Going in Circles; CPAP doesn't seem effective; ENT?

[RainyDog]

Greetings,
New to the forum. 
Got a diagnosis of moderate OSA in Jan. this year.  Machine turned off during time when I have most problems but they pasted my two segments together and went off that.  Thinking about doing Lofta to see what I get.

Started CPAP.   Setting recently adjusted to 6-12; EPR 2, Ramp 5 min.  Resmed 10;APAP full face; no humid.

Seemed like it was going really good at very first, get in 6 hours at a time but the pressure was too high and was adjusting back down fast enough.  It takes months to see Drs. here and I won't see my sleep guy until July and if things are still bad they go for full sleep study (more time).

Now I wake up every couple of hours; usually breathing hard. I have OSCAR and have been trying to use it and also been using SleepHQ free data analyzer.  I wish I could integrate the OSCAR, snore recorder and Garmin vitals.

The bulk of my events are CAs.  However I also snore; many times with mask; and snore recorder picks up my breathing sound getting quieter; little sips of air until the big gasp.  I noticed a strange phenomenon at the dentist that has gone on for years but didn't think much of.  When I'm reclined on my back in the chair I can breath in through my nose but not out sometimes.  I keep sipping in air but then finally have to relax myself to be able to breath out the mouth.  And my tongue is not pushed back; I'm pushing it forward  Don't know if relevant.

I've seen dentist who specializes in apnea and he indicated I have a very crowded airway and that CPAP can only do so much.  He's proposed a mouth appliance with CPAP to try to open things up.  A referral to a ENT and/or specialty surgeon was also strongly suggested. 

I think I'm going to lean on my PCP for a referral since the sleep dr. didn't think much of the large tonsils; however he did note a crowded airway.  He also wasn't aware of what OSCAR was.  Feel like I'm chasing my tail.

Dental will prob provide a little relief but worried about tmj stuff by doing that.  Surgery is a big mountain; don't know how to get there; CPAP isn't doing it. 

It has gotten worse since I moved.  Have been working with an allergist but he's pretty worthless.  I'm sure I've had apnea for a while and I think something is aggravating it to the point of arousal.

Something as simple as sleep; I miss it.  Don't which way to turn. Mind is gone; hours to write this.  I've been reading about OSCAR on the site and really appreciate people doing this because the docs don't tell you squat.

TLDR:  Struggling with CPAP; wondering about options

[Sleeprider]

Every dentist wants to sell a multi-thousand dollar appliance that you will need follow-up to keep adjusted. I am yet to see even one of them be effective. We can get you dialed in on CPAP, but be aware a lot of your events are central. That suggests therapy onset central apnea. We can minimize that that with some adjustments, but sometimes it takes a more advanced machine. First of all, when I look at your results, I see positional apnea from poor cervical alignment. These are the clusters of obstructive events, and it may also be some of the centrals being flagged. Read this wiki article and think about how you can correct the sleep positions or bedding that promote this obstruction, and what measures you might be able to take to protect your airway as you sleep https://www.apneaboard.com/wiki/index.ph...onal_Apnea If you want, I could show you the times you are in positional apnea, and there are a lot of them; for example, look at 4/10 from 23:45 to 01:40 with a brief respite at 00:25-01:00. Those flow limits are because you're choking yourself, and it's most likely positional, because your CPAP can stent your airway for anatomical obstruction. What your dentist is proposing is to do the same thing you can accomplish with a $20 or less soft cervical collar, but that won't put his first-born through college of give you a temporomadibular dysfunction.

For pressure, I want to raise your minimum pressure to 7.0 and turn off ramp. Your median pressure is between 8.0 and 9.0, so this is not an increase in pressure, but it should help calm the pressure changes you experience, and that can help a lot of problems. We're going to cap pressure at a maximum of 10.0. That will limit the pressure that is disrupting your sleep, and won't make any difference if you do your part to address positional apnea. I think most of your CA events are from the positional apnea when you have enough air passing through your airway to appear as an open airway apnea, but in reality, it's obstructive. So in summary for settings
Mode: Autoset Standard
Minimum Pressure: 7.0
Maximum Pressure: 10.0
EPR On, Full-time
EPR Setting 3.
And you have to do your part to be aware of your cervical alignment.

[RainyDog]

Thank you very much for the reply. Very kind. I've ordered a couple of collars to check sizing and am reading through the links. I do side sleep and often fetal.
What is treatment emergent central apnea? It shows up after treatment, is caused by treatment or both? I had a lot of centrals after I started.
I have so many questions but I don't want to overburden.
Excited to give the collar a try. I'm also very curious about this Palatal Collapse that I'm reading about in the wiki. It sounds somewhat similar to what I experience at the dentist, while awake and not being able to breath out nose even though its clear and I can breath in. The breathing graph during events looks kind of like the example of in nose out mouth. I hope its not palatal and its positional.
Actually I hope it all goes away tomorrow for everybody but you know.

[Sleeprider]

You have really launched into this and I hope we can make this a success. We have to tackle one problem at a time, with the first being the "chin-tuck" or positional issues. I have a theory your centrals are false-flags, and are the result of flow limitation. They may be taken care of when we deal with the positional obstruction. If not, we have other pathways. Palatal prolapse is a shunting of expiratory flow caused by collapse of the the soft vellum tissue at the anterior end of the palate. Again, we can identify it, but don't want to get ahead of ourselves. Your description of in nose and out mouth is pretty accurate, but we may resolve that with the higher EPR. Good luck, and give this a chance to really work.

[RainyDog]

Thank you; couple of collars arrive tomorrow.

[RainyDog]

Gave the collar a go overnight.  Was able to deal with it; a little warm.  Neck a touch stiff this am.

Adjusted pressure for night to 6-10; made more adjusts in am for practice run.  Had CA events even tho I'm pretty sure I was awake.  I'll check snore recorder.

Tons of events; AHI doubled; woke up a lot but don't recall being that out of breath for all of them.  One with night sweat. Had some issues with the tube but don't know what would make that graph blow up like that.  I started with nasal mask but switched back to full after couple hours.

I am now pretty conscious of the issue with my throat and nose where there are times I cannot breath out the nose even though I'm not congested.  It feels like tissue gets pushed a certain way if I exhale a certain way.  

I have been trying out a nasal mask and also pillows.  I like them; some tissue comfort issues; but big problem is when nose seals shut and forced to exhale out mouth.  I'm pretty sure I woke up with machine air in through nose and free flowing out mouth.  I switched back to the most reliable mask I have so far the F40.  The masks that work for me tend to push my jaw back; which I'm trying to avoid.

So strange night; going back to 6-12 and try to move more gradually to the values suggested.

I do like a 5 min ramp up but have read that many don't like that setting for therapy reasons, i.e. causes problems?

What triggers flow limit to increase?  I read that in addition to OA events pressure will increase based on flow limit triggers.  I see my pressure increasing without events.
I'm puzzled by some of the clear airway events; some hit when I was awake and testing things.  I breathe pretty slowly at night

So away we go; good day everyone.

           

[BoxcarPete]

If, even while awake, you are experiencing positional blockages despite the CPAP pressure, it is worth at least a consult with an ENT in my opinion. Prior to my nasal surgery and adenoidectomy, if I tucked my chin to my chest it was nearly impossible for me to inhale through my nose, though I could exhale almost normally. This is no longer the case for me; no matter how much I tuck my chin to my chest, I can still breathe almost normally. It sounds pretty likely to me that there is some kind of blockage in your airway that is not responding to CPAP, and it's also possible that the collar is providing support to this abnormality rather than its intended function of ensuring head and neck alignment to prevent it from occurring. A good otolaryngologist will be able to shove a camera up your nose and see what's going on in under a minute. Where you go from there is up to you and him or her.

[RainyDog]

Thanks for the response.  It's interesting I can put my chin to my chest easily without much airway distress.
Soft Palate collapse and floppy epiglottis are two than I'm curious about but I do think something is jacked up with my throat whatever it is.  Floppy tonsil?  The apnea dentist didn't seem like he was pushing the dental appliances very hard and admitted they will cause mouth problems.  He did some scans and my nose; when not running; is really good.  My throat sucks.  He basically told me your kind of f*cked with your airway and should go visit Stanford which is not too far.  He is of the opinion that alot of the osa we see today is a result of childhood orthodontia and teeth pulling and their affect on the jaw.  But I'm gonna keep trying.  haven't decided on neck cushion tonight.

[RainyDog]

Still having loads of CA's; mostly clustered.  Not sure what to do about collar; events doubled the 1 night I wore it.

Do medications have an effect on CA at all?  I do feel sometimes when I'm doing CPAP I have to "remember to breath"  
The air blowing in mouth kinds of messes with mind a bit.  I do hold my breath a lot during day as a reaction to stress and hunger.

When I first started therapy my numbers were good. a few CA's here and there.  Now its CA city.

I sometimes wonder if my pillow is too soft.  I can only handle down; everything else is too firm but I have to really scrunch it up to get good support.  I tried layers without raising my head.  I dunno; feel like I've wasted 6 months when a full study should have been done.
Thank you.

[Sleeprider]

I use a medium fill down pillow and if things get tough, I pull a corner between my shoulder and jaw. What I see is the events are triggered by flow limits. Might be time to upgrade to bilevel.