Dialing in first-time therapy

[rfburns]

So I raised pressure to 10.0, EPR set to off. Was pretty uncomfortable exhaling against the pressure after having EPR on for the entirety of the time I've been on CPAP, but I eventually fell asleep. Since ResMed splits sessions at 12 noon, I've attached two screenshots.

   

   

The large leak frequency in the second screenshot is something I've seen for the very first time - I remember waking up in my sleep to notice that I could hear snoring, and that I was breathing through my mouth. This hasn't happened before, perhaps it's a response to the increased effort of exhaling against the pressure?

I do normally have a habit of mouth breathing without CPAP, but didn't have any events for the past month or so of using just a nasal pillow mask, no tape or cervical collar, with a pressure of 9 and EPR set to 1. I wouldn't have cottonmouth when I woke up, either.

As you've both remarked, though, it might just be very early on in my therapy, and I might just have to ride the centrals out if they're treatment-emergent.

[Ratchick]

OK so as a preliminary, it looks like perhaps turning the EPR off actually worsened the flow limits in the second chart AND your centrals are up a little too, as well as the hypopneas. My initial feeling from that snapshot would be that the EPR maybe wasn't the cause of the centrals. The increase in pressure, however, seems to have worsened things all around.

The trouble is, centrals are SO contrary. The only thing they are consistently is inconsistent. One night I might have a CAI of 9 or 10, and the next night, I might be having a CAI of 30+ (damn, I want an ASV soon). It could, potentially, be that this is normal variation for you, or it could be that the increased pressure has caused the increased centrals too.

How are you feeling in yourself today? If you are feeling drastically worse, then it might be preferable to return to your previous settings, otherwise, maybe try them for a second night at least, and see how it goes with the centrals particularly.

I'm guessing that those big leaks were all mouth leaks rather than from the nasal pillows? It's possible that the higher pressure was just enough to pop your mouth open, which would then make the CPAP ineffective. And that was probably why you were snoring along. That alone would tempt me to drop down again to 9 unless you see some very clear improvements soon at these settings.

[rfburns]

Took your advice and dialed down the pressure. I did, actually, wake up with some sleep inertia and a mild headache with the pressure set to 10 and EPR off. It seems like your hypothesis about the increased pressure popping my mouth open and contributing to the large leak and snoring was correct, although I must note that one night is hardly a representative sample.

Set pressure to 9.4, EPR set to 1 and had a nice nap this afternoon, shown in the screenshot below, but then took my mask off and slept for another 1.5 hours after my alarm. Woke up feeling refreshed afterwards, however. That's something I do from time to time; I'd like to know if there's anything I can do to stop taking my mask off and having another kip.

   

Otherwise, any feedback on the results? Really appreciate the advice and analysis. My current plan is to try these settings out for a week or more and see if the CA/H events show up again, in which case I might increase pressure one click at a time (9.4 -> 9.6 -> 9.8 -> 10.0) and keep my EPR set to 1. I understand it works as a very low-level BiPAP, but I find exhaling against the reduced pressure very comfortable, even if it does potentially decrease the bearing life of the blower from ramping up and down all night - at least I'm maintaining upper airway patency with an EPAP of >=8.4. My PSG noted "moderate, intermittent snoring" at a fixed pressure (IPAP=EPAP) of 8.0 cmH₂O, which is why I'm assuming my consulting doctor gave me an Rx of 8.0 - 9.0 cmH₂O.

[Ratchick]

Honestly, that looks pretty good to me. You've found a pressure that seems to be comfortable with minimal events, so yes, stay where you are for a while and see how you feel. A week is a good plan, especially as centrals can be so tricksy.

As for stopping taking your mask off - if it's a case of you taking your mask off while you're conscious of it, but then immediately falling asleep again, then I would suggest changing your habits. Make sure you sit up and on the edge of the bed or whatnot to make sure that you're physically awake before you stop the machine and take your mask off. That might give you enough time for your sleepy brain to treat it as a "this is time to move" rather than "this is just a quick thing and then back to sleep".

If you're taking it off while you're not consciously aware of it or mostly asleep and you don't always realise you've done so, then there are ways. You can make it more difficult to turn the machine off (maybe put it out of reach or in a drawer or somewhere you can't reach from bed). If you still take the mask off even with the machine running, you can do things to make it more tricky to get the mask off. Some people use bobby pins to help keep the straps against their hair, or using safety pins to make it harder to take off straps. Basically, anything that would mean you can't just slip it off easily. It's a little harder with the magnetic clasps but if you made it difficult enough, it might just wake you enough to put it back on again, even if it doesn't stop you trying to take it off completely.

[SarcasticDave94]

I have heard of a few tape the mask to their face, for the reason of preventing mask removal not leak control. Others wear mittens, again to attempt preventing grabbing and taking masks off.

[rfburns]

So it's been a little more than a month since I last posted, and I went through with my original plan of dialing up pressure up until 10. Haven't had much improvement, honestly - I'm waking up with AHIs all over the place, some good, some sub-optimal. I'm using the hypoallergenic filter (lots of dust due to pollution in the area) and the ClimateLineAir tube now as well.

My main observation is that I'm waking up with a splitting headache every day for the past week. It seems to clear up within two hours of me being awake, but it's a genuine state of confusion, irritation and lethargy up until then. Don't know what's going on. The one part of my sleep hygiene (arguably the most critical) that I have to work on is sleeping at the same time with regularity.

Here's a look at the last two months. Throughout this time, I've tweaked pressure between 9 and 10 and had EPR set to 1.

   

And here's last night's results.

   

Edit: It seems that while I accurately described my mood, I didn't look at any of the upsides I've experienced thanks to all of your advice! But I guess that's the nature of having a headache first thing in the morning...

My AHI has consistently been <3.5 since I raised my pressures, and the ClimateLineAir tube makes me feel a lot more comfortable, with less congestion and dry mouth when I wake up (uses up a lot more water from the humidifier with Climate Control set to Auto, too.)
I seem to be taking the mask off less now, but I haven't taken any measures to do so. Perhaps I just got used to it, even though I did take it off last night, wake up and put it back on - and this seems to happen pretty much every night.
And my centrals have been, well, consistently inconsistent.

[rfburns]

So I upped my pressure to 11 cmH₂O (EPR 1) on 8/11 because I was continuing to have a restless night's sleep, waking up several times during the night and in the early hours of the morning.

The worst thing so far has been a terrible, dull headache lasting about 10 minutes after I wake up. I almost don't even want to wake up, since I always feel like I haven't had enough sleep.

Here are OSCAR results for this Monday and the past Wednesday, which seemed to have a lot of events.

       

What am I doing wrong? Mask fit seems okay, I'm comfortable when I'm drifting off to sleep, couple large leaks from moving around in bed (trying out different pillows to see which one is most comfortable; no luck so far) but nothing that looks too bad to me. Is my pressure too high? I fear that I'm going too far beyond my prescribed pressure of 8-9 cmH₂O.

[SarcasticDave94]

You sleep for 13 hours and 19 minutes and you feel like you didn't sleep long enough? Sleeping too long can be an issue itself.

Lots of CA here, this indicates an issue. From your original post to now the Centrals increased 3x. up from 2.x to 6.x. as shown in August 18th chart.

You also have a high consistent leak at about 16. You need to address this. It could be the mask itself isn't correctly fitting, straps are too loose or too tight, maybe it's the wrong mask. Or it might be a consistent mouth leak. With a pillows mask, this mouth leak gets my vote. Most of your PAP therapy is leaked away.

[rfburns]

You sleep for 13 hours and 19 minutes and you feel like you didn't sleep long enough? Sleeping too long can be an issue itself.

Lots of CA here, this indicates an issue. From your original post to now the Centrals increased 3x. up from 2.x to 6.x. as shown in August 18th chart.

You also have a high consistent leak at about 16. You need to address this. It could be the mask itself isn't correctly fitting, straps are too loose or too tight, maybe it's the wrong mask. Or it might be a consistent mouth leak. With a pillows mask, this mouth leak gets my vote. Most of your PAP therapy is leaked away.

Yes, that's exactly what I felt like. I aim for ~7.5 hours, but if I'm waking up with a terrible headache and sleep inertia and (seem to) need more sleep, the sleep I am getting is likely suboptimal.

Thank you for bringing my attention to the leak, I hadn't noticed that before at all. You're on the money about it being a mouth leak, I often wake to a sense of air rushing into my cheeks or out of my mouth.

Fortunately, these problems seem to have been solved! I dropped my pressure to 10 cmH₂O (EPR 1) and found a cervical support pillow that I am absolutely enamored with. The night I got it, my AHI was ~1.8 IIRC, and my last two nights were both 0.5 AHI. I also no longer have a headache.

I had long suspected my bed posture and pillow type had something to do with it, and after seeing the results, it turns out I may not be predisposed towards side-sleeping as I had thought. I wake up lying on my back just like I'd gone to sleep, which I find quite interesting. Perhaps I was tossing and turning, experiencing arousals and ending up on my side because I just didn't have enough support during the night.

I'll keep this up for a few weeks and report back. A nice, consistent therapy each night would be fantastic to see.