[CPAP] 5-6 Weeks into CPAP Therapy, Sleep Getting Worse of Late

[SleepyLP]

Hi All,

I started CPAP therapy at home at the beginning of December.  At first, it was going pretty well - I got a few nights of sleep that were among the best I've had in years and felt awesome during the day (for example, on December 10 I used the machine for about 8 hours and had an AHI of 4.1 and on 12/22 I had an AHI of 3.2 after using the machine for about 7.5 hours; my settings at that time were for the prescription I got, 4-7 cmH20).  However, my experience has since begun to decline.  I am experiencing a lot of leaks, waking up a lot, etc.  Last night, my AHI was 14.18 and, per Oscar, I had 58 large leak events.  I only began using an SD card in my machine a couple of nights ago but I'll try to post some data at least from my sleep last night.  

Some background (I can provide more if that would be useful): 

Me: Male, age 40, 5'6" tall and 150 lbs.
1st Sleep Study (no CPAP): 11.2 AHI and RDI of 15.9 events/hour.  
2nd Sleep Study (with CPAP, pressure at 4-7): while at 7 cm, AHI was 1.9 and RDI was 3.1 (this was for about 308.5 minutes, 60.5 of which I was awake for - the sleep doctor recommended I treat in CPAP mode at 7 cm H20.  
Equipment: ResMed AirSense 10, pressure settings for last night were 6.4 - 9.6 cmH20, no ramp time, no EPR (a tech told me the 4-7 cmH20 prescription on my machine was very low and I have been playing with the pressure; as I said above, I had an AHI of 14.18 last night with these settings).  I am using the Philips Respironics DreamWear Nasal Cushion Mask currently.  The tech I spoke with thought I've been experiencing a lot of mouth leak and sent me the Evora FFM; I tried it on last night and couldn't get a good seal at all (running mask fit on the CPAP machine showed me only the sad face; I have a pretty big beard).  So I went back to the DreamWear, which I've been using all along and used at my titration sleep study.  

I have a deviated septum; I'm not sure of the severity of the deviation but I battle frequent congestion and use a Navage/Netipot most days to stay on top of it as much as I can.  I believe I am breathing through my mouth at night as my mouth is super-dry when I wake up and I have the higher leaks reported, as described above.  Because of the beard, I don't think mouth tape would be really effective to address leaks and, like I said, I don't think I was getting a good seal at all with the Evora FFM (I love my beard; not ready to get rid of it at this point but would consider doing so if it seems truly necessary).  I previously liked to sleep on my side/stomach but the DreamWear mask I'm using tends to leak when I do that now so I'm trying to stick to my back (I do still roll around at night when I'm less aware).  

An image of last night's stats from Oscar is attached.  Please let me know if I can provide more information to facilitate this request.  Thank you very much in advance for any help you can offer.  Please help this tired guy get some rest.  

   

[gainerfull]

Hi SleepyLP,

Looks like you're experiencing positional apnea, have you considered trying a soft cervical collar?

[SleepyLP]

Hi SleepyLP,

Looks like you're experiencing positional apnea, have you considered trying a soft cervical collar?

Hey gainerfull, 

Yes, actually - I picked one up at CVS today and will try it in bed tonight.  Thanks very much for your suggestion.

[Deborah K.]

You are primarily having central apnea events.  Did your sleep studies show lots of central apneas?  If you can please post redacted pictures of your sleep studies.  It will help us help you.

Your flow limits are high.  Getting those under control will make your sleep more comfortable and allow you to have better treatment.  Turn EPR on full-time and set it at setting 3.

[SleepyLP]

You are primarily having central apnea events.  Did your sleep studies show lots of central apneas?  If you can please post redacted pictures of your sleep studies.  It will help us help you.

Your flow limits are high.  Getting those under control will make your sleep more comfortable and allow you to have better treatment.  Turn EPR on full-time and set it at setting 3.

Thanks very much for your feedback.  Yes, central apneas were an issue for me during my sleep studies, particularly while supine.  I attach a paint/.png file including the respiratory results from my sleep studies and the actual prescription from the sleep doctor for my CPAP machine.  I realized this morning while reviewing my study that the actual prescription from the sleep doctor called for CPAP pressure of 7 cm H20 (see lowest portion of attached .png).    

Unfortunately, my CPAP machine prescription is currently handled by my primary care doctor (I’m working on changing that), who botched the prescription (my original machine settings were for 4-7 cm H20). I haven’t yet tried a constant pressure setting of 7 cm H20. However, looking at last night’s results (attached), it seems to me that pressure never dropped much below 7.5 even when my breathing was nice and steady, so maybe that’s a good setting to start at along with EPR of 1 (would welcome your input on whether or not this is appropriate start level and in re EPR).  

I used a cervical collar last night and had better results (though I was awake for a few lengthy chunks of time and actually got out of bed for a bit - the cervical collar was driving me nuts!) AHI of 6.14 and leak rate of 20.4 (and very minimal leaking once I got back in bed and fell asleep again).  I’m pretty sure I was awake for the whole time when I woke up around 1:30 am and got out of bed at 2:45, so I’m confused as to why the machine recorded CAs and OAs during that stretch … (?!)

Thanks very much in advance for your insights and please let me know if you have additional thoughts based on the above/attached.  

       

[DancesWithCats]

You have EPR set for ramp only. Usual advice it to turn ramp off unless you can't tolerate that (so it goes straight to treatment when started) and EPR full-time, typically 3 (max a standard Airsense can do) unless there's some reason not to...

My gut reaction as "just someone else with sleep issues" is that the way your graph is plateauing at your maximum pressure setting for long periods might indicate that the upper end setting should be raised.

[SleepyLP]

You have EPR set for ramp only. Usual advice it to turn ramp off unless you can't tolerate that (so it goes straight to treatment when started) and EPR full-time, typically 3 (max a standard Airsense can do) unless there's some reason not to...

Thanks very much, I will make those changes.

[DancesWithCats]

I guess you had ramp off already, so just the change to EPR setting. And perhaps upper pressure, unless you can't tolerate more.

[Deborah K.]

I agree that the upper pressure limit needs to be set higher also. I suggest that you move it to 15. It won't go higher than you need, so there is nothing to worry about in making the change.

Hopefully, the experts will respond to this thread. It may be that you need a different type of machine to deal with your central apneas (CA).

[TechieHippie]

In case it's helpful my dad had a beard and used mouth tape successfully, although under a FFM. He used wider strips, of the Buteyko Snorless Strips which I also use; they come in a package of sheets and you cut the sheet to the shape you want.

I use the same mask. I have the full face "hybrid" version (still cushion rather than over the nose, hope that's the right term) and have just started the nasal cushion with mouth tape. I was able to swap out the mouthpiece and the straps and use the Dreamwear frame. (I switch the mask setting when I change types). With the nasal cushion I have to work to keep my tongue up on the roof of my mouth (feels like swallowing the back of my tongue and then resting it there) or my mouth balloons with the tape. I haven't noticed the ballooning happening at night but my numbers aren't as good yet so I'm guessing it does sometimes, but it's more comfortable than the hybrid so it's a tradeoff I'm working with.

I suspect though that with the deviated septum you'll want to find a full or hybrid mask so that you can use your mouth when your nose needs it, and it will keep your mouth humid which is better for gum health. (you can probably get just the hybrid cushion and straps for the Dreamwear; for me the sizing from hybrid to pillow was the same, medium in both.)