Artsyuno Help - Oscar Charts

[artsyuno]

Hello.  I'm hoping for some guidance on any adjustments I should make, please and thank you!

A little history:  I began waking up 2-3x a night in late spring.  By later summer it was 5-6x a night.  In September, I realized from looking at my Apple Health app that I was having some sleeping blood ox drops.  I messaged my PCP and she referred me to the sleep med clinic.  Sleep doc suspected insomnia (it has often taken me 1-2 hrs to fall asleep) and sleep apnea.  I completed a home sleep study in early October.  Results were a score of 16.2 with central apnea of .4.  Blood ox mean of 94, drop as low as 76 but only minute was less than 90.

I received a ResMed Airsense 11 in late October and have used it every night since.  After the first couple nights, I haven't had much difficulty tolerating it other than an occasional sore end of the nose clears if I take the mask off for a minute or two.  I'm using a n30i and switched from the Airfit to the Airtouch a couple weeks ago.  It doesn't seem to have impacted the leak rate and I'm finding it to be more comfortable.  I also tried the Dreamwear a while back for several nights (have some dry mouth issues so thought maybe I was mouth breathing, but it ended up not appearing to be the case and I had a lot of leak issues so I went back to the nasal cushion).  I have been using a chin strap, mostly because the mask frame slides around if it's directly on my head) and a soft cervical collar to address chin tucking + a cpap pillow.  Initial settings were 5-15.  It was changed maybe a week later to 5-20, because I was coming close to hitting the 15 mark.  By the time I had my compliance appt, the sleep doc determined I no longer needed such a large range and changed it to 7-15.  A week later, I popped the bottom pressure up to 8 to see if that had any impact as I was consistently having a mean of the 9-9+ range.

Issues I'm still contending with:  1.  I'm still waking up frequently.  I most often have 2 or 3 wake ups that were significant enough that I remember them in the morning, sometimes more than that.  Apple Health often shows several additional 1-2 minute wake ups.  I'm still not feeling rested and I suspect it's the wake ups more than the apnea creating that problem at this point.  2.  I often wake up super congested.  My nose breathing isn't all that clear on a good day, but I don't generally mouth breathe.  Some of my longer wake ups have to do with me needing to use saline or some other spray (sometimes use capsaicin if saline doesn't do the trick) and wait for sinuses to clear a bit.  I've tried monkeying with temp and humidity but get rain out if I go above humidity of 4.  3.  I sometimes wake in the middle of or just before a hot flash.  I'm not sure how much of the waking up issue is apnea or cpap related and how much is hormonal at this point.  4.  My charts show a lot of OAs, but most of the large clusters of OAs and CAs seem to be when I'm awake so I think the scores are inflated.  I often catch myself forgetting to breathe when I'm on the verge of falling asleep but not quite there.  5.  My daily scores are a bit all over the place.  I tend to have a couple of fairly good nights followed by a couple of bad ones.  It looks like I've generally made pretty good progress re the AHI but still feel like I'm struggling.

[Expat31]

Hi,

You seem to be doing all the right things at the moment, using a collar, chin strap, pillow, with all the key graphs.

What I can see from these, and as you have already noticed, are the clusters of events. 

As you probably know, it's a tell-tale sign of positional apnea. If you haven't already read through this link, good idea to do so, as lots of useful information.

Regarding your sleep study, have you the breakdown of AHI between obstructive , hypopnea and central, with in addition of the breakdown by sleeping position?

Was the majority AHI in supine position?

Do you currently sleep in your back?

During the cluster events, you indicated you were often awake, or were you actually dozing perhaps?

Concerning the centrals, these could be "treatment emergent" and disappear over time once your settings are optimised. 

Additionally they could be provoked by too much EPR causing C02 being flushed. out too effectively, tricking the brain no need to breathe. EPR  could be reduced, but there is a potential  downside that flow limitations could increase. 

You minimum at 8 is probably too low for reducing the obstructive apneas, looks like you need 9 or 10, but I believe the root problem are your clusters.

I see you are on the "soft" setting for response. If it is a necessary comfort feature for you, OK, but the standard setting will give a faster response for tackling obstructive events.

Depending on your answers, suitable adjustments can be made.

[artsyuno]

Thanks.  I didn't make any type of active decision regarding "soft" setting.  Either it was set that way in initially or I accidentally changed it.  I'll switch that.  I am a side sleeper.  I switch between the two sides, but don't sleep on my back or stomach.  I find myself chin tucking a bit at times.  I bought a soft collar and was uncomfortable and thought it was too tall so went down a size.  I'll try the taller one again.  That's the only positional thing I can think of.

I've attached my position info from my sleep study and last night's Oscar chart.  Last night was a little weird - 9 or 10 short wake ups, according to Apple Health with two longer ones, but none super long.  No big sinus congestion problems, though, so that was nice.  Also, it looks like my leak rates have gone up a bit the last couple nights and I'm not sure why.  I'll try switching to a new cushion and see if that makes a difference.  

Would you suggest upping the minimum pressure now or would it be better to leave it alone for the time being while trying to figure out the CAs?

[artsyuno]

Oh, and here's the breathing breakdown from my sleep study.

In terms of the clusters, I'm pretty sure some are while I'm still awake, but it's possible that I'm dozing and don't realize it, I suppose.  I have some periods where I realize I'm not taking breaths where I feel like I'm still trying to fall asleep and it looks like I often have clusters right after putting the mask on or being awake, so either still awake or perhaps not very deeply asleep yet.

[Expat31]

Hello,

I would increase your minimum to 10. This is to reduce the obstructive apneas. Also it will smooth out the pressure fluctuations so they are less "spikey". This may be more comfortable. Also, as the gap between maximum pressure reached and minimum pressure is reduced, it could help reduce the central apnea. 

Your maximum pressure is OK at 15. Your are reaching only just a little less than 12 at the moment, so best to leave as is.

The leak rates are not so bad. You are a long way from 24l/min when things can start to go wrong.

From your sleep study, it looks like most of the AHI problems took place on your right hand side. All I can think of that you were curled up in the foetal position, with your head dropping forward on you chest, and your trachea being somewhat distorted/misaligned, impeding airflow. 

The right collar should solve this.You may want to search in threads about collars of other people's experiences.

Regarding clusters, I understand what you are saying. Could it be that the flexible end tube is being bent/entangled when you are on your side?  

A good thing to read is the mask primer. Useful tips, worth a read.

Concerning your graphs, this time you are missing the flow rate graph, which should be positioned just after the top events graph. If you have insufficient room to slot in, you can either reduce height of the other graphs with your mouse, or go to Preference/ Appearance and reduce graph height, to thereabouts 100. See attached screen shot.

So to summarise, for the moment, just up the minimum to 10, to see where it goes.

 

[artsyuno]

Thanks so much.  Here's the OSCAR chart with the missing flow rate.  I have no idea how it went missing the last time around, but your pic was super helpful for resizing.

I'll try upping my lower pressure number and see if I can spend more time on my left side.  I tend to start out on that side and then turn over.  I wasn't sure if the higher numbers on my right were from spending more time on that side or had been adjusted for that.

Sizing of everything is tricky for me at a hair under 5" tall.  I think my mask frame is likely a hair too large.  I'm really only still wearing a chin strap because it takes up space and creates some friction to hold the frame in place.

[artsyuno]

Well, that was an interesting night.  I changed the setting from soft to standard and upped the minimum pressure to 10.  I could tell pretty quickly that the jump from 8 to 10 was too much to do without a stop in between and was going to keep me awake, so I reset the minimum to 9.  I'll use that for a few nights and then give 10 another try.  I had the longest string of recorded CAs I've ever had although still think I was awake for at least some of it and I was pretty much maxing out my top pressure.  I haven't come that close to 15 in a while.  On the up-side, I think that was my lowest OA ever.  Also, interesting given that my sleep test showed the most apneas when on my right side, almost all of the the CAs were when I was sleeping on my left.  Apple Health showed 6 wake ups.  I was aware of two, one at approximately 3:15 and one at approximately 5:40.  I slept on my left from the time I went to bed until the 3:15 wake up and then from the 5:40 wake up until I got up for the day.  FYI, my CPAP (and hence, OSCAR) are an hour behind.

[Expat31]

Hi,

You did the right thing backing off to 9. What I would like to see is just the last two sessions at 9 cms, which seem pretty good, especially the very last one without any clusters.

To do this you will see some blue and yellow boxes just under the settings section.

To show just the ones you want, you can either click on the boxes to exclude or go a little further down, showing detailed session information, and click on the left hand little boxes to disactivate this way.

Now you will just have these two sessions of 2h20m and 2h.35m to examine, especially showing the important flow limitations, central and obstructive apneas statistics.

To restore the graphs to the original state, just do the reverse procedure, nothing is lost.

Maybe you were right about the jump to 10cms, perhaps a bridge too far. At least we have data of the results of the two options in just one night.

Really curious about the side sleeping, one side centrals, the other side obstructive apneas.

However the increased pressure seems to be doing its job controlling obstructives, so hopefully that's one thing to tick off the list. Just leaving centrals. 

These can be improved by reducing EPR, but the down side is increasing flow limitations.

The ideal level of flow limitations (within the 95%band) is 0,05 or lower. You are currently at 0,10, but that includes the bad sessions at 10cms. It will be interesting to see what the value is at 9cms for the last two sessions.

This facility or analysing seperate session is really a phenomenal feature of OSCAR.

(As an aside, one thing I just thought of, sleep aids or pain killers can mess things up, creating,central apneas.)

So you are right, lets stay with 9cms to see how it evolves.

[artsyuno]

Here are those two segments.  I did wonder if I should lower the EPR after doing some reading today, but it sounds like it has pros and cons.  When I change any settings, it tends to take me a few nights to adjust so it'll be interesting to see if the results stay the same or change with a little time at the current settings.  I assume I should try to do the same thing for now - part of the night on each side and keep track of which is which so we can see how it trends?

I occasionally take 1/2 a trazodone pill if I'm struggling with getting to sleep more than usual.  More than half makes me super groggy and half seems to take the edge off a little bit, but doesn't work as well.  Neither seems to keep me asleep.  I haven't been able to see any patterns/changes in apneas and waking up when I take the trazodone.  A few nights looked pretty good and others were very choppy.  I did take one last night and am keeping notes on that among other things, so we'll see over the next few nights.

[artsyuno]

The flow limitations were much lower in those latter 2 sections!