Fine tune APAP for possible UARS

[tenebrae]

Hi all, hope you're keeping (and sleeping) well. I've been a reader of the forum for a little while now but I'm at the point where I think I need some specific advice.

I've had sleep issues 2-3 years now but only been on APAP 6 months. I've stuck to it consistently with AHI between 0 and 2, sleeping 7+ hours a night, but still fatigued. I'm in my mid 20s and not overweight, but had a deviated septum I think might have been contributing. I did a home WatchPAT sleep study for my diagnosis and scored AHI of 6/hr but RDI of 22/hour, so I'm wondering now if it's UARS issues.

I had a septoplasty 2 months ago after having not being able to breath through my nose. It's still tender but mostly healed and I can breathe through it now. I've switched to the nasal mask the last week. I finally had a night without major leaks or abnormally high AHI so I thought I could post it here and maybe someone could give me advice on fine tuning to improve things, or can tell me where my issues are and why I'm not improving.

Before I used the default APAP settings, Autoset, 4-20 pressure, Full face mask, no ramp or EPR. I was waking up congested so turned up the humidity and tube temperature to max and that helped. To accommodate the FFM I switched from front to side sleeping and sleep on my side every night now.

When I switched to the nasal mask I tried some of the advice I read here about max and min pressures and adjusted the minimum to 8 and max to 15 based on my 95% pressures. I also saw some advice about EPR helping with UARS so set it to 3.

My apneas are generally 75% hypopneas and 25% clear airway with the FFM and standard settings, but this last night with the UARS specific settings they were all CA. My ENT said there was a chance I may not need the APAP after the septoplasty so I'm wondering if the APAP could be inducing CA and making my sleep worse than no machine. It's hard to tell since my machine doesn't detect RERAs and RDI. I slept with no machine the other day and didn't feel much different, but it's hard to tell without sleeping many nights with or without. I wanted to ask here first anyway.

Thanks in advance for any information anyone can give me, I really appreciate this site as a resource. I've attached my graphs, let me know if I need to reformat them. The snore graph had no data so I haven't included it. I also included a typical night from when I was using the FFM for comparison.
   
   

[gainerfull]

Welcome to the board - looks like you're moving in the right direction with a bump in the minimum pressure. Optimally you'd only want to see minimal flow limits every 90 mins or so (during REM) so I'd even recommend bumping your minimum to 9. Is there a reason why you chose a nasal mask? Do you have the machine set to the nasal mask setting? It may make sense to pick up a Resmed F20 as your nose continues to heal from the septoplasty to allow you to breathe through your mouth at night. Depending on your face it can also be easier to control leaks.

Overall, you're doing well so far but have some work to do with leaks, especially large leaks (the grayed out areas in the leak chart). Are you taping your mouth? Have you considered picking up a blood oxygen monitor as an aid in tuning your device? Optimally you'd keep your blood oxygen above 92% all night.

[tenebrae]

Hi, thanks for the reply. And thanks for the tip about flow limits, I haven't looked at them much before but looking back over my data it looks like I've been having them constantly every night. I'll bump up the minimum to 9 and see if it helps.

I actually have a Resmed F20 that I used up until the septoplasty since I couldn't breathe through my nose before. The earlier chart is from when I was using the FFM and the later one is with the nasal mask. I've had the machine on the appropriate nasal/FFM settings. I read that mouth breathing can lead to less refreshing sleep so I hoped a nasal mask would fix my issues. I didn't have any pain or much congestion from the operation anymore so I decided to try and switch. Although I have been getting some pain again from the nasal mask so I think I'll switch back to the F20 for a while at least. I also never had any large leaks with the F20. I've been taping my mouth since I switched to the nasal mask but it has tended to get wet and fall off. I'm still experimenting to get it to stay on.

During my sleep study my blood oxygen dropped to 83 at the lowest so I was considering getting a monitor as a possible next step to figure out why I wasn't improving. It might be good as well if I need a way to talk to my doctor about switching to BiPAP or other treatment if I can't get the APAP to work for me. I can look on the forum for recommendations.

[Jay51]

Here are some tips from our Wiki on stopping leaks:  Mask Primer

I also had a septoplasty (and turbinate reduction).  Better breathing.  I have seen a few charts here where CA's increase after this type of surgery because of increased ventilation from the better breathing.  This caused more CO2 washouts; which caused more CA's. 

You have very few CA's in your charts.  You don't need to worry about them unless they become more frequent than this.

[tenebrae]

Thank you, glad to hear. I was just concerned because when I first went on APAP I had a lot of CAs in the first week, I was worried the machine was inducing them. Once I got used to the treatment they went away though

[gainerfull]

If your mouth tape is falling off you'd likely need to set your humidity lower on your cpap.

[tenebrae]

I only started to mouth tape when I switched to the nasal mask, the tape is just getting wet from my breath and saliva. Although come to think of it maybe I'm inhaling humid air through my nose then exhaling out of my mouth so my breath is more humid, and this makes the tape too wet. I'll definitely try it and see

[tenebrae]

Hey again, I've been following some of the advice in this thread and trying things so I'm back for some more advice.

After the tip about the flow limits, I started researching on the forum about them and saw some advice about flow limits being clustered implies they are positional, i. e. you roll onto your back and start getting flow limits. Looking back at some of my data, I thought mine might be clustered. However, I had trouble fully fixing these with raises in minimum pressure.

I remembered my doctor saying he thought my apnea might be caused by my jaw falling back and closing my airway. I didn't think much of it at the time, but I started looking into it more. I saw some people advised trying a soft cervical collar for this, and ordered one to try. And I would say it was an improvement. I could see on my flow limit charts that there were fewer flow limit clusters, and I could feel in the morning some difference. Also my AHI became consistently lower, like less than 1, but this has never correlated to feeling better for me. However, I'd say I don't feel fully treated and the effect is inconsistent. I have occasional nights where I wake up feeling good but these are not the norm. I wake up 1-3 times a night. I can still see flow limit clusters on my chart as well, so the collar is not 100% effective.

My doctor gave me a prescription for a mandibular advancement device (MAD) as a less intrusive alternative to APAP, but I was reluctant to pursue it because my APAP wasn't satisfying me and I read that the MAD is less effective, so I didn't see the point before I figured out APAP. Now however I wonder if it would actually be better in my case if it is in fact my jaw causing my issue. Would anyone have experience of this, MAD working when APAP/CPAP didn't?

I've attached my data from last night which is fairly typical from the past 3-4 weeks. I wonder if the frequency of clusters correlates to feeling better, as in each cluster is an interruption of good sleep so the fewer clusters then the longer the stretches of good sleep I get.

It might be months before I could get a MAD so I'd appreciate any advice for what I could do in the mean time. I mouth taped for a while but didn't notice much difference, and I tried changing my minimum pressure and EPR settings, but raising the minimum didn't seem to have much effect on flow limits. One thing I thought of trying was some crazy high pressure like 15 but I'm worried about just inducing more apneas.

[DaveSkvn]

Hi tenebrae,

Once upon a time I had a MAD made. To cut a long story short, how far forward your jaw can travel determines its effectiveness. If you can jut your jaw forward more than say 1cm+/half an inch+ then it may make a difference. If, like me, your jaw doesn't have much travel then it won't make much difference. The rest of your teeth have to hold the force of your jaw trying to get back into its old position so the more you stretch to make it as effective as possible the more painful / uncomfortable the device is in use.

Could you upload an Oscar screenshot that includes your respiratory rate graph? It was the key visibility for my UARS-ey like breathing.

Also have you by any chance had your tonsils out?

[ChadBSr]

If tape isn't working you can try a MouthShield or somnoseal