CPAP Newbie In Need of Your Advice

[mydogatemypap]

Hi folks,

I'm a 29 year old lady who has just finished her first full week of CPAP (APAP) for my OSA that I suspect has been going on since my teen years, and I could really use some helpful eyes/advice on what's going on with my sleep according to my Oscar reports. Looking at my data in Oscar kind of freaks me out because it's so foreign and I can't even begin to sort out what kind of adjustments could help lower my AHI. Sleep medicine health care is super impacted in my area, and I also chose to purchase my CPAP directly, so I feel sort of on my own to figure this stuff out for now. Any help is deeply appreciated!


Clear Airway/Central Apnea events - My original in-lab sleep study showed AHI 15.3 overall, and the breakdown was 12.6 Hypopnea, 1.5 Obstructive Apnea, and 1.2 Central Apnea. I'm glad to see my Hypopnea numbers are down to .31 and my OA is down to .13 average so far, but I'm a bit stressed that my CA index is sitting at .99 average. I can't figure out why I have the least improvement with CA so far. The only thing I can think of is that my mask leak may be affecting this - even though I'm a very deep sleeper, I definitely have been stirring from sleep to adjust my mask fit when I suddenly feel or hear the leaking air. 
I'm pretty sure I subconsciously hold my breath when I do this to help tell whether I've successfully closed off the leak. I do this in part because my husband runs a white noise sound machine at night, and I can't tell over the sound of my own breathing whether the mask is still leaking or it's just the sound of the white noise. My dog also sleeps in her bed directly next to me on the ground, and I think I do this exact same thing when the sound of her licking wakes my subconscious (if you're a pet owner, you know exactly what I mean), and I hold my breath to hear over the white noise to discern whether I actually still hear licking or if she's stopped and I can drift back off to sleep. 

Pressure Settings?? My prescription/machine came at the generic 5-20 cmH20, and the first night it felt like a mixture of the CPAP suffocating me from too low of a pressure and then trying to blast the mask off my face with high pressure. I ended up adjusting slightly to 8-18 because I was worried about narrowing the range down too much before having more data to guide me. At what point should I start to mess with this further? I have EPR 3 on because there was no way I could fall asleep not being able to exhale, but my average EPAP so far is showing as 5.5 and I'm worried that's too low - is that ok? Should I try out EPR 2 or 1? I'm also wondering if using EPR is keeping me from seeing improvement with CA events.

Septum Questions - I think I may have a deviated septum - if that is the case, should I absolutely not be using a nasal mask? I've read conflicting advice on this and don't know where I land because I've always been primarily a mouth-breather during sleep, but during the day I naturally just breathe through my nose with mouth shut. I was worried I wouldn't be able to use a nasal mask but so far I've naturally kept my mouth shut all night because the unnatural feeling of air shooting out my mouth is a no-go to my body. I should note that I do have a septum ring (that is on the smaller end), and I use the Philips Dreamwear nasal mask that has one larger opening for both nostrils and allows my septum ring to more than comfortably fit inside. So I don't think my septum ring is causing me any issues in terms of mask leak - if anything, I think my mask leak comes from being a combo back/side sleeper who shifts around a lot because I'm hypermobile and my body simply aches if I stay in any one position too long.

Response: Soft Ramp vs Normal - Is using Soft Ramp a mistake? I don't know if it's really doing anything for me comfort-wise, so I am considering turning that off if there's drawbacks that I'm not aware of.

I've attached the overview screenshots here, and will include snapshots of several days from the past week in the second post below. Any advice/input/education is welcome, thank you kindly!

---

Additional Images

[Phaleronic]

Welcome to the forum mydogatemypap!

First two things that jumped out to me is your leak rate (you're having some large leaks)-so we need to get that resolved asap. You're moving around quite a bit as you stated so you may need something to help you not move so often. Also you're max pressure it too high please drop it down to 13-14cm. This should help leaks a little bit if your mask seal breaks during the night.

I personally don't use ramp as the machine isn't providing adequate therapy with it enabled.

[PeaceLoveAndPizza]

Agree with Phaleronic that the leaks need to be brought under control. Hard to tell if they are mask or mouth leaks, but lets give it some time as being new to CPAP things may settle down. We have ways of helping deal with both kinds of leaks if need be.

Most importantly, how do you feel in the morning? That is a key decision making factor.

Good job on managing your own therapy. You have figured out settings that work for you. 

Regarding your question on low pressure, 5.5 is fine as long as it is handling your specific events, which it seems to be doing. You do have a few centrals which I expect are treatment emergent, so they should for the most part go away over a few weeks of use.

Nasal masks/pillows with a deviated septum are fine, depending on how well you can breathe through your nose. Personally I have septum and turbinate issues, but can use nasal pillows with no problems. We are all different, so the trick is finding what masks and other paraphernalia work for you. It is a bit of a game figuring it out. From your description it sounds like this may not be the mask for you. If you like the nasal masks possibly try the ResMed P10. If you want a full-face type mask or hybrid (does not cover your nose) try the ResMed F30, ResMed F20, or F&P Evora. 

Is soft ramp a mistake? It makes a difference for some, not so for others. What it does is soften the pressure rise for comfort. You can try both soft and standard to figure out what you are most comfortable with.

For your pressures, I would not change anything just yet. Give it time for you to adapt to a new way of sleeping. Focus on solving the leaks with practice or possibly a new mask.

[UnicornRider]

I must commend you on the OSCAR reports you presented for the forum members to review in an effort to assist your journey in to this world of PAP assisted slumber. You evidentially did some background research to format them correctly.

I agree with the previous forum members in that you're a little bit leaky. 

Which is to be expected when new to PAP Therapy. One of the most common mistakes that most new PAP Therapy Patients make, is to over tighten their mask. Also proper Mask Selection is very important.

I will suggest you review several times over the next few weeks the Mask Primer  , it will assist you in selecting the best mask for your facial structure and therapy needs. It will also help getting your mask adjusted to a leak free status. Do not overly stress getting a perfectly leak free mask fit right off the bat. You are in this for the long haul, it is a journey that will have many different adventures before it is ended. Rather work progressively to reducing your leaks as much as possible.

Besure to read and practice the information that Jeffy1958 gives in the Mask Primer . It really helped me get my leak rate down to a near 0.00 L/Minute leak rate. Remember, "Tighter is not always better"

CA Events. Many times new PAP Therapy patients get what is called "Treatment-emergent central sleep apnea (TECSA)" it usually resolves itself within a few weeks to a few months. If necessary you can adjust EPR later. Do not worry about CA events at this time.

Pressure settings, you've done a fantastic job of correcting the pressure settings from the 5-20 cmH2O generic setting your machine came with, to the 8-18 cmH2O your OSCAR Reports show.  As recommended by other forum members, Ramp does not provide any therapeutic benefit. I did notice your Ramp is turned OFF in the left hand panel. But your "Smart Start" is ON, there again there is no therapy during the "Smart Start" delay. After the "Smart Start" delay, your pressure ramps up, overcompensating, only to settle back down to slightly above 8 cmH2O. You would be better off without Smart Start. If needed, later you can incrementally increase your starting pressure, but for now leave it as you have it. Please turn off Smart Start.


Pets, well I am a pet person, come winter it is comforting to have the warmth of two dogs and a cat sleeping with me. Come summer, they sleep at my feet or the cold spot where the HVAC duct vent is located.I sometime consider joining them at that cold spot, during the summer.

Please post back, I have some questions about your White Noise machine, for a later date.

[mydogatemypap]

Thank you for the kind welcome, Phaleronic! 

The feedback about leak rate is very helpful, since I really didn't know at what point mask leak is considered a big enough problem to be addressed. Would lowering the max pressure to 14 help even if my Oscar data shows that my max pressure hasn't gone above that amount any night this past week? 

I think I may have been unclear about what I mean with ramp - I'm not using the actual ramp up feature, I was just referring to the "ramp response" setting which only has two options - standard, or soft.

---

Hi PeaceLoveAndPizza, thank you so much for the great advice! 


Overall, I am feeling maybe 10-15% improvement in how I feel in the morning. Which, for context, is generally quite terrible - I still feel quite fatigued like usual, but just barely less so that I'm at least "waking up" more quickly when my alarm rings, if that makes sense? I feel like that must mean the quality of my actual sleep is improved since starting the CPAP, even if it's not the life-changing difference I know some people experience when starting CPAP therapy (which I assume is actually pretty rare).

Unfortunately I can't do nasal pillows because of my septum ring - I have a sensitive nose & sensitive skin, so changing my septum ring every night isn't feasible for me. I've been thinking about trying out an over-the-nose mask like the DreamWisp, but I'm not sure if that will be any more effective at preventing leaks. I'm still being pretty picky about masks, so I'm hesitant to try a full face mask or any elephant hose mask just yet. This past week I tried tightening up my straps on my DreamWear and I think that helped improve my leak rate a lot - I've attached a few charts here from my Oscar. I also noticed that on nights when I'm too tired/lazy to do my skincare routine I have a lot more leaks   So I'm being more diligent about putting moisturizer on before I mask up because it seems to help my mask seal overall.

I'm hoping like you said that the CAs will resolve over a few weeks of use because it seems those are still the majority of my events. I did also have one night with several RERAs which concerns me a bit. I'm worried that I'm having more RERAs than the machine is actually catching, but I certainly can't read my graphs anywhere well enough to identify something like that.

---

UnicornRider, thank you for sharing your insight, and I really appreciate your kind words. I was actually quite avoidant in getting started with my PAP therapy after my diagnosis because I felt stressed about such a big change - researching online and reading others' experience and advice as well really helped me jump that hurdle and feel confident enough to at least begin. 

I read through the Mask Primer and it's given me a lot to think about! Thankfully I have already learned before even starting PAP about the mistake over-tightening your mask, and funny enough I think throughout the first week my leak issues were in part caused by my mask being too loose! In trying to avoid the issue I was definitely causing it to a degree - I tightened my straps just slightly this past week and had somewhat better results, and definitely woke up far less throughout the night to re-adjust my mask from big leaks. I will say, I'm a little confused by data on leak rate in Oscar - where should I be looking for improvement, the 95% leak rate? I feel like the "Time over leak redline" feels pointless because I assume a lot leaking under the redline amount is still not good.

I'm very curious about what you wrote regarding SmartStart - coincidentally, I actually turned SmartStart off last Sunday night because the delay was starting to feel uncomfortable and I just wanted the machine to get right to my starting pressure more quickly. However, even with SmartStart off, I've noticed on my Oscar data that the pressure still ramps up, overcompensate, and then gradually settles back down around 8 cmH20. Is there any reason the machine is still doing that? I wonder if it has to do with my Soft Ramp setting instead of Traditional Ramp.

Ask away with any white noise machine questions! I've been sleeping with the white noise for more than a decade, thanks to my husband who for the early years of our relationship slept with a box fan constantly running to act as white noise. I eventually convinced him to replace it with a noise machine, for fear of my nose detaching itself and running away from how painful it would get with constant dry air blowing around the room all night.

---

(additional images)

[mydogatemypap]

And this is my overview as of today:
   

Leak rate at least seems to be improving! I am guessing it will just take some more time to see if the CAs go away - it's been 15 days since I started so I'm trying not to get too ahead of myself. Thanks again everyone for your input, it means a lot to hear all of your thoughts and advice. I am still feeling pretty fatigued when waking up in the mornings, but I do think I have more energy once I am up than I have pre-PAP. My biggest struggle has always been "waking up" - I usually feel an overwhelming sense of grogginess, and it doesn't matter how loud the alarm is or if it's across the room, the urge to fall back asleep is stronger. If it's a workday morning, the urgency of getting to work on-time is usually the only thing that can override that powerful drowsiness to get me out of the bed and moving. I am not too optimistic on how much improvement I'll see in that area, as I believe my struggles around waking up have to do with my Delayed Sleep Phase Syndrome and ADHD (which I do take meds to treat). But who knows! Any advice is always appreciated.

[UnicornRider]

If you look at your Flow Limits graph, every time you see Flow limits pop up, your ResMed responds by increasing the pressure. That is except later in the night when you start to get mask leaks, even though the leaks are not above the redline the response of the AirSense 10 is muted or conservative during medium leaks. Leaks are not supposed to affect performance until 24 L/Minute(Red Line). I have found the lower my leaks the better I sleep and It gives the sense of power over my AirCurve 10. It may be that I can sense or feel the leaks during my sleep.

It can take a while for CA events to start to clear up. It can also take several months for the years of sleep depravation to start to rectify itself.
As for the white noise I was going to ask if it came before the PAP machine. You answered that. I thought the leaks may have been bothering your Husband.