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A2CPAP
Unread post  Post subject: Severe Apnea & - erratic AHI score - DreamStation Refinement  |  Posted: Sun Sep 06, 2020 1:17 pm

Joined: Sun Sep 06, 2020 12:06 pm
Posts: 4
PAP Mask: DreamWisp
PAP Machine: DreamStation
Humidifier: removed humidifier
Pressure Setting: CPAP 13.5cmH2o

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I've been struggling to get a consistent score for much of the summer. I'm clearly more tired than years past and in addition to my sleep apnea, I can attribute it to things not worthy of excuses (diet needing refinement/discipline, less adult beverages, more exercise, and more efficient work/life balance). I'm 43yrs old, 6'5, 270lbs and was formerly highly active/competitive athlete. I've been getting scores ranging from 80 AHI to what I feel is my approx average ( 26 AHI or so). I've included an example of my best reading, my average reading, and my worst reading (last night). I'm really hoping to find a balance as well as a path forward in effort to give my 3 kids & wife the "best version of me".

*** I recognize these have different machine settings...I'm hoping to land on the best possible starting point. I understand there's a refinement period to finding the optimal setting.

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LSAT
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Sun Sep 06, 2020 2:32 pm

Joined: Tue Sep 05, 2017 9:40 am
Posts: 634
Location: WI
PAP Mask: F & P Simplus
PAP Machine: Airsense 10 Autoset
Pressure Setting: 12-20

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Don't you think it would be helpful to know...what specific machine you are using? What mask? What are your pressure settings? Did you have a sleep study or are you doing this on your own? All that is obvious at this time is that your pressures are wrong and you have a leak problem.


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Respirator99
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Sun Sep 06, 2020 5:57 pm
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Joined: Mon Apr 27, 2020 1:06 am
Posts: 141
Location: Australia
PAP Mask: Resmed Airtouch F20
PAP Machine: Resmed S9 VPAP Adapt
Humidifier: Resmed H5i
Pressure Setting: Min EPAP: 8.0 Max EPAP: 11.0 PS Min: 3.0 PS Max: 8.0

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G'day A2CPAP. Welcome to the forum.

What LSAT is asking for (in his usual friendly way) is a lot more detail than just the charts you've provided. They tell part of the story, but leave a lot of important stuff out.

So, first - please upload a copy of your sleep study report. Give us the full report including charts and tables, not just the one page summary. Make sure you erase any personal iD before you upload.

Second, please see the link about organising your Oscar charts in my signature below. We need to see all the information in the left side panel of the Oscar daily page, but we don't want to see the calendar or pie chart. They just get in the way of more important data. The graphs we need to see are Event flags, Flow rate, Pressure, Leak rate, Snore. You can leave out the Tidal volume and Resp rate for now. Your chart should look something like this:

Image

Now, turning to your charts, it seems you have a Dreamstation autoset (but which particular model?) set at a maximum pressure of 14. You also have a bit of a leak problem, but that's not the main issue at the moment.

Looking at the events, you're experiencing a too high AHI, predominantly obstructive apneas. These are coming in clusters. While we could raise the pressure to try and blast through these events, I think a more promising avenue would be to try a soft cervical collar. I strongly suspect you're sleeping with your head drooped forward, with your chin tucked down to your chest. This causes stress on the windpipe making it prone to collapse. There is an excellent discussion on this phenomenon here: http://www.apneaboard.com/wiki/index.ph ... cal_Collar Look in particular at the "before and after" charts in that article.

Let's see the additional detail we've asked for, but in the meantime take a trip to the local pharmacy and get yourself a collar - I think it will make a huge difference.

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A2CPAP
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Sun Sep 06, 2020 7:11 pm

Joined: Sun Sep 06, 2020 12:06 pm
Posts: 4
PAP Mask: DreamWisp
PAP Machine: DreamStation
Humidifier: removed humidifier
Pressure Setting: CPAP 13.5cmH2o

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Respirator99 - I appreciate the insight as well as the thorough explanation. It's not everyday you join a forum and get this level of detail/care within hours of joining!!

I've made the recommended updates to my profile and am updating my full report now. You 100% nailed the sleeping position - I'm a "max pillow" guy and just ordered the SC collar. In the meantime, I look forward to reducing my pillow count this evening :D

Thanks a ton for the warm welcome as well as the detailed response!!


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A2CPAP
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Sun Sep 06, 2020 8:10 pm

Joined: Sun Sep 06, 2020 12:06 pm
Posts: 4
PAP Mask: DreamWisp
PAP Machine: DreamStation
Humidifier: removed humidifier
Pressure Setting: CPAP 13.5cmH2o

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Take #2 on report - thank you in advance - I look forward to getting things dialed in.

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Respirator99
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Mon Sep 07, 2020 1:28 am
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Joined: Mon Apr 27, 2020 1:06 am
Posts: 141
Location: Australia
PAP Mask: Resmed Airtouch F20
PAP Machine: Resmed S9 VPAP Adapt
Humidifier: Resmed H5i
Pressure Setting: Min EPAP: 8.0 Max EPAP: 11.0 PS Min: 3.0 PS Max: 8.0

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That's a much more usable presentation - thank you.

Very obviously there is a leak problem here. Once your leaks get above the "red line" the machine has difficulty maintaining sufficient airflow. It also can't always diagnose events correctly. On this night you were above the red line for nearly half the night.

Having said that, the apneas which are flagged generally come in clusters, as discussed above. I think you'll benefit from the collar.

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Pugsy
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Mon Sep 07, 2020 8:01 am
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Joined: Wed Aug 02, 2017 8:01 pm
Posts: 1981
PAP Mask: Bleep/DreamPort nasal mask
PAP Machine: ResMed AirCurve 10 VAuto

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Time over red line statistic is incorrect...by a lot.
There were some large leaks but not a lot and not prolonged....but no where near 45% of the night.
It's because the software is using a red line threshold for a ResMed machine of 24 L/min and that doesn't work so great for a Respironics machine.

See the LL line on the Events graph? That's large leak flagging per the machine. Large leaks were minimal.
The machine reported large leaks trump the statistics detail.

Respironics red line threshold varies with the pressure but your pressure now is fix but it's not 24 L/min. Some where up around 80 to 90 L/min is going to be your threshold. It varies with the mask used and the pressure used.

You can correct the statistics error or at least get it close to more accurate in the statistics by changing the red line in the software.
Go to Preferences then CPAP tab and change the red line threshold to something more suitable for a Respironics machine. Change the 24 to something around 75 l/min which is a nice conservative number. Or just turn off that particular statistic and monitor leaks by looking at the LL line on the Events graph.

ResMed machines report leaks different and use a different red line threshold than Respironics machines. Respironics machines can also compensate for more excess leak before they flag a leak as a large leak than a ResMed machine.

When in doubt though....look at the LL line because that's the machine reporting large leak or not and not a software calculation based on an incorrect red line baseline. If nothing is flagged in the LL line or very minimal gray blocks....leaks weren't considered large by the machine and the machine reporting trumps the statistics.

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Respirator99
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Mon Sep 07, 2020 9:18 pm
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Joined: Mon Apr 27, 2020 1:06 am
Posts: 141
Location: Australia
PAP Mask: Resmed Airtouch F20
PAP Machine: Resmed S9 VPAP Adapt
Humidifier: Resmed H5i
Pressure Setting: Min EPAP: 8.0 Max EPAP: 11.0 PS Min: 3.0 PS Max: 8.0

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My mistake - I saw all that grey as large leak but it's actually "variable breathing" whatever that is. And looking closer I think it's pink, not grey.

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Pugsy
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Mon Sep 07, 2020 10:04 pm
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Joined: Wed Aug 02, 2017 8:01 pm
Posts: 1981
PAP Mask: Bleep/DreamPort nasal mask
PAP Machine: ResMed AirCurve 10 VAuto

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Respirator99 wrote:
My mistake - I saw all that grey as large leak but it's actually "variable breathing" whatever that is. And looking closer I think it's pink, not grey.



My personal opinion...FWIW...variable breathing is in the same category as VS2 snores...needs to be turned off. :lol:
What are we going to do about it anyway?
When I initially glanced at the report I also thought "large leak" but then I looked more closely at the statistics and a light bulb went off in my head. Respironics machine and statistics don't always line up correctly.
I saw this myself when using Sleepyhead and both a Respironics machine and a ResMed machine and my large leak statistic was always incorrect yet I had no large leak flags from the machine itself.

Most of the time it doesn't matter but sometimes due to pressure and vent rate...the threshold gets crossed per the software when it doesn't really get crossed per the machine.

Since I most often used the ResMed machine I left the threshold at 24 L/min and shrugged my shoulders when the statistics time over red line was ugly. It was too much trouble to keep changing it just for a couple night's reports when I could ignore that data point easily.

Now the OP does have some leak issues especially considering the fact the pressure is fixed so the top leak line for total leak should be essentially flat and obviously it isn't. But unless those leaks are waking him up...they really aren't big enough for long enough to impact the therapy itself all that much.
Now if it is waking him up.....totally different story about doing a better job fixing the leaking. For me any leak, no matter the size, that wakes me up....it needs to be fixed. Anything that wakes me up is unwanted.

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A2CPAP
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Tue Sep 08, 2020 8:56 pm

Joined: Sun Sep 06, 2020 12:06 pm
Posts: 4
PAP Mask: DreamWisp
PAP Machine: DreamStation
Humidifier: removed humidifier
Pressure Setting: CPAP 13.5cmH2o

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I can't thank either of you enough for the guidance - I made the changes to the LL threshold and bumped it up to 75. I fell asleep last night before throwing my mask on but put it on when I woke up. I"ll get a full night sleep tonight and look forward to your thoughts. I've been reading about the cervical collar and was wondering if some of the mouthguard options might work?? Logically/optically speaking, it appears the collar is tough to beat...I guess I was hoping I might get lucky:)

Here's the half-night sleep from last night:

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Respirator99
Unread post  Post subject: Re: Severe Apnea & - erratic AHI score - DreamStation Refine  |  Posted: Wed Sep 09, 2020 12:09 am
User avatar

Joined: Mon Apr 27, 2020 1:06 am
Posts: 141
Location: Australia
PAP Mask: Resmed Airtouch F20
PAP Machine: Resmed S9 VPAP Adapt
Humidifier: Resmed H5i
Pressure Setting: Min EPAP: 8.0 Max EPAP: 11.0 PS Min: 3.0 PS Max: 8.0

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You've had a big cluster of central and obstructive apneas at 6:30 am - I suspect these may be sleep-wake junk, as your body transitions from sleep to wakefulness and the section of the brain which controls breathing while asleep hands over to that which controls awake breathing. I don't really know if they are separate areas, or just the same area working in two different modes. Either way, it's not uncommon to see these clusters when dropping off to sleep or when waking up. Apart from that, though, there are still a lot of obstructive apneas, generally occurring in clusters. I notice you've dropped your max pressure to 7 - is there a reason for that?

A mouthguard might help, but I think you'd want to look at a specialised mandibular advancement device (MAD) which pushes your lower jaw forward to open up the airway. These are offered as an alternative to CPAP. I've heard mixed reports about these - some people love them but others experience a lot of discomfort. The other issue is that they don't produce any data, so you really don't know how well they're working. A collar is cheap and easy to try. If it doesn't work, you've lost twenty bucks. If a MAD doesn't work, you might be up for a thousand or more.

_________________
Regards from Australia

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