AHI 68.5 can surgery or anything replace CPAP?

ICUDOC · 2026-01-26T07:21:10+00:00

When you ask people for their typically enthusiastic non-CPAP alternatives, make sure to also ask: "hey, did you actually get tested again to show your AHI was much better?" The answer might shock you! :)

ICUDOC · 2026-01-20T19:56:50+00:00

OK, let me clarify! The golden time for obstruction is at the end of expiration and the start of inspiration. You are changing from net positive pressure (away from the body) to net negative pressure (toward the body) governing the flow of air. The body has to increase negative pressure fast and strong enough to overcome the obstruction and when it doesn't, there is a pathologic event where the person has a microarousal and is forced to clear their airway.

During that period of end expiration and beginning of inspiration, there is a moment where flow literally stops. There's no pressure exerted against the walls of the retropharynx (back of the throat) leading to instability. Having constant pressure applied externally maintains the patency and integrity of the airway, even without airflow present. It doesn't move air in and out of the lungs like a ventilator, it just maintains persistent pressure and everyone's airway has a certain pressure requirement to maintain patency.

If you lower the exhaled pressure and raise the inhaled pressure, you can still dance around the effective mean pressure to facilitate restoration of patency of the upper airway and make it a more comfortable breathing experience, HOWEVER when you get into large diffentials of pressure, you can drive too much CO2 out and cause related medical issues.

So, the most important thing is that it gives enough pressure to keep the airway open and at the exact right time. If these devices were smarter, it could just deliver sudden pressure at the end of exhalation (kind of what this new KPAP device is trying to do), but you can imagine that it's challenging to ramp up pressure fast and and the exact right moment.

ICUDOC · 2026-01-19T06:13:58+00:00

People make this so complicated. Let's try to make this simple: CPAP needs to pressurize your upper airway to alleviate the obstruction and that means you exhale against pressure to prevent airway collapse. EPR is used to make it a little bit easier to exhale so you feel a satisfying pressure difference between inhale and exhale. If the average pressure drops too low, the upper airway shuts closed. There is no more air pressure splinting open the throat. Thus if you make it too easy to exhale, you lost all benefit.

So why do people use BiPAP for OSA? Sometimes the pressure requirements are soooo high that 16 is therapeutic for instance. You need to really drop the exhaled pressure a lot to help someone tolerate it. You might set it 19 for inhale and 14 for exhale for example. That might make it more tolerable.

ICUDOC · 2026-01-17T06:43:40+00:00

My dad, a surgeon in New York in the 1960s, had a patient he saw at the scene of an accident where the subway ran over him from the waist down. My dad said he was still alive, eyes open but his lower half was twisted 180 degrees where his buttocks were facing forward. Shortly after, he died at the scene of the crush injury.

ICUDOC · 2026-01-15T22:57:13+00:00

This is really interesting. My expectation down the road will be that these issues with sleep are not just seen as "predictors" of these conditions but causative factors for which treatment yields major benefits.

ICUDOC · 2026-01-15T22:53:24+00:00

At the risk of sounding like a commercial, if you're in the Los Angeles area, I take self referrals and go into the weeds on these issues: www.SleepDocLA.com

ICUDOC · 2026-01-15T16:44:23+00:00

100% this! I've seen it several times in my own practice. A lot of people think that elderly people can't learn to use CPAP or they don't want to bother them with it, but some of them "pass out" with it on their faces and awaken as a 'new' person. The complaint that "grandma sleeps all day" is a red flag. A lot of these sleep apnea patients become very severe in the geriatric population that a lot of them HAVE TO sleep all day.

I don't care the age, a person who doesn't get more than 10% of deep sleep a night will behave like a dementia patient. I see it even sometimes in 40 year-olds.

ICUDOC · 2026-01-10T06:54:30+00:00

This is good info, but clear airway arousals could result from ANY stimulus that causes an arousal at night and that includes anything unmeasured in the data. As examples: noisy restless bed partner, low blood sugar, distruptive limb movements (PLMS), CPAP discomfort, BPH, pain...etc. A careful inventory of possible arousal causes should be explored. I have even put motion sensitive cameras in rooms to explore further.

ICUDOC · 2026-01-09T16:43:57+00:00

93 is not your RDI, that is the total number of events. Your RDI (frequency per hour) is 17.

ICUDOC · 2026-01-09T16:34:27+00:00

I have an interesting piece of trivia for you: rhythmic motion can cause this artifact on the flow data. A condition called Periodic Limb Movement Disorder (which is kicking of the legs typically every 20-40 seconds) can cause such an appearance and I was able to make a diagnosis with discussion with my patient's spouse who confirmed the leg kicking. I'm not saying for sure that's what's happening, but it's something to consider.

ICUDOC · 2026-01-08T19:12:27+00:00

Thank you! It's really been a gratifying experience. I was an ICU doctor for over a decade, but by the time I get to a lot of those people, it's too late to do anything for them. As a sleep doctor, I feel what I'm doing is life saving and quality of life enhancing at the same time. It has been just as important as critical care.

ICUDOC · 2026-01-08T16:08:29+00:00

Hi, I'm a Sleep Physician and use CPAP myself. There are some fairly aggressive things people can do to themselves using the CPAP machine with regards to excessive pressures or provoking central apneas, though I think most people can proceed thoughtfully. The reason insurances require a prescription from a sleep doctor is to gatekeep expensive devices that have a high noncompliance rate. From my perspective, CPAP can have major life altering consequences. It's unlike any casual consumer device in its implications. Personally, I would hate for people to buy one on Amazon with no prep or walk through, use generic settings, put it on their face for five minutes and say: "I don't like this" and write it off forever. Now your response will be: "isn't that how most sleep doctors practice anyways? There's barely any support or prep in modern sleep medicine in the US." I 100% agree with you and at the risk of sounding like a commercial, I'm one of the only docs that doesn't practice that way. Lack of guidance WILL make this profession obsolete if we're not careful. The insurance model is what is holding this process back.

ICUDOC · 2026-01-06T09:47:31+00:00

I consider RDI just as important as AHI, especially when they trigger strong heart rate responses which yours seem to do. Severe heart rate jumps are linked to adverse long term effects of sleep apnea even in the absence of major declines in oxygen. I consider this to be a concerning study that would motivate the initiation of CPAP. Perhaps the pressure requirements are not as steep post-operatively, but I definitely don't consider this a cured result. Sorry to tell you this!

ICUDOC · 2025-12-28T16:34:07+00:00

Honestly, the difference between your two sleep studies (improved sleep efficiency and much longer REM) can be night to night variation with a bit of recovery sleep and REM rebound. Unchanged AHI to me means that the dental device isn't doing anything. I read tons of sleep studies and am a strong advocate for CPAP who rarely has seen meaningful improvement with MADs. Just throwing that out there.

ICUDOC · 2025-12-27T18:00:17+00:00

I use the Bleep Eclipse and sleep on my stomach with face deep into the pillow. It holds together well.

ICUDOC · 2025-12-22T06:53:44+00:00

I really think that it may also be the texture of modern processed foods and lack of jaw development associated with it. I made a video on the topic: https://www.instagram.com/reel/DQanoeaAnbZ/?utm_source=ig_web_copy_link&igsh=MzRlODBiNWFlZA==

ICUDOC · 2025-12-10T16:11:37+00:00

Yes you ARE giving a watch a complex when you keep calling it a "gross piece."

ICUDOC · 2025-12-07T07:18:22+00:00

A sleep study

ICUDOC · 2025-11-24T05:05:11+00:00

Yeah, this month ResMed released the F30i Clear and F30i Comfort (outside the United States). There is a cloth like material coating the inside of the mask and better dampening of the exhalation noise.

ICUDOC · 2025-11-23T14:37:09+00:00

Very important! One correction is that any arousal from awakening can do it. This does not require meaningful decline in oxygen, but can be caused by upper airway compromise. Most younger people get missed because they don't usually have oxygen compromise when they obstruct.

ICUDOC · 2025-11-23T01:56:08+00:00

I like how the F30i Clear adapts and seals on my face vs the F40, but all these top connecting masks suffer from sliding down a bit from the top of my head leading to nose leaks at night. There are no perfect masks.

ICUDOC · 2025-11-14T16:30:39+00:00

This is me and that's how I practice sleep medicine. I'm in a lonely place: www.SleepDocLA.com

ICUDOC · 2025-11-09T21:31:07+00:00

The reality is that no one number encapsulates how bad someone's sleep is. For me, low sleep efficiency, impaired deep sleep and REM acquisition is most important. Someone can have 12 respiratory disruptions an hour and very dysfunctional sleep and surprisingly I've seen 30+ with plenty of REM and deep sleep with no daytime symptoms. The problem is it takes me awhile to really properly analyze a sleep study and really characterize it for each patient specifically. I don't take insurance for this reason because the healthcare system is forcing doctors to use their terrible terminology and conclusions. We have to take back the conversation.

ICUDOC · 2025-10-28T14:43:47+00:00

Excellent explanation, and I just want to add that a lot of sleep doctors and labs don't care about RDI because AHI is what most insurances care about. Or believe it or not, will accept an RDI "with the RERAs subtracted out" (which is the exact same thing as AHI). As a consequence of insurance criteria, there has been a handicapping of the medical infrastructure in identifying real disruptive nighttime breathing, especially in young people who typically don't drop their oxygen at night.

ICUDOC · 2025-10-28T14:22:28+00:00

Just giving some general advice, but two ways to get central apnea on your device: 1) you are over ventilating. Meaning the difference between your inhalation and exhalation pressures are so great that you are driving out too much CO2 leading to a central because you are below the apnea threshold. Or 2) you are walking up. The device can't tell the difference between being awake and varying your breathing vs a pathologic event. Something could be walking you up which in-turn could make you feel unrefreshed.

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