[Symptoms] 2 weeks into CPAP but not much difference

[reddy]

       
Hi,
I am 34 and recently diagnosed with OSA with AHI of 30. I think I might have OSA for more than 10 years as I was suffering from typical symptoms of OSA for a long time. I am pretty lean with BMI of less than 22. I had septoplasty and turbinate reduction surgery done 2 years back. I had mild dust mites allergy as well.
I have been using Resmed Auto CPAP for 2 weeks with N20 mask. Pressure settings of 8-14 with auto ramp off and EPR of 3. I am able to use it pretty consistently every night without much difficulty except for waking up a few times to adjust the mask or hose etc.
It's been two weeks but I am not feeling much of a difference yet. But still have fatigue during the day, mild headache when I wake up, takes 1 hour for me to wake up, etc. The only difference that I have seen is that occasionally I am getting dreams. 

 My AHI consistently shows between 3 to 4 every day, divided equally between Central and Obstructive apneas in Oscar. Resmed MyAir app shows 100/100 almost every day.

Looking for help if I am doing anything wrong here.  Is there anything I should change to get by AHI down? or is their pretty normal? 

Any help here is greatly appreciated. I have attached screenshots of the last two days' oscar data. If required, I can also provide the raw oscar data but I am not able to paste the link here. 
[url=https://drive.google.com/file/d/19xxKyJPjo4RTd9xlQqHiECjCbz_BdPFB/view?usp=sharing][/url]

Thanks a lot.

[Peach25]

Hi there reddy, it sounds like a few things that need addressing prior to changing settings imho… please bear with me as I attempt to explain
Firstly it seems there is some mouth leak from the screenshots - do you wake with a dry mouth..? If so, would you like to trial a well fitting full face mask, or alternatively a well fitting chinstrap in combination with the mask you already use..? 
Secondly if you haven’t used PAP before, sometimes there’s an unequal balance of muscular fitness in the chest and diaphragm that comes with prolonged OSA; meaning, the muscles associated with breathing are used to making a larger proportionate effort to breathe in than breathe out, so the muscles in charge of breathing out are comparatively weaker and require time to build strength to exhale against the newfound pressures that exist in the chest cavity. This can sometimes impact on CA’s, and if so, this can self correct to a point it is no longer clinically significant, given time.
Thirdly, sometimes CA’s exist as the body adjusts to having comparatively abundant correction of blood gases, and the brain tells the body to pause breathing as the former relatively large effort that was once required has now dramatically altered. This also can change over time to a much more regular rate of breathing, once the body adjusts to therapy. 
Having said that, sometimes there are instances where the CA’s persist, and this would require further investigations. But imho, this is a little early to do so. 
Sometimes with experiencing prolonged OSA, there is a slower adjustment period to therapy with PAP devices; my general approach is gradual, using incremental changes to determine the least invasive options to begin with, to maintain cost effectiveness and simplicity, however I can’t guarantee I’m correct in all instances. 
I hope this is helpful, and I would be interested to see how you go from here

[reddy]

Hi Peach25,

Thanks a lot for taking the time to write a detailed reply. 
To be honest, I find the mask pretty comfortable and never experienced dry mouth in the last two weeks. Maybe the leak is due to mask fit. I will try adjusting the straps and see. Is there any ideal Leak number that we should aim for? Also, regarding the central apneas, as you said I will give more time and monitor the progress. Regarding the OA count, what is the ideal number I should aim for? The doctor said anything less than 5 overall AHI is good, but I believe even 5 is also higher.

Regarding the pressure, currently, it is very broad i,e 8-14. I read in this forum that it should be very close to 95% pressure. Do you think I should experiment with the pressure settings?

Thanks a lot once again.

[Peach25]

Very sorry for the delay…
Yes; readjusting the mask may help for sure - keeping the silicone cushion really clean and dry overnight can help with mask leak, too. Try not to overtighten, and lift it gently so it can inflate and the edge sits against your face when you first turn on the flow 
Less than 5 AHI is acceptable, however it’s all about how you feel when you wake up in the morning. Feeling refreshed and having energy is what matters.
Having an auto adjusting machine is of great advantage because you can narrow the range of the settings to suit your 95th percentile if you don’t have a great deal of pressure variation needs throughout the night; however there are some people that might need from 8-20 as they have very different pressure needs depending on their stage of sleep, medications they may need, positional issues they have which they can’t overcome (physical disability, injury, etc)…the main thing is, that you’re not bottoming out or topping out for long periods on either end of your range.. hopefully that makes sense..? If you top or bottom out, it means (topping out) you need to raise the max pressure, and bottoming out means you need to lower the min pressure. 
Having said that, unless there are intrinsic pathological processes that limit the pressure for safety (contraindications that are medically advised), then usually taking the approach that the range covers your needs without topping or bottoming out is appropriate
Please do post how you are going and what your thoughts are regarding this post

[reddy]

Thanks for the reply again. Now I am trying out a pillow mask and experimenting with pressure. AHI now is hovering around 2.5. So, far no difference in how I feel. I will continue to use this for a couple of weeks and see if there is any difference. 

Thank you once again.

[pholynyk]

Although I felt marvellous the morning after my titration study, it was about six months before I realised that I actually was feeling fine day-to-day. Be patient, it takes a while to recover from years of poor sleep.

[Peach25]

Persistence is the key; keep at it, and please do post OSCAR outcomes if/when you’re ready. 
I also felt awful for some months as my body readjusted to normal ways of function, after many years of sleep related breathing issues. 
You’re not alone

[Dormeo]

Patience, yes! And let us know how the nasal pillows work for you.

I do think you might raise your minimum pressure in order to see whether you can reduce OAs without increasing CAs. You could raise it in small increments; no need to make a big change all at once. But as Peach 25 says, the CAs may well dwindle on their own as your body gets used to PAP.

I notice that you aren't spending a lot of time per night on the machine, at least on the two nights you posted. Six hours of sleep is too little for most people. Factor in time falling asleep, and you're really skimping. See if you can schedule more time for sleep.

Also, just curious: do you go to bed at around 6:30 a.m. most days? Is that necessitated by your work schedule?

[Peach25]

I just thought to add an interesting aspect of therapy commencement, that I experienced: when I started, I had some really good nights of deep sleep (once I became accustomed to the mask/flow, etc), however after about 2 months, I didn’t sleep well at all for around 3 months, which I put down to the adjustments being made inside my body, as it got used to a completely different chemical environment, and having had a chance to get some deep deep sleep after years of low oxygen/high carbon dioxide overnight. I dropped down to only being able to sleep for a few hours at a time, as I felt like I was getting too much sleep (seemed an impossible conundrum due to little hours of sleep, however in terms of the change in quality of sleep and ability to breathe, those few hours were better metabolically than 8 or more when struggling to breathe). After those few months, I was able to settle down into a good routine of slowly increasing hours of sleep, which has persisted till today. 
At this stage of internal adjustment, little changes in small increments are good to fine-tune delivery, to enable the body to become accustomed to both delivery and internal changes that happen from having sufficient gas exchange while sleeping. And as always, spend every time you sleep using your device

[hh9797]

Only 2 weeks in I hold hold off on adjusting anything yet, while yes some people see immediate improvement to the point of feeling good, other people see immediate improvement but still not quite good yet and then a slow path to good, and other people see no improvement for a long while and then over time notice the effects, and other people see no effects even over a long period of time. The people seeing immediate perfect results is in the minority.

I fall into that second category where as within the first night or two I noticed a great increase in the fact I went from consciously waking up every half hour to not noticing waking up at all and felt ever so slightly less tired in the morning but have seen a very very slow improvement since then. But while there are some people that see fast acting results for the majority of people rather then looking at it like say Tylenol or Aleve, you can look at it like Thyroid hormone replacement, something that you need to do constantly and consistently on a good schedule for at least 6 weeks before you can even notice any changes in any prescription level because Thyroid hormone adjusts slowly over time and isn't just like popping a pill and getting the entire dosage right away.

I assume having only been on it for two weeks so far your follow up appoint is still 2-6 weeks out before you even see the doctor again to discuss what changes you have noticed and what not so that they can judge from a mix between your data and how you personally feel as to how they need to tweak the prescription. I would wait at least until that appointment to start playing with settings because if everything is constant then it makes it easier for the doctor to get a baseline to appropriately change things for you, if you are tweaking settings every night then the numbers are next to useless because there is no baseline. Only thing that you should really be adjusting before that first follow up would be the humidity, temperature, and trying a different mask if you don't feel the one you picked at first is working for you (since the first 30 days most insurances allow you to change masks free of charge no questions asked but after that 30 days you gotta pony up the money if you want to change masks), those are really the only three things that should be tweaked before that first follow up, after that follow up then tweak to your hearts content, but before hand I would suggest making as few changes as possible to allow your doctor to see what prescription should be set because as the first person said it can take a while for you to properly be able to fully exhale if you are not use to breathing against pressure.

That is my suggestion is to only adjust humidity and temperature and possibly mask prior to that follow up and then after that follow up you can see what works for you, but prior I would leave things alone so your doctor can get an accurate baseline.