[CPAP] Trouble staying asleep with CPAP

[sarahsleeps]

Hi! CPAP newbie here, it's been about a month since I received my diagnosis of severe OSA (AHI 77). The first few weeks were very tough as I battled anxiety and fear of suffocation when using the CPAP. At first I would panic after having the machine on for a couple minutes, now I have gradually been able to increase my usage to the point where I can last 1-3 hours at a time, but I am not sleeping much in those periods. Usually I give up around 2-3am, sleep without CPAP for a few hours, and then put it back on for an hour or two in the early morning. I just recently downloaded Oscar to try to see if I can determine what is causing me to wake frequently and remove the CPAP. It looks like I tend to have clusters of CA's when trying to fall asleep, and I've had mostly CA's since getting the CPAP with little OA's showing up on my data. During my sleep study I did have a few CA's and a few central hypopnea's as well, but the majority of my apneas were obstructive.

I use a ResMed AirSense 10. My pressure is on auto set 5-20 and my CPAP provider and sleep dr want me to collect a few weeks of sleep data to look at before eventually setting my pressure to the 95th percentile. I hesitate to mess with the settings before I am able to sleep all night with the machine and see what my pressure truly needs to be, but right now I would guess it's going to end up around 10. My CPAP provider has played a little with the settings in terms of adding EPR (at first we set to 3 and then I had them bring it down to 2 to try to help with the CA's). They also gave me a ramp of 4 for 20 minutes while I was still getting used to putting the mask on. I have since reduced this to 15min or sometimes I will put to 10min if I have gotten up in the night and am putting the mask back on.

I'm a 40yr old female, bmi is a little high at 26.7 but not in the obese range. Since my diagnosis i have implemented a daily routine of 30 min cardio, 10-15 min of somatic stretching, and guided meditations when anxious. I have also started EMDR therapy to work through my anxiety and negative feelings about using CPAP.

I have a deviated septum with a very small nasal airway, and i think I also have a nasal polyp in my right nostril (that nostril blocks completely throughout the day and night, and I think I can actually see the polyp - it's either that or extreme turbinate swelling). The sleep dr who diagnosed me didn't examine my airway at all or discuss any actual cause of my OSA, so I am awaiting an ENT visit in about 2 months. I use a steroid nasal spray every day (avamys), take an anti-histimine (reactine) once a day, and I use a saline irrigator a few times a day. I find using the CPAP is pretty uncomfortable with the nasal obstruction, and so I use the hybrid mask (ResMed F30i) so I can take some deep breaths and in case I need to breathe with my mouth during sleep. I started off with the N30i and even though I loved how much smaller and lighter it felt on my face, the feeling of wooshing air if i opened my mouth just wasn't for me. I don't feel safe mouth taping as I am concerned about the obstruction in my nasal airway.

I use the heated hose at 21 degreees celsius (bedroom temp is around 19 degrees at night) and I have the humidity at 4. I actually prefer the humidity at 5, but I find I get some condensation in the hose and have to bring it down to 4.

I'm attaching some screenshots of my last two nights Oscar data. Aside from looking at when the events are occurring and whether there are any obvious leaks or anything, I'm not really sure the best way to analyze the info. If anyone has any input, I would love to hear from you!  

[CPAPfriend]

There is not a lot of data to work from in your case, which is of course due to the fact that you're experiencing difficulty with wearing the mask itself, so the best place to aim our efforts for the time being is in improving your relationship with your machine. I'm not an expert in this area, but what seems to work for a lot of patients is spending more time wearing the mask with the machine on while awake, such as while watching tv, reading a book, or working at the computer, as a practice to normalize the experience.

[sarahsleeps]

Thanks for the reply CPAPfriend! I’ve actually watched a couple of your videos over the last few weeks. At the beginning since I was having such a rough time with the mask, I did wear it while awake and watching tv etc to get used to the air pressure and idea of the mask on my face. I wore it without the air on, then with the air on, and got to the point where I could drift off while watching tv with the air on. I’ve been focused now on trying to stay asleep with it so only putting it on at bedtime or close to bedtime, so maybe I need to go back a step and spend some more time with it while awake or try a day time nap. Hopefully I’ll be back soon with more data, wish me luck! Thanks again!

[Sleeprider]

Sarah, I understand you have some significant nasal issues, but I have found nasal pillow masks are actually better for individuals with your issues. BoxCarPete recently had a thread where he went from a full face to nasal pillows and ultimately had nasal surgery to resolve the issue. His use of nasal pillows was quite successful. Nasal pillows work by applying positive pressure directly to the nares and this inflates the passages in the nose allowing normal breathing. Compare that to a full-face mask which presses along your sinuses at the side of the nose and applies positive pressure to the outside of the nose. This actually makes nasal obstruction worse. So as counter-intuitive as it seems, I recommend trying nasal pillows like the Airfit P10 or P30i to individuals with nasal obstruction. Sometime the use of Flonase (fluticasone propionate) can also help relieve inflammation.

Your charts show quite a few CA events, and sometimes this is made worse by the use of EPR (exhale pressure relief). While this is marketed as a comfort feature, it is actually bilevel pressure providing a lower expiratory pressure and higher inspiratory pressure. Your EPR is set a 2. I think you can safely try reducing EPR to 1 without interfering in your doctor's evaluation. If you choose to do this, you can evaluate it for both comfort and to see if it reduces your events. It may be helpful for us to take a closer look at how your CA events arise by providing a zoomed image of the flow rate. The idea is to zoom into a view that shows the individual breath wave forms, and this would be a 3 to 4 minute segment, for example on 2/9/24 from 01:00:00 to 01:04:00. This link shows how to access the settings to change EPR https://www.apneaboard.com/resmed-airsen...setup-info

[sarahsleeps]

Hi Sleeprider, thank you so much for your reply and input! The mask I am using right now is a hybrid so it has the nasal cradle rather than the full face that goes over the nose. Do you think that the cradle could also worsen nasal obstruction? I do think it has felt worse since starting CPAP, but I assumed my mind was just focusing on it more as I'd previously gotten used to the feeling of "congestion". Due to my experience with the N30i I haven't yet tried any of the other nasal types, so perhaps the pillows are worth a try! The Avamys spray I use is similar to flonase, it's fluticasone furoate.

I'm attaching some zoomed in screenshots from Feb 9 at 1:00-1:04 & 1:09-1:13, as well as shots from last night Feb 10 -  I had a new experience last night where I woke up to the pressure literally blowing the mask off my face and causing major leakage. When I look at Oscar it seems like I had a sudden flow limitation causing a respiratory arousal, and the CPAP responded by increasing pressure pretty quickly and steadily until I woke up from the leak.
Overall when I look at the breaths zoomed in, it seems like my inhalations look sort of shallow?

Thank you again for your input! Going to go check out BoxCarPete's thread as per your suggestion.

[Sleeprider]

On Feb 9 the first event looks central as breathing diminished into a pause, but there is strong recovery breathing and some "loop gain" with periodic volume changes. The second CA event arises from an arousal with much deeper breathing, which fades in to the CA and and some more periodic breathing. The events on Feb 10 look very different with very high flow limitation at 03:39 and continuing through much of this period. Your full-night chart shows lots of flow limitation and your therapy is fractured by the high pressure where you pause therapy. Both nights are pressure 5-20 with EPR 2 and 15 minute ramp from 4-cm.

I think it would help to stabilize pressure if you increased the minimum pressure to 7.0 and capped the maximum pressure at 9.0 and used EPR 2. If you can tolerate it, turn off ramp. This will avoid the situation where pressure immediately increases above your comfort level in response to flow limits. It may avoid some obstructive breathing events that trigger the CA by causing some hyperventilation. As far as masks go, the N30i is similar to nasal pillows but cradles under the nose where slits admit the air. This kind of mask can shift off the nose easier than the nasal pillows which seal to the nostrils rather than rely on a seal on the outer nose. I don't know what your experience was with the N30i. The hybrid full-face seems like a good compromise. Do you feel you can get decent nasal airflow, or do you find a need to recruit some mouth breathing?

[sarahsleeps]

Thank you so much for looking at this! In terms of the mask, I started with the N30i but found that I wasn’t getting enough air flow through my nose and would need to take a deep breath quite often where I would instinctively open my mouth and then the whooshing would freak me out. With the hybrid mask, I will also take a deep mouth breath here and there while getting settled into the mask but it’s been much easier to get used to. I know I’m not getting good nasal airflow, but my body is definitely trying to nose breathe as much as possible in the machine. When not using cpap I often wake up with dry mouth telling me I was mouth breathing. Haven’t noticed that with the cpap.
I know I can change the settings myself but for now while I still have the cpap provider watching me so to speak I’ll call them tomorrow and ask to stabilize the pressure. Wondering if 9 is too low as the max? I see the 95th percentile creep up to 9.5 or 10 ish. I do think it makes sense that having a more stable pressure could help me stay in a stable sleep state.
Is there any other way to tell what’s actually causing the flow limitations? I don’t have any real major leakage I don’t think. Is it just the physical obstruction nasal or otherwise, and because it’s on auto 5-20 the cpap isn’t at pressure yet to prevent the obstruction? Am I understanding that correctly?

[Sleeprider]

It's often easier to ask for forgiveness than permission. Your provider cannot change your machine settings without an order or prescription from the doctor. The suggested settings are within the current prescription, and is a permutation that may relieve the specific problems mentioned. Settings can be changed like this: https://www.apneaboard.com/resmed-airsen...setup-info

[Jay51]

Sarah, before I had successful septoplasty and turbinate reduction surgery, I had similar problems that you are having at night with your pap therapy.  At times during the night, I would wake up and couldn't breathe at all out of my left nostril.  My lateral nasal side walls would collapse when I tried to breathe very deeply also (like you having narrow nasal passages).  I can say without a doubt, having the septoplasty and turbinate reduction surgery has made my pap (ventilator) therapy much more tolerable.  I struggled tremendously in the beginning, but sleep very well now.  I currently use a full face mask, but may try a hybrid with either a cradle top or nasal pillows top in the future because I can breathe out of my nose so much better now.  

It is 100% your decision what you plan to do after you see your ENT.   I just wanted to share my experience with you to hopefully make your pap therapy and pap experience better.  Keep following Sleeprider's suggestions also.

[sarahsleeps]

Oh I didn’t realize that, my prescription said to set at 5-20 and then change to the 95th percentile after a couple weeks. They’ve been really good about tweaking things for me, like adding and adjusting EPR and ramp at 4 when I was having trouble getting started (which I think I can remove now). I’m in Canada so not sure if it works any differently?
Thank you so much for your expertise, I can’t say how much I appreciate it!
Am I understanding the possible issue properly that flow limitations are being caused by whatever physical obstruction is present, and because I’m not set to a steady pressure the cpap isn’t quite responding in time?
Thanks again Sleeprider!