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Bi pap may give you the higher pressure you need for inhaling, and then lower the pressure to make exhale much easier. Could be that this is what the doc. implied when he thought you couldn't tolerate 19.

Surgery may be relevant if its a deviated septum or big tonsils causing your obstructions - have you had either of those diagnosed?

And having yourself checked for GERD may also be a good idea - certainly worth insisting on before surgery is considered.

Good luck

O.

I had my tonsils taken out at a Chinese hospital, in Taiwan, when I was 16. As I recall, the surgery lasted 4 hours and they had a lot of trouble stopping the bleeding. Maybe I have a lot of scar tissue that is taking the high pressure to blow through. I'm 5'8 and 125 pounds, so I wouldn't think it's fatty tissue.

From what I saw of your reports, your "problem" is massive leakage from your Hybrid mask. As you keep leaking, you're having events and your pressure is going up and consequently additional leakage follows. It's a vicious spiral. Literally, all of your events are occurring while you're leaking is at its worst.
The night you didn't have a leakage problem, you had an AHI of 2.5 and your pressure hovered around the vacinity of 8 - 10.

Den

I'm going to bring in my mask and show them how much it leaks. They always say that the leakage is within the intentional range for that mask. I've ordered another mask, as you suggested.

OutaSync wrote:I'm going to bring in my mask and show them how much it leaks. They always say that the leakage is within the intentional range for that mask. I've ordered another mask, as you suggested.

It's YOUR money.....but......I'd try a different mask FIRST, before spending the money for another sleep study.
That ONE good night in your reports looked REAL good!

Den

You are right! And I still don't know why that one night was so different from all the other nights. i didn't do anything differntly.

It's one thing to have a higher leak rate with a relatively flat line, but on those leaky nights you had, the leak line was nowhere in the vacinity of "flat".

Den

When the pressure goes up doesn't the exhalation (leak) rate have to go up, too? Otherwise where does all that extra air go?

A little, but not to the extremes that I saw.

If everything is sealing "well", the "leak line" should be relatively flat.

Den

My opinion:

That Hybrid interface is horrible for auto therapy. Might be okay for cpap where the machine doesn't need to "read" your events, but on a autopap is screws it up and you cannot rely on the data being seen. Then that interface has too large a intentional leak rate making it noisy and any external leak encountered it can easily exceed the limits of the machine to compensate for said leak.

When you get up in the higher pressures over 15cm it gets even worse.

I would try a conventional nasal mask and compare your numbers. Are you a shallow breather? That can trigger the machine into false pressure increases resulting in NR's showing up on the report.

If the AHI remains high and NR's are also present on the report, keep in mind before the machine registers a "NR" (aka Non-Responsive Apnea/Hypoapnea or NRAH) it has to see 3 of those events (events that triggered the NR) in a row. So now if the machine only sees 2 of the needed 3 it continues to log those events at either an apnea or hypopnea or FL. I would assume here you are also having FL's at those higher pressures. Since you mention "clusters", I'd be your report resembles the report below (red annotations are mine for another discussion):



IF AHI is the only thing considered, maybe you would do better limiting the pressure to about 8.0cm for a few nights and comparing to the higher along with "how you feel". If you are feeling like the walking dead at those higher pressures then those events may be central from over titration and your particular breathing pattern. A shallow breather can make those machines go nuts, that hybrid mask is probably the worst you could have selected for those conditions. If you have a UltraMirageII or a ComfortGel I would try that and taping before I'd use a Hybrid.

If those NR's are caused by GERD, you can try taking a PecidComplete right before bed a few nights and then compare AHI numbers. If AHI drops you can explore the GERD aspect more fully. No CA's showing up on your PSG doesn't really mean anything, we've seen that happen many times then they magically appear when they go to another sleep lab.

If your doctor is NOT sharing your Sleep Studies with you, I wouldn't waste any more time with that doctor, I'd be finding one that will work with you, because it is only when you fully understand your disorder will you take the steps to address it.

If you put your machine in CPAP mode at 8.0 cm pressure, that should be enough to take care of about 70% of your SDB events and still provide enough air to keep your oxygen levels up near normal levels, but more importantly using that constant 8.0 pressure should be low enough to avoid any central apnea. Machine will still record the events seen.

Snoredog,

Thank you for your insightful and very helful response. Every thing you say makes sense. The doctor chose the Hybrid for me, after I had problems with FF masks hurting my rather large and previously broken nose. Every FF mask I've tried has also blown out around 16. I've ordered a nasal mask (Activa) and will try taping. I am a shallow breather. Even during the day I realize that I haven't taken a breath for awhile and have to take a deep breath to clear out my lungs. Will they be able to tell if shallow breathing is causing the events during a sleep study? My oxygen levels were down to 65 during the last sleep study.

I am going to take your suggestions with the pressure and with the Pepcid (I guess I should try one at a time) and see what happens. Thanks again.

OutaSync wrote:Snoredog,

Thank you for your insightful and very helful response. Every thing you say makes sense. The doctor chose the Hybrid for me, after I had problems with FF masks hurting my rather large and previously broken nose. Every FF mask I've tried has also blown out around 16. I've ordered a nasal mask (Activa) and will try taping. I am a shallow breather. Even during the day I realize that I haven't taken a breath for awhile and have to take a deep breath to clear out my lungs. Will they be able to tell if shallow breathing is causing the events during a sleep study? My oxygen levels were down to 65 during the last sleep study.

I am going to take your suggestions with the pressure and with the Pepcid (I guess I should try one at a time) and see what happens. Thanks again.

Only observing your neck size from your picture, you appear to have small anatomy so the question becomes why do you need so much pressure.

I think your doctor is wrong with the micro-management statement, an OA of 17 is inadequate treatment in my opinion. You mention a past broken nose, have you had that examined by a qualified ENT since? Broken nose can leave you with a nearly blocked nasal valve.

- for CPAP therapy to be effective you MUST be able to breathe through your nose.

Common nasal congestion is what most people on this therapy have to deal with. If you have a past history of a broken nose that should throw up a red flag to see an ENT to make sure you can properly breathe through your nose. If anything you want to rule OUT nasal anatomy being a problem for CPAP therapy.

If you don't, and you apply too much pressure with CPAP to get past the obstruction you can over titrate the patient and cause uncesessary arousals during sleep.

While pressure is important in splinting your airway, so is the volume flow getting through the nose. Pressure can get through a small obstruction and eventually splint your airway, it just takes it longer to do that. However, if your nasal valve is 60% blocked for example, you are only going to get 40% of the volume flow of air you need to breathe.

In other words, applying that much pressure may be the result of nasal blockages (due to prior broken nose, scar tissue, polyps etc.). If your OSA is caused by the tongue falling into the back of the throat the CPAP therapy pressure is obstructed before it can ever reach the tongue to perform its splint.

My suggestion:

Contact your GP doctor for a referral to a good ENT for a nasal exam. Indicate to that ENT of your complications with CPAP pressure being so high.

A good ENT should be able to tell you with a simple office exam if you have nasal obstructions that could be contributing to that higher pressure. They can look at the base of your tongue and past surgery for tonsils making sure nothing there is causing a problem. You may want to ask them about the possibility of vocal cord dysfunction. They can check that out with a fiber optic scope, all done in their office.

OutaSync,

I too have just started therapy and have been struggling with high ahi's. After finally starting using the Encore reader program, I was able to see that my problem was mask leakage. It wasn't real bad leakage, but it was apparently enough to prevent the apap machine from doing its job. Whenever the apneas would start, the pressure would go up and also so would the leakage and usually the apneas were not stopped. I tried a ff mask, then a hybrid. Both were extremely uncomfortable, plus the leakage. I started using the Comfortlite 2 several days ago. I'd thought I breathed out of my mouth so much a nasal mask wouldn't work on me, but I was mistaken. CL 2 comes with four mask interfaces. I tried all of them. The last I tried was the one I thought least likely to work. But it did! I finally got down to an ahi of 5.1 and a very level leakage line. I'm using a makeshift chin strap and have ordered a store-bought one.

I'm telling you all this to suggest that leakage could be a major problem in your therapy. You have to get it under control before the cpap can work effectively. I hope your new mask will solve your problems!

Good luck!

dand

I've never been to an ENT. Didn't even see a doctor when I broke my nose at 13. Thank you for giving me all of this information. I was getting pretty frustrated after 6 weeks of "therapy" and being worse off than when I started. At least now I know where to go from here.