8 AHI - 6 months later

Greetings,

After being on CPAP for 6 months, I'm still averaging over 8 AHI. I started out at 28 AHI (including 7 centrals). My pressure settings started at 12 to 14, then moved to 13 to 16, and now I'm at 12 to 14. I'm still getting a significant amount of clear airways, but there are still hypopneas and obstructives. I'm also experiencing a RERA of around 4 - which has been increasing over time. I've moved from a nasal mask to nasal pillows and am now using the Mirage Quattro Full Face Mask after the doc said I had too many leaks. I am still hopeful and can see a bit of a difference, but am still unsatisfied and losing some patience. I notice it most when I miss a night, but will still feel fairly tired and foggy after a full night of compliance.

I have my third followup appointment tomorrow and was hoping for any advice. I've brought up BiPAP and ASV but he wasn't very convinced about it. I was supposed to be titrated with biPAP during my sleep study, but it never happened. I'm still having some leaks, but it's not very much above the intentional rate. I also notice that event clusters happen before flow rate increases, so I'm think the events (struggling, increasing pressures) might be causing the leaks rather than the leaks causing events or misidentification of events.

Any advice/encouragement/success stories welcome.

Here are my SleepyHead summaries and last nights data. If there's anything else that would be helpful, let me know.













Thanks

Hi,

I see two things of interest:

1) your pressure is maxing out, which means that your machine is probably not delivering as much treatment value as it could. I'd raise that upper number considerably, and see where it ends up on the graphs. Since any kind of event at all moves your pressure up past 13, I think I'd consider raising the lower number to start at 13.

2) RERA events are not effectively treated by an auto machine. The machines will not ramp up high enough to treat them. You might need to run on a fixed pressure, which is determined by setting it higher and higher until you consistently feel good in the morning. Since that number is apt to be above 15, you might want to use a BiPAP machine so you can exhale at a lower pressure.

As an example, my breathing issues are primarily RERA. I rarely ever have an OA or H event anymore. I have found that I need a pressure of at last 18 to feel good, but if I run in auto mode, my machine doesn't adjust above 10. As a result, I run with a fixed pressure of 13 exhale, 19 inhale.

RERA is a newer area in sleep medicine. You might need to find a specialist in this area in order to get a workable treatment plan.

-john-

I would re-set your upper pressure to 20....14 is not high enough.

Thanks for the feedback. I had a max pressure of 16 before but the results were worse so we moved back down to 14. My doctor moved my settings down even lower to 12 max this week. He's concerned that increasing the pressure more would increase central events. If I don't see an improvement in a week, he wants me to move to a VPAP machine to help address centrals. Just a question of whether my insurance will approve it.

About changing masks, in my case it was the opposite. For almost a year I used full face masks (several kinds including your type) and pillows type but my leak was hi and so was the treatment. As soon as I switched to my present mask and a chinstrap and set up my results improved a lot.

It appears you are caught between a rock and a hard place. Need more pressure to address the obstructive events and RERAs and more pressure increases the centrals so you are just swapping events and not making any headway.

Time to push for bilevel machine trial of some sort. May or may not end up needing the high end ASV type but it is fairly plain that this isn't working now and I can't think of anything that might make any difference with this machine. Over time some people see a reduction in centrals but if you haven't then it time to move on to Plan B.

zeleni wrote:Thanks for the feedback. I had a max pressure of 16 before but the results were worse so we moved back down to 14. My doctor moved my settings down even lower to 12 max this week. He's concerned that increasing the pressure more would increase central events. If I don't see an improvement in a week, he wants me to move to a VPAP machine to help address centrals. Just a question of whether my insurance will approve it.

Comment,

The fact that your Doc is jumping with pressures and machine type changes, without sleep studies, or thinking about insurance coverage, indicates to me the he is a beginner with very limited experience in this field.