First week - One "good" night and waking up with mask off most nights

[ghost10]

Hi everyone. I'm new to this forum and I'm just starting CPAP therapy again. I have a few questions about my first week and would really be appreciative of any insights that might help me out or lead me in the right direction as I continue therapy. If helpful, I'm including a quick background for context below, but feel free to skip this section as well:

Background:
I'm 30 years old, relatively healthy/active but I've been struggling with sleep and breathing issues for the majority of my life. I have a history of nasal obstruction (severely deviated septum) which was operated on twice (Septoplasty) once in 2013 and then recently a revision this past July. Even after these surgeries, I'm still a bit unsure if my nasal obstruction issues have been fixed and still working with an ENT on this. Due to these nasal obstructions, I have a continued history of mouth breathing. I was first diagnosed with sleep apnea several years back - at that time I tried CPAP for about a year and was unable to make it work (unable to keep the mask on at night/a few other issues). I stopped for several years, but this week I am starting again as I believe these sleep/breathing issues are still really impacting me. This time around I am trying to take this all into my own hands and learn as much as I can and make adjustments on my own. I'm realizing there is a lot to learn but would really appreciate some insights from you all. I still have a valid prescription so I ordered a device on my own and have the ability to order any additional equipment/try new masks if needed.  

Equipment: 
ResMed AirSense 10 AutoSet
PAP Mode: APAP
Min 4.0 Max 20.0 (cmH2O)
F&P Vitera Full Face Mask

First week Dec 07 - Dec 13:

It's been about a week and I've had one "good" night (Dec 11th) and the rest I woke up waking up with mask off my face and on my bedside table without me remembering anything. For the Dec 11th night, I say "good" in quotes because I was able to keep on the mask most of the night and had 7 hours of therapy. I felt noticeably better the following day, but think there is still some room for improvement and want to reproduce these kind of nights more often.

The remaining nights during this week I did not get very many therapy hours (usually only 1-2.5 hours). The mornings following these nights, I woke up with the mask off of my face and on my bedside table with the machine off and no recollection of anything. I know this takes time and I'm committed to working though this but want to make sure I'm not missing anything as I get started again.

I'm attaching my OSCAR data for three nights, the "good" Dec 11th night and then the following 2 nights Dec 12, and Dec 13 which the mask was taken off. I'm new to OSCAR so please let me know if you need me to take screenshots of other sections/graphs.

My questions:

1. Is there any indications from the current OSCAR data that suggests why I would be taking the mask off? 
   
2. I noticed that my leak rate chart on my "good" night still had a number of spikes. Can a good night still have some leaking or should I be aiming for no leaks at all?
   
3. I think I may still be mouth breathing some subconsciously after I'm asleep, is that evident in the data? How can I tell? Any suggestions for solutions here?
   

I recognize this is early on still and the data as it stands might not be sufficient yet, but would really appreciate any insights that might be evident/early indications that I can make adjustments for. 

Thank you, and look forward to contributing to this community going forward.

[PeaceLoveAndPizza]

You are using the basic default setup with no customisations. We can help find a better setup for you.

Set it to a more reasonable setting of pressure range 7-12 EPR 1. That should help with comfort. 

You also have a rather high baseline leak, likely due to mask fit. Try watching some mask fit videos on YouTube by LankyLefty27 or Uncle Nicko of CPAP Reviews. That may help.

Give that a go and we can help tweak from there.

[ghost10]

Thanks for the reply. Mask seemed to fit ok without many noticeable leaks while I'm awake but not exactly sure what happens after I go to sleep -  I will check out the mask fit videos to see if I need to make any adjustments there.

In regard to switching pressure to 7-12 EPR 1, can you explain how you arrived at those numbers? I recognize now that default 4 - 20 is quite a large range and most likely not what I want, but not really sure how to understand what ranges I should be focused on. Is it just trial and error? Or is there a better way to understand where these ranges should be? Would love any insight/educational materials here.

In addition, on the better night I had the pressure was around 4 most of the night so should I be concerned about moving the min to 7 in that case? Is that where EPR comes into play?

[PeaceLoveAndPizza]

4 is too low for most adults for IPAP. For EPAP it’s okay, but a bit higher pressure will be not only more comfortable but will help control the events you are already seeing.

If you look at your OSCAR charts your median pressure is mid 4’s and 95% is more than 8. Picking a number higher for inhale (IPAP) than the 4 that is closer to 8 makes sense, then a bit of EPR to help make your exhale (EPAP) more comfortable.

I think your pressure is being held artificially low as you do not have a lot of flow limitations. Getting the pressure to a level that will handle the apnoeic events and will also help with the arousals I see in your flow rate is the goal.

[ghost10]

Ok thanks so much for the info here. I'm going to give 7-12 EPR 1 a try and report back.

[ghost10]

Reporting back after trying 7-12 EPR 1 last night and while I did keep the mask on most of the night I seemed to have a lot more events, specifically a lot more CA events. I also had some mild aerophagia. I'm attaching OSCAR data from last night. 

Should I keep trying at these settings? Any other insights? Leak rate seems decently high still even after making some adjustments. Do you think these are mouth breathing leaks?

[PeaceLoveAndPizza]

Thanks for giving that a go. You look to fall into the “low pressure, no EPR” category. 

I think the leaks are mask shifts. No worries as it takes time to find the sweet spot for a mask. Typically folks get them too tight, but you need to have them fairly loose to allow the cushions to inflate. Best to keep them loose, start the machine, then tighten them just enough to stop the leaks but remain comfortable.

I think there are two settings for you to consider trying. The first is a fixed 7, no EPR, no ramp. The second is a range of 7-10, no EPR, no ramp. 

The fixed may be best as there will be no pressure swings. The second may be more effective, but the pressure changes may impact sleep quality. The pressures may have to be moved up or down a wee bit from there, but it is a good place to start.

Personally, I would go with the fixed pressure first and see how it goes.

[ghost10]

Thank you I really appreciate it, I will definitely give a fixed 7 no EPR or Ramp a try and report back again. Can you tell me generally what causes some of these clear airway events? I've done some research which seems to suggest these are central apnea events but recognize sometimes the machines categorize these incorrectly.

[PeaceLoveAndPizza]

They are not true central apnoea events. They look to be from periodic limb movement, position shifting, or other external cause. 

You hold your breath, change position, get comfy, then breathe. The machine flags it as a CA. Depending on how it goes with the changes we may need to dig in further.

The CA’s at the end look to be more positional from a chin-tuck. They may need a soft cervical collar, flatter pillow, or other technique to mitigate them.

[ghost10]

Ok thanks for the info. I'll try the pressure changes first and we can dig in further after that.