CPAP issues after tonsillectomy + septoplasty

[bloom25]

Hi everyone. My first post here, glad to be part of the forum 

A little background: 32/M. I was diagnosed with severe sleep apnea in February, and since then, I’ve been using a CPAP (Airsense 10). The CPAP helped a lot – I was waking up feeling refreshed most mornings. But, my ENT mentioned that I was a good candidate for a tonsillectomy and septoplasty because I had a deviated septum, large tonsils, and seemingly no other risk factors for sleep apnea. He said that there was a good chance I wouldn’t have to use the CPAP anymore (at least for a few years) if I had the surgery, so I went ahead with the surgery 5 weeks ago.

The jury’s still out about whether the surgery has helped – after several nights that I’ve tried sleeping without a CPAP, I’ve woken up fatigued. My doc said that it takes a few months for the inflammation and swelling to go down before we can fully evaluate whether it’s alleviated the apnea, so I’m just giving that time. 

In the meantime, I’ve gone back to using the CPAP in the last couple of weeks. When I first began using it again, I had 5 nights in a row of great sleep! But, since then, I’ve felt refreshed after only about 2 nights out of the last 10 – on the rest of the days, I’ve felt very fatigued and low energy. I’m puzzled as to why some nights I wake up refreshed and other nights not.

I’ve attached my Oscar data from two consecutive nights. The night of August 11th, I apparently slept well – I felt great the next day. The night of August 12th, I apparently didn’t sleep well – I felt fatigued the next day. I’ve tried to keep as many of the variables (mask fit, chin strap, etc.) the same as possible.

If it helps, I can also post my Oscar data from some nights before I had the surgery done. I'm not experienced with Oscar at all, but the one thing that stands out is that the 95% pressure seems to have gone down significantly since the surgery: from around 12 before to around 8 now.

Would greatly appreciate your perspective and feedback.

[bloom25]

Not sure why it didn't upload the August 12th data, but here it is, as well.

[bloom25]

Updating this with some more data.

Over the last few weeks I’ve been trying some new settings (turning ramp off and increasing min pressure to 6). I also switched to a full face mask due to comfort issues with the nasal mask.

I’ve had some really good nights where I wake up feeling refreshed, but these good nights continue to be frustratingly inconsistent. I’ll feel well-rested one day, and then the very next day, I’ll feel very fatigued. The only pattern that I’ve been able to decipher is that I’m more likely to sleep well if I slept poorly the night before, and vice-versa! 

I’m attaching my Oscar data from 6 nights, 3 of them “good” nights and 3 of them “bad” nights (based on how I felt the next day). Does anyone have any insight into what might be happening?

8/27 (good night)
8/28 (bad night)
8/29 (good night)

9/8 (bad night - tried a nasal mask again)
9/9 (good night)
9/10 (bad night)

The only thing I notice is that there’s occasionally a larger mask leak (e.g., on 8/27 and 8/28). But what’s strange to me is that sometimes with those larger leaks, I still sleep well (as on 8/27) but then on some nights with little mask leak (e.g., 9/8 and 9/10), I don’t.

Thanks for any input. 

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These are the next three nights.

[bloom25]

Hi everyone. 

The inconsistent nights have continued, so I got another sleep study done a couple of months ago to try to understand what’s happening.

I’m linking the original sleep study (from February 2nd of 2023) as well as the newest one (from November 27 of 2023). Both of them were split studies. 

First sleep study: https://drive.google.com/file/d/1b1R0Hla...sp=sharing

Second sleep study: https://drive.google.com/file/d/1bDEophl...sp=sharing

The studies are in Spanish, but the charts on the last three pages of each study should be clear regardless of language.

To briefly summarize, I was diagnosed with sleep apnea in the original study with an AHI of 34.1.

Based on that first study, the sleep clinic recommended that I use a CPAP. Due to enlarged tonsils and a deviated septum – as well as seemingly no other risk factors for the apnea – the clinic also thought I may be a good candidate for a surgical intervention, and recommended that I consult with an ENT.

I decided to go with the CPAP therapy first, and I used a ResMed 10 and n20 mask for several months afterwards. The CPAP therapy was pretty effective – with it, I was sleeping well about 80-90% of the nights. 

However, I eventually decided to consult with the ENT due to the 10-20% of the nights that weren’t restful and due to the original recommendation of the clinic. The ENT who I saw agreed that I’d be a good candidate for the surgery, so I had the tonsillectomy, UPPP, and deviated septum surgery done in July of 2023.

After waiting a few months for the inflammation of the surgery to go down, I tried sleeping without the CPAP. I did this for 41 days. Out of those 41 days, I felt well-rested on 19 of them… so about 46% of the time. I also tried going back to the CPAP, but it wasn’t providing anywhere near the same relief as before the surgery. (My earlier posts in this thread documented those attempts.)

After consulting with the ENT who performed the surgery as well as another ENT, I decided to get another sleep study done to try to understand what was happening. I got this second sleep study done on Nov 27th. 

This second study showed a reduction in AHI to 9.8. The doctor told me that the surgery had successfully reduced the AHI significantly, but that I should still use the CPAP given that 9.8 still puts me in the range of mild sleep apnea. The clinic recommended using either a fixed pressure of 7 or an automatic pressure range of 4min-9max.

Since the time of that study, I’ve tried both of these recommendations. After trying the fixed pressure of 7 for 13 days, I felt well-rested on 5 of the days… so 38% of the time.

Over the last 17 days, I’ve tried the variable pressure of 4min-9max. It seems that I’ve had better results with this, because I’ve felt well-rested on 11 of the days… 65% of the time.

Still, the effectiveness of the CPAP now seems much-reduced compared to before the surgery, and I’m confused as to why. 

When I look at the sleep studies, a few things stand out to me:

• In the original sleep study, after they put the CPAP on me midway through the study, the “sleep efficiency” (“eficiencia del sueño”) was 94.7%. This is on page 6 of the PDF. 
  

In the second sleep study, after they put the CPAP on me, the “sleep efficiency” was 83.6%. This is on page 5 of the PDF.

At least to my untrained eye, this seems to support what I’ve noticed subjectively, which is that the CPAP was more effective before the surgery than after the surgery. 

• In the original sleep study, I didn’t have any central apneas.
  

In the second sleep study, I had 2 central apneas before being put on the CPAP, and then 10 after being put on the CPAP. (The doctor suggested that this is treatment-emergent, given that most of the central apneas occurred during CPAP usage. Still, it’s curious to me that I didn’t have any similar central apneas in the first study.) 

This can be seen in the graphs on the final page of each sleep study.

• In the first study, I had a periodic limb movement index of 0.
  

In the second study, I had a period limb movement index of 2.8.

This can be seen on page 2 of each PDF.

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Based on these results, does anyone have any insights into what might be going on? And particularly, why the CPAP doesn’t seem to be as effective post-surgery as pre-surgery? At this point, I would be completely happy to go back to the CPAP if it were to provide me the same type of relief it was providing before the surgery.

My only hunch at this point is that I may need to keep increasing the pressure maximum on my CPAP machine. Even though the CPAP therapy still feels very inconsistent, it seemed to help going from a fixed pressure of 7 to a variable pressure of 4-9.

Any thoughts are very much appreciated. 

[bloom25]

For Oscar data, here are a couple of nights from me using the CPAP on a fixed pressure of 7, post-surgery. One of the nights (Dec 22nd) was "good" and restful, the other (Dec 23rd) wasn't.

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And then here are two nights with the apap 4-9 settings, post-surgery. Again, one of the nights (Jan 14th) is "good" and restful, the other (Jan 15th) isn't.

[BoxcarPete]

Are you using the same machine with the same settings? Your OSCAR charts from August and September show EPR and few flow limitations, while your latest charts show more FL throughout the night and EPR not activated. The FL you see on Jan 14 and 15 can contribute to less restful sleep independently of AHI.

That said, I'm sorry to hear that your surgery hasn't helped you much. Deviated septum is run-of-the-mill for any ENT and correcting it generally improves airflow through the nose, but does not necessarily solve apnea problems. It can really help with CPAP tolerance for those who struggle to use a nasal mask. Tonsils can certainly contribute to blockage as well, though I have not experienced that since I was 8 years old. I had my tonsils and adenoids out and it changed my life. Just last week I had another surgery to correct my own septum deviation along with turbinate reduction and adenoid removal (again).

Sorry if you don't care about hearing my surgical history, but I typed it out to let you know that I've had some of those same procedures done myself and they are (for 20 years and so far, respectively), working well for me. UPPP is much more controversial, being higher risk and lower reward. I would not personally have considered that particular procedure unless I had tried absolutely everything else already.

The good news is that you may still have some options on where to go from here. There are palatal expanders that can widen the hard palate to adjust the soft palate behind it, though I don't know if your prior procedures might contraindicate you for that, along with other things that can be done. Sleep position can be another major player, not just your body position, but your neck alignment from pillows and mattress firmness as well. There is some reason your airway is blocked, and if you keep looking you're likely to find it.

Best of luck!

[bloom25]

Hi BoxcarPete, 

Thanks a lot for the perspective. 

Just to clarify, the August and September charts reflect the therapy after the surgery (which was in July). I’m attaching a few charts before the surgery to compare as well – each of those charts reflects nights with refreshing sleep.

I’m using the same machine (Resmed 10), and after the surgery I initially kept the settings the same (EPR on, APAP mode, and an n20 mask). After weeks of feeling really lousy with those settings, though, I began to experiment and found that I now sleep somewhat better with a full face mask, for whatever reason. I also turned EPR off, thinking that it might be contributing to central apneas.

Your observation about flow limitations is interesting. I didn’t know anything about FL (still learning the ins-and-outs of Oscar), but I’ve now read up on them and it seems like the general approach to address FL is to increase EPR. And in fact, when I look at my past Oscar data, there’s clearly a drop in FL when the EPR is turned on compared to when it’s turned off. So that seems like a good variable to experiment with next. 

Glad to hear that your surgeries have worked well for you, including after 20 years. I definitely feel that I breathe much clearer through my nose now, which is nice for exercise and such. And other than the CPAP difficulties, I haven’t had any negative lasting side effects from the procedures. The ENT who I saw for a second opinion after the surgery examined the outcome and said that everything looked to be done very well, so that was reassuring. 

As far as next steps, I’m going to try upping my pressure for a week so that it’s at 4-12. If that doesn’t help, I’ll try turning on EPR again to see if that helps with the flow limitations that you pointed out.

As far as the CPAP alternatives route, I’m also thinking of exploring mandibular advancement devices. Given that the AHI is now in the mild apnea range, maybe that’ll be a more relevant intervention.

[BoxcarPete]

Did you use a FFM much at all before the surgery?

What I meant by the comment about 20 years is that from age 8-28 I slept well, but as I got up to my 30s I had problems again. So, if this latest procedure buys me 10 years off PAP, I'll consider it a smashing success. I'm glad the second opinion from your other doctor was that the surgeries did in fact come out well.

Min pressure is typically more important than max pressure. I would not set it any lower than 8 if I were you, maybe closer to 9.

MAD isn't something that will work for everyone. I used one for a year based on the algorithm of OSA treatment we have here in the states: start him on CPAP, if he doesn't like it, make him an MAD. If that destroys his jaw, tell him he didn't try hard enough to make CPAP work! It somewhat alleviated my issues (snoring and daytime tiredness), but others cropped up in the meantime (hypertension and minor cardiac rhythm disturbances which I cannot prove were related to the MAD but appeared shortly after I started using it and mostly resolved when I stopped). The more I used it, the more my jaw moved out of place. This lowered the efficacy of the device, causing me to continue to advance it so that I could keep some of the good effects, and worsened my bite and jaw alignment further. Be cautious with that line of treatment. I would go down that path only if I were scoped while laying on my back and the doc confirms a significant positional benefit with minimal jaw adjustment.

Now that I've scared you away from the MAD, I found it much more tolerable than CPAP after a few weeks of getting used to it and it's much more convenient, especially for travel.

[bloom25]

I tried using a FFM a few times before the surgery, but I always found that the nasal mask worked better for me. After the surgery, that seems to have reversed, for whatever reason. It’s been a few months since I’ve tried the nasal mask with my pre-surgery CPAP settings, though, so I’m going to try those “OG” settings again for a few days. At least it’ll help to compare apples to apples. 

And that makes sense, about your surgery. Hopefully it does provide you with several solid years without the CPAP. That was how my surgery was originally framed to me, as well – not as a permanent solution, but as something that could buy me a few years off CPAP.

As far as the MAD, I’ll keep that advice to be cautious in mind. When you talk about being scoped, are you referring to having a sleep endoscopy done? And, irrespective of exploring the MAD route, do you think that getting a sleep endoscopy is a reasonable next step to consider, in terms of trying to diagnose the underlying airway blockage? 

[Sleeprider]

Blom25, after looking at a number of your results, I think your settings would be optimized in Autoset Standard mode, at minimum pressure 8.0, maximum pressure 12.0 and EPR full-time at setting 3. If you could give that a try and give some feedback on how it feels, that would help. I missed this thread when you started it back in August, and I'm sorry you didn't get more help early on. I assume you have now recovered from surgery. While tonsillectomy often relieves flow limitation and can reduce obstructive apnea, there are other factors at play in sleep apnea that makes surgery unlikely to be a cure, but it can certainly help. I don't think a mandibular advancement device is helpful to many people, however we have seen a lot of "positional apnea" on this forum that is relieved by changing the sleeping position, pillows and even a soft cervical collar. https://www.apneaboard.com/wiki/index.ph...onal_Apnea