[CPAP] OSCAR interpretation help

[jefferiestube]

Hi all-

I'm not sure what to tweak next, and posting a recent example night's data, hope you folks can help.

• Equipment: ResMed AirSense 11 with AirFit N30i nasal cushion, ClimateLine heated tube
  
• Issues:
  • Tons of aerophagia, it's distracting and uncomfortable, and often wakes me up.
    
  • I started taping my mouth to try to prevent mouth leaks, but always notice pretty bad dry mouth throughout the night and upon waking, especially the back of my mouth.  (I use a dry mouth spray and SLS-free toothpaste, hasn't really helped)
    
  • Trying to sleep on my back because it seems to result in fewer leaks, but often end up on my side out of habit
    
  • Minimal slow wave sleep, usually tiny amounts of REM, and it's been worse on CPAP (except for the morning headaches, which are much better).
    
  • I know wearables have real limitations on estimating sleep stages, but mine have always been a reasonable proxy for subjective sleep quality, and it's decreased since starting therapy for sleep apnea (went from small amounts of REM to minimal, and a few minutes of slow wave/deep sleep to 0 deep sleep).
    

• Sleep history:
  • My home sleep test showed AHI 15.  No snoring or history of mouth breathing (until starting to use the equipment), but always non-restorative sleep and morning headaches.
    
  • I'm a middle-aged woman with a normal BMI, some co-morbidities including dysautonomia (POTS and sometimes nOH), symptomatic generalized joint hypermobility syndrome (causes some low level chronic pain), Mast Cell Activation Syndrome, GERD, Raynaud's, Small Fiber Neuropathy, and migraines.
    
  • I'm rarely sleepy during the day (although lately I am starting to get sleepier in the evening, but it's not translating to sleep very well) and instead struggle a lot with fatigue.  For my whole life I attributed it to other diagnoses, but decided to explore whether I might also have a sleep disorder, and it looks like I do, but now I wonder if there's more going on in addition to OSA.
    

Any advice is most welcome!

[CPAPfriend]

Reducing pressure, enabling EPR, bilevel, or using a chinstrap can all help with eliminating aerophagia, and so too can avoiding food and drink within 3-4 hours of bedtime.

You have extreme amounts of flow limitation and moderately high amounts of leak. Your EPR is already on 2, so looking at your graphs suggests to me you could be a candidate for bilevel on a higher pressure support. Seeing as you're already experiencing aerophagia on your current pressures, it's probably not viable for us to further increase pressure in attempt to eliminate the FL, but what you can start with trying is increasing EPR to 3, if you can handle it.

[Gideon]

Min pressure =7
EpR=3
To manage flow limits
Max pressure=8
To reduce aerophagia
Note: the max is a temp measure to control the aerophagia. Plan would be to evaluate your need to increase max from there based on aerophagia. Increases would be slow.

Your pressure increases are from the flow limitations. Let's see what happens.

[multicast]

Currently you're using the device as a leaf blower. Have you considered to use an FFM?

[jefferiestube]

Wow! Thank you both so much! 
I tried the settings suggestions for two nights, and it's worked surprisingly well.
Of all the permutations I'd previously tried, this was the narrowest pressure, but also the most soundly I've slept in a month. 

Both nights I only remember waking once and thinking I'd forgotten to put the mask on or that I must have accidentally taken it off (I hadn't), and went right back to sleep.  I think I'd gotten so accustomed to struggling with all the pressure changes and aerophagia while sleeping that the absence was novel.

I had minimal aerophagia (which is interesting since I'd tried EPR = 3 previously, but not with this more restricted pressure range), and got similar amounts of deep and REM sleep as I'd have prior to starting CPAP therapy (which is good!  that's going in the right direction).  I felt sleepier during the day, but perhaps this is common initially as sleep quality improves.
 
And importantly, my AHI was 0.57 and 0.81 for the two nights, which means it's still controlling apnea events.

On the basis of this new data, would you recommend any further adjustments?  (While I await the referral to a sleep specialist, which.. who knows when).

Reducing pressure, enabling EPR, bilevel, or using a chinstrap can all help with eliminating aerophagia, and so too can avoiding food and drink within 3-4 hours of bedtime.

You have extreme amounts of flow limitation and moderately high amounts of leak. Your EPR is already on 2, so looking at your graphs suggests to me you could be a candidate for bilevel on a higher pressure support. Seeing as you're already experiencing aerophagia on your current pressures, it's probably not viable for us to further increase pressure in attempt to eliminate the FL, but what you can start with trying is increasing EPR to 3, if you can handle it.

Min pressure =7
EpR=3
To manage flow limits
Max pressure=8
To reduce aerophagia
Note: the max is a temp measure to control the aerophagia.  Plan would be to evaluate your need to increase max from there based on aerophagia.  Increases would be slow.  

Your pressure increases are from the flow limitations.  Let's see what happens.

[Gideon]

Evertthing now depends on how you feel. Comfort is King,

That said your flow limitations are really high. So what "symptoms" remain? A BiLevel such as the VAuto may help with the capability of a PS larger than the 3 of EPR may, not will, help with that. You are currently on BiLevel therapy with a PS of 3 and an EPAP of 4-5.

[Sleeprider]

I agree with Gideon. We could reduce flow limitation by supporting inspiration with pressure support. Low exhale (EPAP) pressure is not a 9problem. It looks like you could use bilevel settings of EPAP 5, IPAP 9 (PS 4) or IPAP 10 (PS 5) and resolve the inspiratory flow limitation, but we are always going to avoid triggering aerophagia and sleep disturbance from other pressure related causes.

[jefferiestube]

An update: it's been going pretty well!


I've landed on using CPAP mode at 7cmH2O, with EPR 3cmH2O (essentially a BIPAP-lite).  
I had some rough nights recently around a migraine cluster & dysautonomia flare (those are common for me, not related to CPAP usage), and it was interesting to see how it negatively impacts my sleep.  (Validating, but unfortunate.)

Anyway, two recents nights (one about 10 days ago and the other last night) saw the most slow wave sleep I've had since beginning CPAP usage (49" and 48", and the one from last night was even in one continuous stage which is almost unheard of for me), and subjectively felt more restful.  I've hit my attachment quota for this thread, but it was notable that the deep sleep stage is reflected in the flow rate chart: the breathing pattern is much more uniform than at other times.  My AHI for these nights were 0.17 and 0.14, with small numbers of RERAs, hypopneas and CA events.  Still small leaks and flow limitations (generally not at the same time, which is curious), but they're both much smaller in magnitude than before.

I ultimately landed on CPAP since even at narrow pressure ranges, the flow limitations and RERA were often immediately preceded by tiny changes in pressure.  In general, I've felt better with continuous rate, which really surprised me.  I tried setting it at 8cmH2O for one right recently and saw increased leak rate and a slightly higher AHI, but it was also a rough day, so perhaps not the best test.  I might still try out 6 or 8 again, but for now this setting is where I'll probably stay for a bit.

I'm still eagerly awaiting my sleep specialist appointment, and planning to ask one of my physicians about restarting gabapentin but just at bedtime (for help with some restless leg symptoms that might be due to neuropathy or maybe it's actually RLS? and to encourage slow wave sleep), but in the meantime I feel I'm starting to make some progress, thank you all!