AHI & CA Climbing, Headaches, Mask Fit Declining, Feeling Awful

[eyeheartny]

I'll include as much info as seems reasonable below. I've been really struggling with therapy for the last month and feeling run down, poorly rested, and like I don't know what to change to get back to the better-rested feeling I had before. Feeling pretty desperate to get some relief and a good night's sleep again. 


Stats: Male, 36 years old, 6'2", 215lbs. 
Diagnosis: Mild/Moderate OSA via 2 in-person sleep studies in December 2016. Positional component to my OSA-- much worse on my back. No centrals or other complicating issues. 
Therapy: started June 7 2018. Immediately noticed an increase in feeling rested. I was waking up before my alarm, noticed that I didn't feel exhausted all the time, etc. I saw my sleep specialist a month after starting therapy and everything looked good in terms of my numbers. My RXed pressures are 5-15, but as you can see below I've tweaked that a few times. 

Current Issues

• Starting in August I began experiencing poorer sleep. My numbers began to climb, and I also started suffering from sinus congestion. 
  
• I did not change mask types during this time. 
  
• My body weight has not changed either. 
  
• My CA index has climbed a lot as well. After ta
  
• I feel like garbage in the morning. So even though I'm waking up before my alarm, it's not because I'm feeling rested. 
  
• I've been waking up with headaches the last week or so as well.
  
• When I test my mask fit now using the Run Mask Fit option in the menu, I get the red frowny face on the INHALE, but not on the exhale. I'm not sure whether this could be caused by sinus congestion, but this was not the case earlier in my treatment. Additionally, when the pressures ramp up higher during the test, the red frowny face happens less often. So I suspect I have a mask seal/fit issue inside my nose but I can't figure out what to do. 
  
• I've changed hoses, headgear, pillows, and the connector piece between the main hose and the nasal pillows. All these changes in the last few weeks have not helped the fit issues. 
  
• I tried a different mask (Phillips Dreamwear Nasal Pillows) and saw similar leak issues on the Run Mask Fit test on the inhale portion. The ResMed mask appears to be worse at the moment. 
  
• I've tried treating the congestion with a Neti pot, Claritin/Allegra, Flonase and Nasalcrom spray. None of them seem to make a long-term change. I was taking Claritin/Allegra earlier in the summer when my numbers were better, so I've gone back on Allegra and will be seeing a sinus specialist to determine whether I have underlying issues. 
  

Here are my overviews/historical info (please note there are three separate views here): 
   

   

   

Here is a bad night from last week: 
   

Here is a "good" night from early in my therapy: 
   

A few questions:

• Could the centrals be "false" centrals and attributable to tossing and turning/post-arousal events? 
  
• How can I understand the change in mask fit, specifically why I'm getting the frowny face on the inhale but not the exhale? Is this attributable to my chronic nasal congestion I've been battling the last month?
  
• What changes can I make to my therapy to try to get back to the good zone I was in in June/July?
  
• Any questions I should bring to my sleep specialist/CPAP coach?
  

Thanks so much for any help, I'm a wreck over how poorly I feel and have been sleeping. 

[Sleeprider]

Eyeheartny, your settings are not the same between these two night. Your more active events had 5.0 minimum, 13.0 maximum EPR off. The better night was 5.0 minimum, 15.0 maximum with EPR 3. It appears you tolerate the EPR, but your pressure is moving around too much to figure out a good stable pressure. I'd like to suggest a minimum pressure of 6.0 and maximum pressure of 12.0 with EPR 2.0. This will make EPR a constant 2.0 cm all night. Note that the minimum pressure for your machine is 4.0 cm, so when the minimum pressure is set to 5.0, you are only getting 1 EPR until pressure rises, and the full EPR 3 does not happen until pressure exceeds 7.0. I think using a range of 6-12 EPR 2 will stabilize your pressure a lot and perhaps improve your results for both hypopnea and CA events. I would rather try to get your pressure moving less than plus or minus 3-cm through the night and then try to optimize from there.

[eyeheartny]

Eyeheartny, your settings are not the same between these two night.  Your more active events had 5.0 minimum, 13.0 maximum EPR off.  The better night was 5.0 minimum, 15.0 maximum with EPR 3. It appears you tolerate the EPR, but your pressure is moving around too much to figure out a good stable pressure.  I'd like to suggest a minimum pressure of 6.0 and maximum pressure of 12.0 with EPR 2.0.  This will make EPR a constant 2.0 cm all night.  Note that the minimum pressure for your machine is 4.0 cm, so when the minimum pressure is set to 5.0, you are only getting 1 EPR until pressure rises, and the full EPR 3 does not happen until pressure exceeds 7.0.  I think using a range of 6-12 EPR 2  will stabilize your pressure a lot and perhaps improve your results for both hypopnea and CA events.  I would rather try to get your pressure moving less than plus or minus 3-cm through the night and then try to optimize from there.

Thanks Sleeprider. I made a few changes last night and just grabbed the data. I'll enclose it below. I will also try your suggestions tonight and see how it goes. I'll also put EPR on full-time, not just for ramp only like I had it last night. Do the leaks from the recent charts tell you anything about whether it's a mask fit issue, a sinus congestion issue, or a mouth breathing leak? I'm considering trying to tape my mouth tonight to see if that helps get the leaks down. 

Thanks again, this is so hard. I was feeling so good for a while and I feel like garbage now. 

[attachment=8439]

[Sleeprider]

In your most recent results, pressure was mostly from 6.0 to 8.0, and your previous results suggest you do better with EPR. I think your CA events are mainly sleep disruption. Events are not well correlated to either pressure or leaks, so there is a bit of randomness going on. I think using EPR for comfort, but at a moderate setting of 2 just makes you sleep better. I think the leaks are from air escaping from your mouth rather than mask fit. My usual advise on nasal pillows is, try a size larger.

[eyeheartny]

In your most recent results, pressure was mostly from 6.0 to 8.0, and your previous results suggest you do better with EPR. I think your CA events are mainly sleep disruption. Events are not well correlated to either pressure or leaks, so there is a bit of randomness going on.  I think using EPR for comfort, but at a moderate setting of 2 just makes you sleep better.  I think the leaks are from air escaping from your mouth rather than mask fit.  My usual advise on nasal pillows is, try a size larger.

Thanks again. I ordered a size up in the pillows I've been using, will be here tomorrow. I'm going to follow your advice tonight and we'll see how it goes. 

The leak issue is weird, for a few months I had very low leak rates and then they started to jump up about a month ago when my nasal congestion got worse. I'm breathing a little better through my nose now so hopefully this will improve. I'm going to try taping my mouth but I have a full beard/mustache so it may not stick well based on my test earlier. I can only really keep it on my lips as it won't adhere to the hair on either side of my mouth.

EDIT: Forgot to ask what your thoughts are on the sleep disruptions. I tend to sleep in a cool room, with a BedJet to cool me down even further. I do have back issues and have been having some pain/discomfort lately, so that may be disrupting my sleep. Any other ideas on what could be making me wake up so much?

[Sleeprider]

I think if we can resolve the leak issues, some of the sleep disruption might go away. One method that has worked to solve mouth leaks is to use a soft cervical collar. While we usually talk about this in terms of keeping the airway open and resolving positional apnea, it also applies gentle pressure to the back of the jaw. This is ideal to keep the jaw closed and improve the kinds of smaller leaks we see in your images. I don't even think it needs to be long-term, but used as more of a "trainer" to encourage your mouth shut. You would look for something with a comfortable, loose fit that contacts your jaw in a neutral head position. When I detect I'm having mouth leaks, I often sleep on my side and pull a down pillow over my shoulder where my jaw rests on the pillow. This usually removes the leak and distraction long enough to fall asleep, and the problem doesn't re-emerge for me. I don't think you need to go overboard on this. A travel pillow, neck roll or something from your local drugstore could work well.

[eyeheartny]

I think if we can resolve the leak issues, some of the sleep disruption might go away.  One method that has worked to solve mouth leaks is to use a soft cervical collar.  While we usually talk about this in terms of keeping the airway open and resolving positional apnea, it also applies gentle pressure to the back of the jaw. This is ideal to keep the jaw closed and improve the kinds of smaller leaks we see in your images.  I don't even think it needs to be long-term, but used as more of a "trainer" to encourage your mouth shut.  You would look for something with a comfortable, loose fit that contacts your jaw in a neutral head position.  When I detect I'm having mouth leaks, I often sleep on my side and pull a down pillow over my shoulder where my jaw rests on the pillow. This usually removes the leak and distraction long enough to fall asleep, and the problem doesn't re-emerge for me.  I don't think you need to go overboard on this. A travel pillow, neck roll or something from your local drugstore could work well.

Thanks, I'll head to the drugstore today to look for a cervical collar. 

Here's my chart from last night with the new settings applied. Doesn't seem to have changed things much. One thing I'm curious about is that I woke up around 4:30am (you can see the cutoff in the data) and my lips felt like they were glued closed with saliva-- very sticky. It is surprising that it seems like I'm leaking air out of my mouth. If I had to guess, it's actually that the mask is shifting. I sleep on my side and the AirFit P10 seems susceptible to moving quite a bit at night. I don't know what to do about it, but my gut says it may not be mouth leak. What are your thoughts? I'm happy to be wrong about this! 

[attachment=8457]

[Sleeprider]

Good luck with new settings. The dry-sticky mouth is pretty typical with mouth leaks and confirms what I was assuming.

[eyeheartny]

Good luck with new settings. The dry-sticky mouth is pretty typical with mouth leaks and confirms what I was assuming.

Interesting. Thanks. I have a travel neck pillow but it's open in the front-- a U shape. Will that work to try tonight or do I need a full-circle O-ring?

[Sleeprider]

wear it backwards, or with a piece of Velcro or tape to hold it in place. All we are looking for is the pressure at the rear of the jaw.