[Treatment] Difficulty with TECSA and Hypopneas

[jjl468]

Hello!

I've been on CPAP since the beginning of May, and after working through some issues with mouth leaks, it's definitely helping a bit with my sleep, but I still feel quite tired and fatigued.  My AHI has historically been between 1.5 and 3 and was on a general trend of improving but has been hovering just above 3 for the last week or so I was hoping to see if you guys see anything I should change or if I should trust the process and continue on as-is. While these numbers sound fine, or even good, the majority of my events happen in the second half of the night, so my AHI is great for the first half of the night but then jumps around between 5-10 for the second half.

My main issues are with CAs and hypopneas, which seemingly have contradicting solutions as hypopneas are improved by increased EPR and pressure, both of which also exacerbate CAs. I've noticed in my OSCAR graphs that my CAs do mostly occur during periods of high pressure, but my hypopneas still continue throughout those times as well, as do flow limits. I've tried turning EPR on/off but it doesn't seem to have a notable impact on my sleep, but I've also only tried messing with it for a few days at a time.

I've attached the 3 most recent nights of OSCAR data in this post, with EPR off last night and being on 2 full-time for the others. I'd say these have been well-representative of my sleep lately except that my leak rate was slightly higher than normal last night than it usually is. Finally, I've also seen a lot of talk about PLM on other threads, but I do not see any such data in my sleep study results, which were recorded with a ResMed ApneaLink Air, but I would definitely say that I do move around a decent amount in my sleep.

Thanks in advance and please let me know if there's any other information I can provide that may be helpful!

---

Adding OSCAR data for my 2 best nights of sleep in case that's useful, with very low CAs despite EPR being on.

[Gideon]

Welcome to the forum.

For now let's leave EPR off.
FYI your min pressure should never be lower than 4 + EPR so you can receive the full therapeutic benefit of the EPR in treating hypopneas and flow limits. Additionally I generally like to see it a bit higher, say 6 for now as I think you will fel more comfortable there and to reduce your pressure fluctuations which may, not will, increase central apnea.

Additionally for the most part your centrals are occuring in the higher part of your pressure range so I want to cut your max back to 8. This also narrows your pressure range providing less room to fluctuate which also can, not will, increase centrals .

So for now
Kep EPR off
Min=6
Max=8

Then post the results.

[jjl468]

Thanks for the warm welcome and the solid advice, Gideon! You seem to be extremely knowledgeable (and that may be an understatement) based on the other threads I skimmed through so grateful that you took the time to look through my data. I went ahead and plugged those settings into my machine and well let you guys know how it went in a few days!

[jjl468]

Hey everyone, I have an update but it unfortunately isn't a good one.

The first night I tried Gideon's recommended settings, my numbers were fairly normal, but every night after that, I've had an AHI at or just below 5 and I'm not really sure what may have caused that. I've attached my OSCAR graphs below for these nights with the exception of 6/23, for which my data wasn't recorded onto my SD card for some reason. I also turned EPR back on at 1 starting the night of 6/23 for comfort reasons as I experienced aerophagia and found it difficult to exhale with it off.

Does anyone have any recommendations on what to do here? I doubt that such a small change in my settings could result in such a massive shift in my AHI, especially since the first night was fine, but I'm not sure where I can make changes to help this elsewhere. My mask (P10) has also felt like the fit has been degrading lately as I woke up at least 3 or 4 times to the noise of a minor leak last night, but that may just be because my headstrap is loosening, so I tightened it a bit more and will see if that improves things tonight.

[jjl468]

Another update, with better news this time:

Not sure what caused the few nights of 5 AHI, but I think that my body just has very high variance in terms of AHI and it's now bouncing around between 1-3. I decided to go back to my originally prescribed machine settings as I haven't had my initial follow-up with my sleep doctor yet and she said that she would like me to maintain those settings until then to make sure she has enough data to go off of. I also decided to turn on my heated tube as I was getting congested every now and then, which has pretty much gone away since turning on the heated tube. I've noticed that on my good AHI days, the the flow limits isn't notably better between them and my ratio of CAs to hypopneas remains steady, but leak rate is really low and all events just go down evenly.

Will continue as-is for now and hope my body continues to acclimate while waiting for my follow-up with my sleep doctor but also included OSCAR graphs for my best AHI day in the last week and my 2 most recent nights for those curious.

[jjl468]

Hey everyone, since my last update I've switched to a fixed CPAP pressure of 8 and have turned off EPR. I do think that this has helped improve my sleep, but it's still not quite where I would like it to be. My AHI has generally hovered in the high 1's or low 2's, with some days having more CAs and others having more hypopneas. However, when looking at my OSCAR data, I find a lot of what seem to be unreported RERAs based on a pattern of repeated multi-peak or flat-top inspirations followed by a large, sharp inhale. Additionally, when looking at my CAs, they all seem to be preceded by an unreported RERA, so I think my CAs are actually just from me waking up from an RERA and just holding my breath as I turn and fall back asleep.

Based on this, I think that increasing my pressure would help and I plan on increasing my pressure to 9 tonight and will look for similar trends tomorrow and will continue to increase the pressure if necessary. However, I wanted to sanity check myself here as the machine isn't reporting any RERAs and I'm not very familiar with reading detailed flow rate graphs. I've attached a screenshot of the overview of last night's data along with an example of a machine-reported hypopnea, a machine-reported CA with a preceding RERA, and a few examples of unreported RERAs. Any insights or thoughts would be appreciated, thanks in advance!

[jjl468]

Increased pressure to 9 last night and still seeing multiple RERAs in my flow rate charts so will bump up again to 10 tonight. Subjectively, I slept pretty poorly last night and my AHI (2.98) was a bit higher than normal but I had quite a few nightmares which woke me up and mouth leaks were out of control. I doubt those would be caused by the machines so I'm just gonna brush them off as a random bad night of sleep and will continue with this experiment.

[jjl468]

Last night was much better, mouth leaks were still a bit out of control but my AHI was still just 1 with only 2 CAs all night. My Oura Ring has also previously reported a few breathing disturbances every night that lined up with OSCAR events but last night it did not detect any. I know the Oura Ring is far from a scientifically validated medical device but it's still one of the best objective tools I have about what my SpO2 did overnight and I'll take this as a good sign. Subjectively, I still feel quite tired today but I also got an hour less sleep than I would normally like.

I still see a few cases of flow limitations so I will bump up my pressure slightly to 10.4 tonight and repeat the process. I don't want to keep spamming this forum so I'll just continue this pattern for a bit and will report back after a few more days.