.

Jas_williams · Post by **Jas_williams** » Tue Oct 01, 2019 11:18 pm

You may find that your pressure needs could be reduced by using a soft cervical collar to prevent your chin tucking down towards your chest and restricting your airway.

K5MOW · Post by **K5MOW** » Wed Oct 02, 2019 6:11 am

Welcome to the forum.

Roger

Huge jump in AHI - Altitude-related?

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Additional Comments: Auto PAP; 13.5 cmH2O min - 20 cmH2O max