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I don't think you are going to get a response from the OP on this. I suspect this thread was started to get hits on a YouTube channel.

My first question would be what is your breakdown of AHI events into CA, OA, and Hypopnea?

I was also diagnosed at an AHI of 33, but now I average 0.8 for AHI. To get they I initially adjusted the machine in Auto mode, and finally switched to fixed pressure mode once I knew what pressure worked best for me.

Im having to help several people with this at the moment. Im formulating a guide with some of the sleep therapists im working with so feel free to send me a email and i can get you in touch for some guidance. Chris@medisource.tech

I hope this helps...

AHI 21.83 Obstructive Apnea (OA) Index 1.16 - Hypopnea (H) Index 10.27 - Unclassified Apnea (UA) Index 0 - Clear Airway (CA) Index 10.41 - 95% Flow Limitation 0.21 - RERA (RE) Index 0.87 - % of time in Cheyne Stokes Respiration (CSR) 0.0265

Those numbers would suggest the APAP is not set up as well as potentially could. Just based on those numbers alone, about the only possible quick fix may be to increase the EPR to 3 cm full time, if it is not set that way already. That MAY reduce the hypopnea. The other big issue is the high number of Clear Airway or Central Apnea events. Unfortunately since the airway is already open, more pressure does not help to reduce CA events. In fact especially with new users of the APAP, the pressure may even be making the CA frequency worse. But, without seeing more detail, I would not suggest just reducing pressure. What are your min and max pressures set at?

This said the best way the I could possibly help would be if you could download your data on the SD card to the OSCAR program, and then you could post your detailed daily report here. First you need a SD card in your machine. Some clinics unfortunately remove them. A 4 to 32 GB card is enough if there is none. Then you need a card reader and a PC or Mac to run the OSCAR software.

This software flags all the events you are having, when they are happening, and what the pressures are throughout the night. With your issues the first think to look for would be when the CA events are happening and what the pressure is at the time.

Post back if you need any help getting OSCAR working for you, and when you do post the daily report here. Save it as an image file, left click on it, and then drag it into an open post.

I do live at 5,300 feet in altitude. Thanks so much for your help. I will adjust as you describe.

Yes, you did not respond well to the full time 3 cm EPR, other than hypopnea seems significantly reduced. For sure go back to having it on ramp only. You may want to revisit it later at a lower level than 3 cm. The concerning part is how much OA you are getting with pressure at the max of 17 cm. It is also concerning that the CA events seem to be happening at a lower pressure. I would go back to ramp only EPR for a couple of nights with max pressure the same at 17 cm to see if the OA events come back down.

I would be interested in seeing a zoomed in detail shot of the mask pressure, Flow Rate, and Minute Ventilation in a couple of the areas where you are having a high frequency of CA events. This may help understand what is causing the CA events. Here is an example from my data of what you might see.

Although your machine has not flagged it as Cheyne-Stokes respiration (CSR), I am pretty sure that it is. CSR is a period of increased depth of breathing followed by decreasing depth of breathing, followed by a period of apnea with the airway open (CA). The reason that it repeats over and over is that the CO2 intensity signal is not getting back to the control system quickly enough. High CO2 causes you to breath more deeply, while low CO2 causes you to breath less deeply, and even stop breathing (CA). Your breathing rate gets out of sync with what it needed. You are breathing more and more deeply when CO2 has already recovered, but the control system does not know it. The control is essentially unstable. It never catches up like a dog chasing their tail.

While what is happening is fairly obvious, the root cause is not. In the worst case it could be a sign of heart failure, or a neurological issue. It can also be caused simply by the APAP machine pressure, but I am not so sure that is your case. In your previous post I see the multiple CA events even when your pressure is quite low and under 10 cm. Your could experiment with lower pressures or even fixed pressures in the CPAP mode, but I can't say I would be all that optimistic about it working. Because of your altitude the issue is likely aggravated by the elevation effect. The test of this would be to see if this still happens at an altitude closer to sea level. Another option would be to get a sleep apnea test where the pressure is not increased by the machine to see how frequent the CA events are.

Probably the first thing you should do is be seen by a cardiologist. Be sure to take the printouts of your overall results and some printouts of the expanded examples of your CSR. Potential solutions could be the prescription of the elevation sickness drug I mentioned earlier, or an ASV machine. Something needs to be done, as the AHI is currently way too high to leave things as they are now.

Here is a link that looks worth reading about CSR causes and treatment.

https://nchmd.org/health-library/diseases-and-conditions/con-20166460/

Altitude is likely causing your issues to be worse than average. I live at about 2,000 feet and CA's are my most significant contributor to AHI. I also have CSR flagged from time to time. When I vacation at sea level my AHI almost always goes down. I have not traveled to an area at 5,000 feet and I am sure my issues would get much worse at that elevation.

Thinking about this a little longer I would suggest these steps as the best approach.

1. Determine if there are any underlying medical conditions which could be causing it.
2. If not, then consider an ASV instead of an APAP.
3. Or, consider drug treatment to reduce the negative impact of elevation using acetazolamide.