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40 yr old male, 140 lbs, diagnosed with "medium" sleep apnea 4 years ago. Gave up CPAP therapy after trying for 2 months due to mask fit issues.
After struggling for 4 years without therapy, I have started using CPAP again from December, 2023. Found the right full-face mask this time (AirTouch F20)
I read through apnea-board posts and wikis and have gradually adjusted my CPAP settings to get the AHI below 5 and low flow-limitation.
I also started using a soft-cervical collar around the neck for the last 1 week as I was seeing "clusters" of apneas. Also started using a flat pillow. This seems to have helped reduce the clusters.
My current device settings:
Mode: APAP
Pressure Min: 12.40 cmH2O
Pressure Max: 15.40 cmH2O
Antibacterial Filter: No
Climate Control: Auto
EPR: Full Time
EPR Level: 3 cmH2O
Essentials: On
Humidifier Status: On
Humidity Level: 4
Mask: Full Face (AirTouch F20)
Ramp: Auto
Ramp Pressure: 11 cmH2O
Response: Standard
Smart Start: On
Temperature: 27 ºC
Temperature Enable: Auto
Issue: Despite using the CPAP the whole night and OSCAR showing < 5 AHI, I still feel groggy when I wake up and irritable throughout the day.
I am at a loss here and not sure what next step should I take. Any insight / help is greatly appreciated.
Good job on using a soft cervical collar. It sounds like you did well reading the OSCAR charts to come up with the same conclusion we would have done.
It seems to me that the flow limitations are causing pressure increases which are then triggering the aponea’s. Some of us are sensitive to the pressure changes and end up having events triggered by it. The goal of any changes would be to try and find the correct pressure such that the pressure changes are minimal.
How well are you handling the higher pressures? If it is not a problem I suggest giving the following a try:
Mode APAP
Min pressure 14
Max pressure 16
EPR 3
No ramp
That way we start with a higher pressure a bit above your median and leave a little headroom for the pressure to increase. You could use a max pressure of 15.4 as you do today, but I’m wondering if the max pressure used will go above 15.4, hence the use of 16.
If you are willing, give it a go for a few days and report back.
The best we can do is review your data in detail and ask whether your breathing has been normalized. Until that is achieved, it's speculation to arrive at conclusions regarding why you may still be feeling not your best. Unfortunately, AHI (and RDI) are not comprehensive measurements of the presence of sleep-disordered breathing, but additional information can be gleaned by reviewing the flowrate on a smaller timeframe and then asking oneself if disordered breathing is present. Instrumentation exists that allows us now to determine whether your body is physiologically responding to disordered breathing (pes, EEG, thermistor, etc.), but the data we can gather simply via OSCAR is limited, as we're confined to the flowrate and experimentation, both of which can be directive, however. I personally believe pulse oximeters hold diagnostic power as a retail option, because many patients will have coinciding pulse spikes with their airway flow limitation / resistance, but, again, they won't cover the whole picture. Pulse spikes beyond 3bpm are almost always associated with a coinciding EEG-wake signature and flow limitation, even if subtle.
Tldr; try applying more pressure in varying ways, as peaceloveandpizza suggests, via increased pressure and / or changes in EPR. Bilevel should also be a consideration, as it can allow you to customize your PAP therapy into territory you've yet to explore but that could match your true pressure needs.
03-25-2024, 11:20 AM (This post was last modified: 03-25-2024, 11:23 AM by rekaviv.)
RE: Therapy help
Thanks @CPAPfriend for the suggestions.
I have attached 10 drill-downs (across multiple posts) on the Mar 20 chart I posted in the original thread. Let me know if there is anything that can be inferred form these.
more drill-downs
more drill-downs
final drill-down
I did try out PeaceLoveAndPizza'ssuggestions. here are the results(attached OSCAR chart for the 3 days) :
Trial 1: Min: 14, Max:16, No Ramp
Found it very difficult to fall asleep at high pressure without any ramp
Even after I fell asleep, I kept waking up very often
This probably indicates that I am not tolerating high pressure
Felt groggy / foggy in the morning
So next night I decided the narrow down the pressure a bit with ramp on
Trial 2: Min: 13, Max:15, Auto Ramp start: 11
Was able to fall asleep
Still was waking up multiple times throughout the night - tossing and turning around
Felt groggy / foggy in the morning
Trial 3: Min: 13, Max:14, Auto Ramp start: 11
Was able to fall asleep
Still was waking up multiple times throughout the night - tossing and turning around
Felt groggy / foggy in the morning
These experiments suggest that something is waking me up throughout the night and not allowing me to go into deep-sleep state and get that restful sleep.
I don't mind trying out a BiLevel if data points in that direction.
Is there a way to get a BiLevel machine without prescription?
03-25-2024, 12:22 PM (This post was last modified: 03-25-2024, 12:24 PM by PeaceLoveAndPizza.)
RE: Therapy help
You can buy a used Vauto machine from Facebook Marketplace or other online source, and can quite often find a good deal. Note that you can get a prescription to buy a CPAP from any doctor, even your GP or Optometrist. We can help make the case for a bilevel if needed.
Before going that route, you fall into an interesting place for therapy. You need higher pressure, but cannot tolerate it. You do not have a significant amount of flow limitations, but what you have drives up pressure. At higher pressures you still have apnoeic events and are very uncomfortable.
This means we need to look at it a bit differently and focus specifically on better quality sleep.
As even at higher pressures you are still getting clusters of apnoeic events, this leads me to think you are chin-tucking (positional apnoea). You can manage those with a flatter pillow and/or a soft cervical collar to keep your neck more correctly aligned.
You may have already done this, but one thing to consider trialling is using a lower pressure and constraining the range to avoid the higher pressure wake-ups. It will mean more flow limitations, but as your pressure will be upper bound limited it will not go higher. Whether done with APAP or CPAP mode, it may be a worthwhile experiment. Something like:
Min pressure 12
Max pressure 12
EPR 3 full-time
No ramp
That would tell us a few things. Specifically whether you feel more rested even with flow limitations or whether that is enough pressure to manage the apnoea’s sufficiently. The best case would be you feel better. The worst case is you don’t do that again.
Thanks for the suggestions. Never tried min/max fixed pressure. Will try that tonight.
I suspect my 3" height cervical collar is not enough. I have ordered 3.5" one.
Also, I do have year around allergies - so, I tend to alternate between nose and mouth breathing. Not sure if that affects the therapy. I assumed it should not, because I use a full-face mask which fits me perfectly without any leaks
Slept without waking up in the night (even though it was only for 4 hours)
Felt relatively better in the morning.
Not sure if the cluster of apneas in the OSCAR chart is because of chin-tucking or because of not enough EPAP pressure. Going to try with 3.5" SCC collar next.
Insights so far:
1. Fixed Min / Max pressure seems to work better for me than APAP mode.
2. With pressure around 10, I seem to sleep without waking up much.
Next:
Going to stick with Min: 10.4, Max: 10.4, EPR: 2 for few days and sleep for 7 hrs
Increase the SCC height from 3.3" to 3.5" and see if cluster of apneas go away.
