21 nights in, seeking advice

[smmille1]

Hello all, this is my first post and I'd like to start by thanking everyone here, as I've already learned so much. OSCAR lets me see the data that myAir apparently doesn't take into account with the overly optimistic scores it usually gives me. I've decided to post because in terms of trying to find things relevant to my experience here, it's a bit like drinking from a firehose. So I'm seeking advice on what I should prioritize working on.

I just hit 21 nights of usage and most of the nights have been spent testing out mask fit/seal and have started messing with the max pressure in the past two days. I've had a beard in some form for around 20 years now, so shaving that is somewhere in the nuclear option range. I do mouth breathe some while sleeping. I can breathe through my nose, but it always feels somewhat restricted. The one time I had it looked at by an ENT, whatever he sprayed in there before using the scope was about the only time that it felt fully open so of course he said it looked fine other than a deviated septum. I can't really tell a difference in flow between nostrils, so I don't think the septum is the problem. I've tried Flonase off and on at various times with limited impact.

I started with a F&P Vitera but that absoultely crushed my nose bridge when tight enough to do any good (high bridge, low cheek bones). I was then given a F&P Evora Full and a ResMed AirFit F20. I like how the Evora Full forces my nose open, but I've had trouble with all three masks clogging pores and causing irritation at the highest pressure points (Evora Full between my nostrils and the other two on the bridge). I've had better luck with sealing with both of the newer masks, so that led me to start looking at the max pressure. I did a titration and that said 8 for a recommended pressure, and they sent me home with it set at 6-12. I loaded an SD card before night four and had several days of data before I went back for the mask problem, and I could see the pressure plateau at 12 with high corresponding flow limitation. I asked about upping the pressure, but was advised to work on the seal first. I messaged my provider about it five days ago and didn't hear anything back so I upped it to 13 two days ago and 14 last night.

In terms of sleep quality, I've had one day where I felt rested (after March 5, attached). Other than that, I've had some fair nights, and some bad nights. I haven't been able to figure out how to sleep on my side without either pushing the mask loose (Evora Full, mostly) or putting too much pressure on the bridge (I had to take two days off after bruising it with the Vitera). One other issue of note is that I still end up with a lot of RERA events even when it's not logging apneas/hypopneas. I'm guessing this is why myAir thinks it's great even though I'm still tired.

Notes about the OSCAR attachments: March 5 was the Evora Full and good sleep but irritated nose. I tried adjusting the straps for March 6 but that led to lots of leaks, so changed it back closer to how it was and got the first night that it had 0% large leak for March 7 (despite pressure increase to 13). March 8 was no adjustments to the mask, but max pressure increase to 14. I have no idea why it was so much worse.

So, what next? I'm planning on no changes for tonight just to see how much variability I'm getting with the current setup.

Other comments:
The time zone is set wrong on the device, so it reports an hour later than it actually is. I didn't learn that until using OSCAR but didn't change it because I read that it would clear the data and I don't want to mess with that until I'm sure insurance is happy with compliance. Also, I've already seen it noted that ResMed misidentifies CSR. The one in the attachment is the third time it's appeared in my data.

[grubsztyl]

I wouldn't touch the pressure till you get leaks sorted out. Leaks are your number 1 problem. Evora Full is a bit tricky to fit right. I've read some fitting guidelines and somebody suggested to start with top strap and adjust so that the cradle doesn't smash the nose too tight. It turned out to be opposite for me... unless I adjust the top strap really tight, I get leaks from the nose area. I also have facial hair so I need to wear straps tighter than most people, I also run much higher pressures than you do and unfortunately still get farts from the cheek side but it's much more manageable and doesn't compromise my therapy. You need to experiment with the straps and see what leaks the least. Do it during day-time, crank the pressure to your max and adjust while lying down. Try different positions, on your back, on your sides... try to relax your jaw, see if it causes leaks. If it does, consider a soft cervical collar or a proper chin strap so your jaw doesn't drop too much. If you leak while you're on your side, consider sleeping on the edge of the pillow. I've found that all my masks if pushed into the pillow leak.

Don't give up on Evora Full just yet. If you can't get leaks under control, consider switching to nasal pillows... but that's an entirely different story because you'll most likely need to tape your mouth.

On the other note, you seem to get most events in your REM sleep... just like I do... you might end up needing much higher pressures, especially because you hit your max. A lot of people are undertitrated. But let's leave that till you fix your leak problem.

[Deborah K.]

No, your leaks are not the big problem.  They are pretty mild.  But your flow limits are extremely high.  You need to set EPR to full-time at a setting of 3.
 
Also, your pressure settings need to be changed.  I suggest that you raise your low-pressure setting to 7 and your high-pressure setting to 20.  Your machine will not go higher than you need, so you don't need to worry about that.

You also have what we call positional apnea.  This is when you sleep with your chin dropped down toward your chest.  This causes something like a kink in a hose, interfering with your breathing.  No setting can fix this.  You need to sleep on a flatter pillow or wear a soft cervical collar.  Personally, I sleep on a child-sized pillow that is flatter than a regular pillow and has a raised front edge which tips my head back slightly, keeping the airway open.  This works great for me.

[smmille1]

Thanks grubsztyl and Deborah. Of course, last night's data says "oh, you're fine." These are the exact same settings (machine/mask/straps) as the last two nights. I don't know how typical this much variability is. I'm still tired from running a sleep deficit but my brain does feel like it's operating better than usual.

My pillow is a Tempur Pedic neck contour one so I'm not that high off of the bed, although the angle can vary if I have my head on the lower part that's supposed to be on my neck. Today, I just rigged up version one of a hose holder as I've been running it around behind my head to keep it from tugging and that may have been making me creep lower on the pillow to avoid it touching the top of my head. I did try starting off on my side at the edge of the pillow last night. I feel like I remember rolling onto my back before I fell asleep but it looks like I was out pretty quick so maybe I'm imagining it.

I do get most of my events in REM. Right now, the Evora Full is tighter on the bottom than on the top, but not so tight that it takes sustained effort to keep the bottom straps from pulling my jaw back. When testing the mask before going to bed proper, it's most likely to leak by the sides of my mouth assuming I've got it positioned properly on my nose. Pushing the facial hair sideways away from my mouth and resetting usually improves that. I'm a bit worried about nasal pillows and mouth taping as depending on how congested my nose feels, it can feel suffocating when I've put the mask on but not turned pressure on unless I breathe through my mouth. But it looks like there's hope for the current config if I can sort out the other variables. I did shower in the evening yesterday, and I think I've noticed a positive correlation with that vs. just washing my face before bed.

I'll keep it the same again (with the addition of the hose holder) and see what I get next time.