Flow Rate Interpretation and PAP Mode / Pressure Settings Suggestions

[ABC1234]

Hi everyone,

Hope all is well. First-time poster here. I’m a 34-year-old male, about 5 feet 8 inches tall and weighing approximately 150 pounds.

I’ve been using a CPAP machine since 2018, when I took a WatchPAT test that showed an excessive number of arousals / high RDI (upper airway resistance syndrome) even though I think my AHI was normal or close-to-normal. I was prescribed an AirSense 10 AutoSet machine auto-set at 5 – 15 cm H2O, although the pressure rarely if ever went above 6 cm H2O. I felt a lot better as I woke up feeling more refreshed and had more energy during the day.

Fast forward to this year, when I had COVID in February and then a septorhinoplasty in May to correct a badly broken nose / deviated septum. I felt like I had recovered from the fatigue, non-refreshing sleep, and “brain fog” (not feeling as sharp mentally) from COVID by the time I went in for the surgery, but they seemed to emerge again after my surgery.

So about a month ago I took a WatchPAT home sleep apnea test to rule out any sleep issues. To my surprise, the test showed an RDI of 14.7 (per hour) even though I was using my CPAP machine. Interestingly, the RDI was only 7.1 for the two hours I spent sleeping on my left side. The test recorded an hourly RDI of 14.7 but my CPAP machine only listed a total of 22 events for the whole night (about two-thirds of which were RERAs). Similarly, the WatchPAT test showed an AHI of 4.2 whereas the machine reported an AHI of only 0.99.

Following the WatchPAT test I began looking back at the data on my SD card for the first time. I noticed a fairly clear doubling in the average flow limitation and pressure (from 6 to about 12 cm H2O) the machine was recording when I looked at the periods before and after my May nose surgery.

I then bought a new AirSense 11 machine auto-set at a broader pressure range of 4 – 20 cm H2O (based on the recommendation of the doctor who reviewed my WatchPAT results). But when I looked at the data on my SD card I noticed there were still a lot of flow limitation events on the AirSense 11 (and it was already set to what I believe is the maximum pressure at 20 cm H2O). So I wanted to try a bilevel machine to see if the pressure support made me feel better.

For about the past 10 nights I’ve been using an AirCurve 10 VAuto machine in VPAPauto mode. My current settings are:

·        PS: 4 cm H2O
·        Minimum EPAP: 6 cm H2O
·        Maximum IPAP: 15 cm H2O
·        TiMax: 3 seconds
·        TiMin: 0.3 seconds
·        Trigger: High
·        Cycle: Medium

The first night I used bilevel I woke up feeling a lot better and noticed that the flow limitation was back to what it looked like before my surgery. But I still wake up feeling somewhat tired sometimes (which never used to happen before COVID / my surgery) and continue to have some “mental fuzziness” at times during the day.

I’ve tried slightly increasing the pressure support and maximum IPAP but I’m not sure it made me feel any better (and possibly worse). Last night I also changed the trigger from “medium” to “high” but it’s unclear to me if it made any difference.

I’m using an AirFit F20 full-face mask, having previously worn the similar Quattro Air mask. I also wear a mouthguard (having clenched my teeth during sleep in the past) and use mouth tape as I’ve noticed my AHI is lower when I tape my mouth.

I should note that I’m trying to take care of any other possible causes for the fatigue / mental fuzziness – I have a good diet and have been able to start exercising again recently after COVID and my procedure took me out of action for a while. To the extent I’m still having lingering COVID symptoms or nose swelling those should both (hopefully) continue to fade with time.

There’s a few other things I’ve been considering trying to help optimize my treatment:
·        Losing even just a little bit of weight
·        Sleeping with a soft cervical collar / neck support
·        Philips NightBalance sleep apnea therapy (or otherwise just using a larger body pillow to try to get myself to sleep on my side)
·        ExciteOSA

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Does anyone have any recommendations or thoughts on my PAP therapy based on looking at my data (see attached)? I’m particularly interested in what my flow rate graph shows to a knowledgeable eye and whether the breathing patterns are normal or possibly still show some flow resistance or other abnormalities (possibly missed by the machine?).

My sleep SpO2 (I have a pulse oximeter I can wear when sleeping) seems to be fairly stable, although there was one event last night where it dropped down into the low 90s (it went as low as 90 during my WatchPAT test). More of concern, though, is that I see looking at last night that my pulse rate spiked from the baseline nearly 20 times or so.

I did have a recent appointment at my sleep doctor’s office but I’m pretty sure they’re not looking at the same detailed charts and data I am – they seem to be open to whatever makes me feel like I’m getting better sleep given that my AHI has almost always been normal whether on APAP or bilevel (even though we know my issue is the RDI rather than AHI and that the machines apparently undercount events as compared to the WatchPAT).

I have another WatchPAT test I can use but I don’t want to do so until I feel like I have my therapy optimized in terms of mode (APAP v. bilevel), pressure, etc.

Thanks so much in advance for any insights or suggestions.

[ABC1234]

Hi,

It seems my screenshot didn't post - please see attached for that.

[gainerfull]

Your current settings look like they're providing good support. How did you feel after this night? Surprised to see so much snoring recorded - this is typically solved by more IPAP but going beyond PS 4.0 often leads to tons of central apneas.

Our setups are similar and what I found that has helped me the most is taking a minor sedative at night which increases my arousal threshold and allows for REM to be more consolidated. The supplements are called apigenin & magnesium glycinate. The apigenin is the active ingredient in chamomile and I take 50-100mg per night and wake up feeling incredible.

[ABC1234]

Thanks gainerfull, this is helpful! I did notice more central apneas when I increased the pressure support above 4. I'll look into the supplements too.