Bad at Breathing

[Haldir]

Hello Fellows,

I'm new to CPAP.  I started treatment on August 27 and it's been a struggle ever sense.  My sleep study was done at home through an online company (I live over 100 miles from the nearest place I could do an in person study).  I've attached a summary of the results (I can't post the full .pdf yet).  My AHI is only 5.8 but my wife complains about my snoring and waking up gasping.  I was prescribed an APAP with 5-20 cmH2O without any titration visits.  I'm using a ResMed AirSense 10 AutoSet.  I started with the ResMed F30i mask but had really bad leaks out of the nose.  I'm now using the ResMed AirFit F20.  I have another few weeks to swap out the mask if this one doesn't work.

Short Story: I have a messed up face and throat (and sense of humor?) so I breathe through my mouth most of the time.

Long Story:  I have a deviated septum that I inherited from my Cleft Lip/Palate at birth.  I had a surgery that let me breathe partially out of my nose, but it's still not comfortable for long periods.  When I was young I had a pharyngeal flap attached to my soft palate to help me talk.  This was later removed in a jaw surgery when I was 18.  The doctors were considering having my adenoids removed when I was young, but decided not to.  Another fun fact about me is I don't have a Uvula .

With that out of the way, I'm having a hard time getting my settings right.  I've been reading the forums for a few weeks and found a lot of help and encouragement, but I don't really know what I'm doing.  If I leave the auto settings on 5-20, the machine likes to ramp up to unholy pressures that wakes me up unable to breathe (15+).  I've found that anything over about 9 cmH2O leaves my stomach hurting the rest of the day.  I wake up several times just to burp up air (Aerophagia?).  No matter what pressure I get up to it seems like my Flow Limitation is poor.  In fact, my inhale breaths look really flat even when I'm awake (is this normal?).  I've been reading about UARS and wondering if that's related to my symptoms.  I've ordered an O2Ring that I want to use to supplement my OSCAR data.  I think my natural O2 levels are low even when awake?

So far I've changed my APAP to be 5 to 8 with EPR of 1 only on ramp.  When I had EPR on I seemed to get a lot more Clear Airway events.  These numbers let me get enough sleep to at least feel the same as when I take the mask off.  I'll attached a few days worth of screenshots.  My AHI numbers don't seem to match how I feel the next day.  The numbers seem good but either I can't sleep through the night or I feel bloated and terrible the next day.

Any suggestions would be appreciated.  Feel free to just tell me to keep going and I'll get used to it over time.  I'm just hoping to get closer to the right settings for me.  Let me know if I can provide any more data to help.  Thanks!

[G. Szabo]

From your sleep report, the number of CAs they observed is unclear. Would you mind clarifying it?

Until then, High EPR helps your Aerophagia and improves your flow limits. Considering your problems with higher than 9 cm pressure, I suggest setting the min/max pressures to 7/9 cm with EPR =2 full time; ramp off; response Standard.

[Deborah K.]

On that type of sleep study, the CAs show up as pAHIc, and he only had one CA, so his large number of CAs must be treatment-emergent, as his full AHI was only 5.8.

[Deborah K.]

Haldir,

Your starting pressure is too low for most adults, and lots of pap machine providers set the start pressure at 5 out of laziness.  You would likely feel better if you set your starting pressure at 7.  You would also benefit from setting your EPR at 3.  That will not help your high number of CAs, but I think it is more important to lower your flow limits, as they are short, unreported apneas and are not good for your sleep.  Your high CAs are treatment-emergent and will lessen on their own as time passes.  I suggest that you ignore the CAs for now.

[Haldir]

Thank you for the responses!  My understanding was that it was treatment emergent CA as well.

Here's another snip from my sleep study.

"PHYSICIAN'S CLINICAL INTERPRETATION

IMPRESSION:
Mild obstructive sleep apnea (OSA). (ICD 10- G47.33)
• Mild elevation of the apnea hypopnea index. (AHI = 5.8)
• The minimum oxygen saturation was 89% with a mean saturation of 94%. The patient spent 0.0% of the study
with saturations less than 90%.
• Episodes of tachycardia (sleep heart rate >90 beats per minute) were noted.
• Snoring was detected in 28.7% of the study."

I've also attached a few more days in OSCAR where I let the max pressure get high.  I had bad aerophagia on those days, almost like i was bruised.  I have bad slouching posture so maybe it was actually stretching out my torso?  I sleep on my side curled up with a body pillow between by knees and arms.  Maybe I'm hugging the pillow too tight at night?  

I'll try the EPR at 3 and starting pressure at 7 to see if that helps.  I just watched a video on the V-Com, is that something recommended for the air swallowing?  It seems like it's the opposite of EPR though, decreasing inhale rate while leaving the exhale alone?

[Deborah K.]

You could try a pressure range of 7 to 11.  That will get you where you should be and the range is small enough that I don't think it would cause aerophagia.  If it does we could drop the upper limit a little until the aerophagia stops.

You have a bit of positional apnea.  It's not terrible, but maybe we should look into it once you make the above changes.

On 9-1, you had somewhat high leaks, but not on the other nights.  Were you wearing the same mask?  Do you often have fairly high leaks? It's probably a mask fitting problem.  Especially with full face masks, folks tend to tighten them too much.  You need to put the mask on so that it is sitting lightly on your skin, not mashed up against it.  Then when the air enters the mask fills and grabs the skin a little tighter on its own.

[Haldir]

On 9-1, you had somewhat high leaks, but not on the other nights.  Were you wearing the same mask?

Oh yes, I should have mentioned that 9-1 was my last day using the F30i before I got my F20 in the mail.  I have much fewer leaks with the F20, possibly because of the crooked shape of my nose.

[Haldir]

Last night was very interesting.  I really liked the increase in EPR level.  It's like my breath gained momentum as I breathed in and then the extra pressure carried me over the top to the rest of my breath (Like a type of flywheel or inductor for my fellow engineer nerds).  My aerophagia doesn't feel great, but it's on the edge of tolerable.  I feel more rested than other nights somehow, even though the AHI is higher.   It was harder to fall asleep because of the new sensation (which actually felt good).  I think I was awake or semi-awake for the first grouping of CA's.  I remember almost having to remind myself to breathe (could have just been a dream).

Halfway through the night I woke up and checked the data.  I noted the leak rate and tightened my mask a bit.  That seemed to really help for the 2nd half of the night.    From the OSCAR report I'm wishing I had a BiPAP to try.  I don't really want to increase the inhale pressure, but might benefit from more pressure differential.  What are the odds of being able to exchange my machine with my DME for the more expensive option?   Is that even the direction I should be looking?

Thank you so much!

[Jay51]

A long term strategy may be to try this current machine for a couple of more weeks and see if all of the CA's that you are having are treatment emergent or permanent.  

If in a few weeks or so your CA's diminish, then they were probably treatment emergent and you might do well long term on this particular machine.  

If after a few weeks, you still have a high number of CA's, it might be wise to start looking at a different machine.

[Deborah K.]

For now, I suggest that you lower your upper-pressure limit to 10.  See if that stops your aerophagia.  You clearly need higher pressure, but it causes you bad aerophagia.

You might be able to convince your doctor to prescribe you a ResMed AiCurve 10 Vauto.  This can be any doctor, dentist, nurse practitioner, physicians assistant, etc.  I did this with SleepRider's help.  Here's a link to my very long thread in case you'd like to read it.  It may give you ideas.

https://www.apneaboard.com/forums/Thread...s+bi-level

P.S. Jay, Haldir only had one CA on his sleep study.