Still getting high AHI after 2 months of APAP.

I recently got diagnosed with severe sleep apnea (33.4 AHI). My sleep test said that I had 8.9 hypopneas, 24.5 obstructive apneas and 0 central apneas. I was prescribed an APAP.

Now, all of my events are mostly central. For about 2 months this has been the case. Is this normal? I've heard of treatment emergent central sleep apnea, but does it take this long for it to go away?

There was one week where my AHI was consistently over 4 and under 5 but it now started going back up again. Other than that, my AHI is always in the range of 5 to 13 and it never really consistently stays at one value.

Here's yesterday's more in depth info with sleepHQ: https://sleephq.com/public/5e01f580-de4 ... 7824ba9b04

How is your sleep quality?
Waking often or sleeping soundly for the most part?

Pugsy wrote: ↑

Mon Jul 08, 2024 4:00 pm

How is your sleep quality?
Waking often or sleeping soundly for the most part?

I sleep soundly!
I'd say I wake up when sleeping maybe 2-3 times during the entire week

Okay....do you take any medications of any kind? If so, what?
At what altitude do you sleep?

I didn't scroll through every second on your report but what I did look at sure looked like you weren't sound asleep when those centrals got flagged.
Later this evening I will try to find the time to scroll through the entire night. If you aren't asleep then those aren't treatment emergent centrals.

Have you considered trying a fixed pressure and not the auto adjusting pressure mode?

Pugsy wrote: ↑

Mon Jul 08, 2024 4:26 pm

Okay....do you take any medications of any kind? If so, what?
At what altitude do you sleep?

I didn't scroll through every second on your report but what I did look at sure looked like you weren't sound asleep when those centrals got flagged.
Later this evening I will try to find the time to scroll through the entire night. If you aren't asleep then those aren't treatment emergent centrals.

Have you considered trying a fixed pressure and not the auto adjusting pressure mode?

I take cipralex for anxiety. I think the equivalent brand name in the US is lexapro.
I'm in Ottawa, the elevation is around 70m.

Ah, maybe it's possible I actually wake up often but I remember just a few times?
What gave you the indication I don't sleep soundly? I'm not too familiar with reading these graphs yet

I can definitely try using a fixed pressure!

adrien123 wrote: ↑

Mon Jul 08, 2024 4:40 pm

What gave you the indication I don't sleep soundly? I'm not too familiar with reading these graphs yet

The flow rate (your breaths) prior to the flagged events don't look like asleep breathing to my eye.

Take a look at these threads as I have some examples showing both asleep and not asleep breathing.

viewtopic.php?f=1&t=187767&p=1451526#p1451526

viewtopic/t188071/Suggestions-from-my-waveforms.html

I have lots more but nothing handy.

Pugsy wrote: ↑

Mon Jul 08, 2024 4:47 pm

adrien123 wrote: ↑

Mon Jul 08, 2024 4:40 pm

What gave you the indication I don't sleep soundly? I'm not too familiar with reading these graphs yet

The flow rate (your breaths) prior to the flagged events don't look like asleep breathing to my eye.

Take a look at these threads as I have some examples showing both asleep and not asleep breathing.

viewtopic.php?f=1&t=187767&p=1451526#p1451526

viewtopic/t188071/Suggestions-from-my-waveforms.html

I have lots more but nothing handy.

Ok yeah, that makes a lot of sense. My girlfriend also told me I move quite a bit when I'm sleeping, which is probably impacting my breathing as well?
Now that I think about it, the few times I remember waking up is mostly while I was switching sleeping positions

Sounds like one of the first things I can try to is somehow train myself to sleep in only one position

adrien123 wrote: ↑

Mon Jul 08, 2024 5:10 pm

Ok yeah, that makes a lot of sense. My girlfriend also told me I move quite a bit when I'm sleeping, which is probably impacting my breathing as well?

Not so much "impacting your breathing" as resulting in a normal breathing pattern that your machine is mis-interpreting as sleep disordered breathing.

It's perfectly normal to arouse slightly (which almost always means taking a larger than normal-sleep-breathing inhalation) when the body decides it wants to change position in bed. As long as you go right back to sleep, it's nothing to worry about.

Now that I think about it, the few times I remember waking up is mostly while I was switching sleeping positions

Sounds like one of the first things I can try to is somehow train myself to sleep in only one position

Nope. I would not recommend trying to train yourself to sleep in only one position. Anything that causes you to sleep in a way that does not feel "normal" to you is likely to result in additional sleep disruption, and possibly more sleep disruption than you are currently experiencing.

For some new CPAPers, once the body fully trusts the machine, the general "restlessness and excess movement" settles down naturally because the body finally learns it doesn't need to keep arousing itself before a string of events can start happening. Occasionally we'll have new PAPers discovering that once they quit moving around so much in bed, they complain about various things "hurting" simply because the body needed to move around a bit more than it did.

I would urge you to not overthink the amount of time you spend moving around in bed. I also suggest that you not obsess about the night time wakes: If you don't remember them, that means they were short (less than 5 minutes) and that you got back to sleep without any significant trouble. It's perfectly normal to have a few short wakes during the night---many people awaken after every REM cycle for example. But as long as the wakes are less than 5 minutes, most people don't remember waking up and as long as there aren't dozens of these wakes each night, they don't negatively affect the overall quality of the sleep.

Now having said all that, when I look at the data you posted at https://sleephq.com/public/5e01f580-de4 ... 7824ba9b04 this is what I see:

1) I agree with Pugsy: There are several periods where it looks like you were pretty restless and you may have been bouncing between very light sleep and wake---i.e. you may have gotten trapped in sleep-wake-junk breathing. These events might not have been "counted" on an in-lab sleep test since the EEG data may well have scored the epoch in which they occurred as WAKE. (You have to be asleep for something to count as a sleep disordered breathing event.)

2) Since you don't recall a whole lot of wakes or long periods of restlessness, you just might be dealing with some garden-variety sleep maintenance insomnia. Would you describe yourself as a "light sleeper"? And how would you describe your sleep before you started PAPing? And were you super-surprised to be diagnosed with sleep apnea? Regardless of your answers, it's worth looking at your sleep hygiene to figure out if there are behavior patterns that may be contributing to night-time restlessness that you don't particularly remember when you wake up in the morning.

3) Your obstructive event index (OAI + HI + UA) is 3.21. Not super low, but not excessively high, and some of the Hs may be events that would not have been scored if this were an in-lab sleep test. In other words, there's room for improvement in the obstructive event index, but establishing good quality sleep may be as important or more important than just doing a knee-jerk pressure increase in the hopes it would bring the OAI + HI down a bit. The CAI is concerning on paper, but many of the CAs seem to occur after large inhalations, and that would indicate that many (most or all?) of the CAs are just post-arousal breathing being inaccurately flagged as a CA as you transition back to real sleep. In other words, the problem may be with too many micro-arousals, not with real central apneas. It's worth asking: What's the long term trend in the CAI look like? And compare that with your subjective sense of how well you are sleeping: On extra restless nights does the CAI seem to be higher than on nights where you remember no wakes and you don't think you moved around in bed as much?

4) You have a lot of activity in your Flow Limitation graph. Flow limitations are best described as "possibly problematic inhalation patterns" that are nowhere near severe enough to be flagged as a hypopnea or an obstructive apnea. Essentially, the "shape" of the inhalation is somehow distorted. (There are several different ways it can be distorted.) And the distorted inhalations can sometimes be associated as indicating a higher risk that the upper airway is in danger of collapsing in the very near future. So APAPs are designed to increase the pressure when they detect flow limitations. The problem is, however, that other things, including plain old nasal congestion, can cause flow limitations. And so not all flow limitations smooth out with increased pressure. And for a few people who are sensitive to the pressure changing on their APAP, the increased pressure in response to flow limitations can counter-intuitively cause more problems with flow limitations and/or general restlessness with lots of mini-arousals and sleep-wake-junk stuff. It can sometimes be tough to sort out what's going on when there's a lot of activity in the flow limitation graph.

In your case, some of the flow limitations seem to occur when you may very well be asleep, as in the snippets shown below.

You were almost certainly asleep during this period:


It's not clear whether you were asleep or just restless for most of this next period, but the largest of the inhalations don't seem quite as large (to my eyes) as inhalations in areas that look more clearly like SWJ breathing. I do suspect the leaks woke you up.


This last snippet is again somewhat ambiguous. You might have been tossing and turning and going back and forth between light sleep and wake. Or you might be asleep and just having some flow limitation problems. Without spending a huge amount of time looking at your breathing patterns over many nights, it's tough to say. But it's not clear that you are awake during these flow limitations.


But some of your flow limitations are occurring during what is likely SWJ breathing. Here's a snippet where you've got both flow limitations and a bunch of events scored by the machine:

Notice the bigger inhalations that precede each of the CAs in this snippet? That's what makes this look like SWJ breathing to me (and probably Pugsy). The first OA in this snippet looks like it is probably a real OA: The breathing right before it happens doesn't include any relatively larger inhalations. Also notice that there are some flow limitations just before the OA. To my eyes, it looks like the OA may have triggered some restlessness and that it took a while for you to get firmly back asleep after that OA occurred.

5) Do you have smart ramp on? If so, what is your minimum pressure setting? Here's why I'm asking: The beginning of the night looks like this:


You almost certainly were not soundly asleep until 12:12 (after those CAs, which may be normal sleep transitional centrals). And your pressure is a constant 6cm throughout this entire period. And there's a pretty steep pressure increase right after you fall asleep that is caused by a set of flow limitations. But lowest your pressure ever goes after that initial period is about 8cm.


What should you do in order to try to improve your sleep and hence how you're feeling in the daytime? I'd start by doing the following:

1) Do not obsess over the CAI for now.
2) Think seriously about your sleep hygiene. If there is room for improving the sleep hygiene, work on that right now. If you don't know what sleep hygiene is, let me know and I'll give you some pointers.
3) Since you have EPR turned off, you might want to turn it on. That might help smooth out the flow limitations. And smoothing out the flow limitations might mean fewer steep pressure increases leading to periods of SWJ breathing because you wind up getting restless after the pressure is increased. If you turn EPR on, don't make any other changes and keep EPR on for at least 3 or 4 days before making a decision that somehow your CAs are being caused by EPR rather than just being part of SWJ breathing being mis-classified as CAs.
4) If the pressure is not causing you any problems with aerophagia, you might want to bump the minimum pressure up a notch. If you've had no problems with aerophagia, you could bump the min pressure up by 1 cm. (If you've had problems with aerophagia, be more cautious and only bump it up 0.2 or 0.4 cm at a time.) Keep the new minimum pressure in place for at least 4 or 5 days before making any other changes---unless you have some kind of disastrous night or aerophagia raises its ugly head. And in that case, bump the minimum pressure back down to its current setting.
5) Don't make the changes in #3 and #4 at the same time: Pick one change. Make it, and leave the settings alone for 3 or 4 days unless there is some kind of disaster.

Really appreciate your super detailed analysis. And thanks for taking the time to write all of this.

For the questions on your second point:
I wouldn't describe myself as a light sleeper. But I'm not the heaviest one either.
I do feel so much better in the mornings and throughout the day ever since starting using my APAP. However, I'd say I still wake up and move/roll as much as I used to.
I was actually surprised to be diagnosed with sleep apnea. I had no idea I could have it and the only reason I did the sleep study was because my girlfriend told me I sound like I'm choking at night. I probably wouldn't have thought about doing a sleep study otherwise.

For your fifth point:
I do have smart ramp on. My minimum pressure is 6cm. Looks like it is indeed sleep transitional centrals for that period.

Sounds good for not obsessing over CAI and sleep positions. Probably wouldn't want to make sleep a stressful thing in the end.
I'd like to know more about sleep hygiene! I never really researched or read anything about it.

I will probably start with turning the EPR on tonight and see how it looks like after 3-4 days. I'll post my results here again after 4 days.

We've tried increasing the pressure with my respirologist for a few days. We even went up to 10cm minimum pressure but the results unfortunately didn't change that much. My AHI was staying in the 10+

Thanks again for all your recommendations