Brain fog, lack of energy -- why did dropping my EPR make such a difference?

[SarcasticDave94]

OK copy, sure try the therapy a bit and look to see if therapy trends appear. If you run into a speed bump you can post at any time the concern.

There's options when we post that we can select to get messaged either via email or Apnea Board PM.

[Geer1]

There are lots of options to try and improve leaks and if it is mouth leaks those include

a) Finding more optimal settings. A common cause of mouth leaks is body mouth breathing because settings are not comfortable. I believe that usually this is because EPR or PS are not high enough so the body has trouble exhaling so instinctively opens mouth.
b) Methods of keeping mouth closed to make it harder to mouth leak. Taping, chin straps and cervical collars are all options.
c) Full face masks if you can find one that fits well and is comfortable.

We are already trying to determine best settings to deal with option a. Options b and c both have positives and negatives as they can minimize leaks but are more intrusive, all you can do is try out the different options and see if anything works good for you. Some people end up living with the leaks,

I ended up trying a full face mask and will never go back. I went from semi constant leaks to almost non existent leaks and didn't find comfort to be an issue for me.

[SarcasticDave94]

If you want some mask homework, research the Fisher and Paykel Vitera full face mask. I've got it as my go-to whenever the QUACK doctors get me a correct machine.

You're going to find that mask selection and leak control will be the hardest aspect to conquer IMO. That doesn't mean it can't be done, because it can with patience, self advocacy, and diligence.

[Albigensian]

Hello to anyone who is reading this thread.   As promised, I have gone off for a while to see how the recommended settings work out.  Here is my report on what happened.

Reminder:  I got these recommendations after I asked for some input about why I felt so much better when I changed my EPR from 3 to 1 (with Min Pr 5 Max Pr 12).    With only this tiny change,  I went from moderate-to-serious brain fog and lassitudinous lack of energy to feeling much better.  
Some very generous and knowledgeable folks jumped in to look at my Oscar data after I posted my case.    

I was urged to consider moving up my minimum pressure from 5 to something higher because a review of my data showed that my pressure rarely went below 8 or 9.   As that was the case, the experts said, why struggle with a lower pressure when I started out?   Good point.   Along with that, I was urged to see what happened if I changed my EPR from 1 to 3.

So, here is my report.   I have inched up my minimum pressure from 6 to 8 and finally to 9.    I have kept detailed daily notes.    I attach a representative OSCAR screenshort from a typical night with the 5min/12max/1 EPR setting and the 9min/12max/3 EPR setting.  

I also attach summary data so you can see what has happened since I started my experiment.
I certainly feel better with Min 5/Max 12/EPR 1 or Min 7, 8 or 9/Max 12/EPR 3 than I ever did with my original stupid DME/MD settings of Min 5/Max 12/EPR 3.   I was surprised to discover that I have more apnea events with the higher minimum pressure and the 3 EPR than I did with the lower minimum pressure and the EPR of 1.   As the min pressure was increased, I found that I had more nights with lots of sleep disturbance and a high AHI.  They weren’t frequent but they did occur.    Sometimes, they are clearly positional apnea.  Most of the time, though, I can’t figure them out.   


SUMMARY:  Overall, though, I’d say that I’ve finally emerged from the fog of treatment-related clear airway events that clouded my first eight months in treatment.    My nights used to have lots of “clear airway” episodes that were not SWJ and that disturbed my sleep.  (Treatment-related central apnea, perhaps.)      Changing my settings has wiped them away.  I still have SWJ clear airway events, but those are easy to recognize. (For newbies, that's "sleep wake junk" and it means that these are not "real" events but are part of the characteristic breathing patterns that we have when we are half-awake, tossing and turning, etc.   So, they aren't anything that our settings can do anything about and they aren't "real" apnea events.) 
 
In general, my OA (obstructive apnea) events are down.  I append an OSCAR screenshot of a decent night of sleep.  I also append a screenshot with trend data and notes about what my settings were at different points in the trend data.

And, of the course, the real question is:  do I feel better in the day?  And, yes, I do.

I still have some problems to solve but these adjustment have made a big different.    Thanks to all of those who contributed their expertise to this project!   ApneaBoard is the best!!

LINGERING QUESTIONS, if anyone out there has any insights to share:


QUESTION ON MINIMIZING THE DISTANCE BETWEEN MIN AND MAX PR:   I keep reading advice that seems to suggest that it is best to minimize the distance between Min Pr and Max Pr.  Is that accurate?   Are there general reasons why Min Pr 6 and Max Pr 16 would be more likely to cause problems than Min Pr 9 and Max Pr 16?

QUESTION ON SETTING MAX PRESSURE:    I am puzzled by what’s going on with my maximum pressure.   My sleep doc dropped my maximum pressure from 16 to 12 back in July.    I trusted him when he said that he was doing it because I never went over 12.   Now, though, I look back on my data from the months prior to July and find that I was hitting 14, 15 and even 16 occasionally.  True, my 95% pressure averaged at or under 12.   But is there a reason why one should put the ceiling at the 95% level? 

I am asking because my AHI was higher during that two months after he dropped the Max Pr from 16 to 12 than it was when the Max Pr was at 16.  Right now, I am even hitting my maximum pressure every so often with 9 Min/12 Max/3 EPR and so have started inching it up towards 13.   Is it best to have a Max Pr that you don’t hit?  Or is it okay to hit the Max Pressure?  

Appended:  a "good" night (i.e., I felt reasonably rested the next day); trend data on my various settings and their outcomes.

BACKGROUND INFORMATION, if anyone wants to look at the OSCAR charts

Note:  the Oscar charts show interruptions in being connected to the machine.  Few of them involve getting out of bed.   As part of gathering data, I have been disconnecting my hose when I wake up for more than a few minutes as a way of marking when the wakefulness happened.   I’m finding that many of these events are now unrelated to any apnea events.   When I first started doing this, almost all of them followed apnea events.    So, clearly, I have sleep issues other than apnea issues – mostly related to pain, I’m sure.

Background information:  I mostly have to sleep on my back and do struggle with positional apnea.  I think I have fewer positional events when I lie flat on the bed with only a very flat pillow and shallow roll under my neck to maintain the normal cervical curve.  I sometimes sleep on a slant pillow with the same shallow roll and very flat pillow.  I know that I struggle with positional apnea.  I wear a cervical collar but it doesn’t always do the trick.   I also have started taping my mouth to prevent leaks.   I don’t like doing it but I do think it is necessary.    The Oscar data shows me that I always have fewer events if I can sleep on my side.  Alas, I can’t always do that because of joint pain.

[Albigensian]

And a reminder to those who have learned anything from this or other threads on ApneaBoard:  consider contributing to Apneaboard's functioning by making a donation.   Any amount makes a difference!    Remember, even though lots of labor is donated by some great folks, someone has to pay for the basic costs of creating and maintaining this on-line presence.    

The "donate" button is on the main page.  So, do your part!  Yes, I sound like an NPR ad -- but, it's true.   We all need to pitch in.

[SarcasticDave94]

EPR at 1 has cut the CA shown on the summary in a decently consistent trend, at least for these CA that is. I myself can't suggest any edits, unless of course I've missed something.

See what others have to say.

[Gideon]

Working with TECA is a tradeoff with obstructive events.  
You lower EPR from 3 to 1 and CA vents decrease AND
obstructive events, in your case specifically your flow limits significantly increase.
It is literally a balancing act between central and obstructive events.

IMHO you are better taking the under 2 CA events, which will most likely diminish over time and go with EPR=3 which bests reduces your flow limits.

Final choice will be heavily influenced by how you feel, so let us know.

[Geer1]

Finding min EPAP is important.
Finding comfortable and effective EPR is also important.
Minimizing Min pressure to max pressure range is not important unless your max pressure regularly runs out of control. In both your examples your pressure barely touches 12, increasing max pressure beyond that would make little difference because the machine isn't trying to run higher.

The reason you found low pressure and high EPR to be less effective is because that results in a low EPAP which is not satisfactory.

The reason you can get by with lower pressure when using lower EPR is because EPAP isn't kept low (if you use min pressure of 5.6 with EPR of 3 your pressure has to raise all the way to 7 before EPAP starts increasing above 4, if you use min pressure of 5.6 with EPR of 1 your EPAP starts at 4.6 and increases as soon as pressure increases). Also at lower EPR you have more flow limitations which increases the pressure (and therefore EPAP) faster.

If you look at both your examples you will see average EPAP was pretty close around 8, that seems to be your sweet spot. Choosing which EPR level depends on what seems to be most comfortable and provide best results.

[Phil7]

Have you tried turning EPR off?   I might have missed that.

Bad things happen when I turn EPR on.   I get a higher AHI and worse sleep every time I try it.

[DaveL]

I'm so happy I found this thread. I've learned a lot!
Thank you!
Dave