Unable to fine tune my setting to improve AHI.

I have been on xPAP now for almost 2 months. I have a Resmed S9 Autoset w/ the Climate Control hose and a Quattro full face mask (I can not breathe very well through my nose).

I spent about 10 days with the original setting of 7cm (my sleep setting titration was 6) and found a variance of 0.9 (lowest) to 4.0 (highest) with an average of about 2.0 AHI when sleeping 7.5-8.0 hours (my normal range). Usually an equal split between Apnea's and Hypopnea's, and the Apneas are equal split between obstructive and central.

I usually experience one event during the first 4 hours of sleep, then the rest pile on during the last 2 to 3 hours.

I check the detailed graphs virtually every day and aside from the first night I have almost never have significant leakage, and when I do it is for a very short duration (and does not seem to correlate to events).

So, I have tried many things to lower my AHI, I set the CPAP settings to both 6cm and 8cm (no apparent difference). I set the machine to APAP with a wide range (6-10), a middle range (7-9), and even a short range of 7-8cm. With the APAP it typically stays at the low value until an event then rides the high value the rest of the night.

I spent several days at each setting, and I tend remember waking once or so per night to reposition the hose after turning over. I sleep on my sides, rarely on my back. Nothing I do appears to have much effect on my pattern of AHI's, and all else being equal I will probably stick with a 6cm CPAP setting as it is the easiest to deal with.

Do you guys have any suggestions for my situation? Do you think a different mask may help?

If you are savvy enough to strip actual values out of your Res Scan software, and then plot AHI vs pressure like the plot below in a spread sheet or graphing package -



... You can then optimize your pressure by selecting the pressure at the lowest AHI.

The real question is how are you feeling? An AHI under 5 is considered normal in any case, so if you are feeling fine, I don't see any reason for you to tweak at all given that your highest AHI was 4. If you are still feeling tired, focusing only on AHI may not be the best approach. So, could you provide more information on why you are concerned?

Actually, I think you're doing pretty well, for 2 months in. Though I certainly understand your wish to fine tune your therapy, because I was the same way. Here are my thought:

Are you using EPR? If so, this decreases your exhale pressure by 1,2 or 3 cm, so I raise my minimum pressure accordingly.

What is your 95% pressure, and Maximum pressure? I would set my minimum pressure 1 cm below the 95% pressure. If I'm hitting my maximum pressure, then raise it by 1 cm. I don't like to leave the maximum wide open because of aerohagia and/or leaks, but have gradually raised by maximum so I can tolerate it. Others are fine with leaving it wide open at 20.

In your Detailed Graphs, zoom in on the obstructive apneas, and look at the pressure immediately before the event, and then what your cpap raised it to. I don't worry about centrals, I only have 1 or 2, if I'm over-tired or stressed. You can do a search on Centrals, to alleviate fear of centrals.

I used to get apneas in the last 2 hours of sleep also, around 4-5 am. I think it's because that's the time of longest and deepest REM, and in the beginning we are REM deprived from years of sleep apnea. During your sleep study, did you have more apneas during REM?

You said you cannot breathe very well through your nose, and that is something to discuss with your doctor or a ENT. That could be affecting your therapy. I just listened to a talk by Dr. Steven Park called Un-Stuff your Stuffy Nose, and he said that breathing through your nose is better--because your sinuses make nitric oxide (which dilate blood vessels), and then you can absorb 20% more oxygen. He discussed different ways to deal with congestion: allergy meds, sinus rinses, Breathe Right strips, and surgery options. He has a very informative website.

Hope this helps.

DreamStalker wrote:... You can then optimize your pressure by selecting the pressure at the lowest AHI.

Would the higher numbers (in your graph) at higher pressure be Centrals, or still OAs?? I've been concerned about increasing my pressure due to the risk of increased centrals (which keep showing up in my Resp. Encore reports) as they are the majority of my Apnea events. Is this just a reporting issue?

Thanks

While how one feels may be important, treatment efficacy is more complex than that.

I lived with untreated OSA for over 20 years and did not notice how bad I felt because my body had gotten used to the condition.

As for AHI under 5 being considered "normal" ... it is NOT. Having apneas is NOT normal anymore than sleeping while water-boarded. The AHI value of 5 is just a standard that the sleep health industry uses to determine if your "un-normal" apnea condition needs to be treated ... more specifically if insurance will cover the cost of treatment.

Having said that, it is true that "feeling" tired has multiple causes of which inadequate CPAP settings may be just one component. Remember, CPAP treatment is NOT just for alleviating a "feeling of tiredness" ... more importantly, CPAP treatment is used to mitigate if not eliminate hypoxia induced tissue damage and hormonal disregulation.

Tielman wrote:

DreamStalker wrote:... You can then optimize your pressure by selecting the pressure at the lowest AHI.

Would the higher numbers (in your graph) at higher pressure be Centrals, or still OAs?? I've been concerned about increasing my pressure due to the risk of increased centrals (which keep showing up in my Resp. Encore reports) as they are the majority of my Apnea events. Is this just a reporting issue?

Thanks

In my case, I think they would be OSA since centrals were not significant in my PSG. Nonetheless, centrals should show up with increased pressure on a plot.

I'm not that familiar with the S9 so I'll defer to other members with more experience w/ S9. (BTW - If you have S9 machine, your software must be ResScan ... Not Encore.)

Hodr wrote:I spent several days at each setting, and I tend remember waking once or so per night to reposition the hose after turning over.

You might want to look into hose management techniques so that changing sleeping position doesn't wake you up - like hanging the hose from your headboard, wall, or ceiling.

I appreciate the responses guys. I think I mentioned that while running in APAP mode, after my first event, the machine stays pretty close to pegged to the upper value. The highest I have run it is 10cm, and even at that level I start to feel as though and air bubble is stuck in my throat. I have never tried higher than 10cm because up to that point I saw no change, and I wouldn't want to run the machine open ended, end up breathing against 20cm all night, just to end up with the same numbers that I would get running 6cm.

I wouldn't say I feel refreshed when I wake up, but I do believe I am a bit more rested as I don't seem to be falling asleep as often in the early afternoon.

Hodr wrote:I appreciate the responses guys. I think I mentioned that while running in APAP mode, after my first event, the machine stays pretty close to pegged to the upper value. The highest I have run it is 10cm, and even at that level I start to feel as though and air bubble is stuck in my throat. I have never tried higher than 10cm because up to that point I saw no change, and I wouldn't want to run the machine open ended, end up breathing against 20cm all night, just to end up with the same numbers that I would get running 6cm.

I wouldn't say I feel refreshed when I wake up, but I do believe I am a bit more rested as I don't seem to be falling asleep as often in the early afternoon.

Your mention of air bubble in throat points to additional complicating factor ... have you been checked for GERD?

I might suggest that if you've tried all those different setups in only 2 months, you aren't giving things a chance to stabilize after the change.

Do you even have leaks under control in just 2 mos? Something as simple as a mask leak can toss all your fine-tuning out the window.

Patience, Grasshopper...

LinkC wrote:I might suggest that if you've tried all those different setups in only 2 months, you aren't giving things a chance to stabilize after the change.

Do you even have leaks under control in just 2 mos? Something as simple as a mask leak can toss all your fine-tuning out the window.

Patience, Grasshopper...

Thanks for the reply.

Leak doesn't appear to be an issue. As I mentioned in my initial post, other than the very first night (where there was some significant leak) I have had virtually no leak issues (as in the my running total median and 95th percentile for leak are both 0.0). I really don't mind having my mask fit extra snug. I get funny looks at work for the red spots on my nose and forehead, but that doesn't bother me (and the tight mask doesn't hurt).

I spent more than 2 weeks with the initial setting, and I believe I gave each subsequent change a week or so. Guess I will just continue to collect data points and see where things fall out.

FYI- Last night (set for CPAP at 7cm) I had one of my best nights (1.1 AHI), the last time I had it in APAP (the 11th) It was set a bit wide at 7-10 and the median was 8.9 while the 95th was 9.9.