Help with Ed's Therapy

[Grateful Ed]

Hi everyone, Ed here. I've been browsing the forums for a while, and seeing all the great assistance that is provided. I’m hoping you can help with my therapy.

I have severe OSA (AHI=80) and have been on CPAP for about a year. From January to July of this year I was using min/max pressure settings of 8/15. In July, I had a titration study done, which recommended very similar pressures (8/14), which I have been using since. I use a nasal pillow mask with mouth taping and a soft cervical collar, and have EPR set to 3.

Based on my numbers, my therapy seems successful. Over the past six months, my average AHI is 1. My 95% flow limits seem reasonable to me (0.02 average) and with the mouth taping/collar I think I have the leaks under control most nights.

Despite the numbers, I’ve had what I consider only a partial clinical response. My symptoms have improved somewhat on therapy, but my sleep is still very fragmented, with frequent awakenings after an initial 1-3 hours. I still often struggle to stay awake during low energy activities, particularly in the evenings. I feel like I've come only part of the way, and want to further improve the quality of my life.

At this point my sleep doctor is useless. Since my AHI is less than 5, she has declared that my OSA is well controlled and that any further sleep issues are caused by insomnia, and has no interest in treating me further. While I’m open to considering that I have two separate sleep disorders, I’m think it’s more likely that my CPAP therapy is still not optimized. I’m looking for guidance around modification to my settings to improve my sleep quality and wakefulness. I’m hoping that I can be helped as many others have been on this forum.

I’ve attached several recent Oscar charts for review. One (Oct 7) is from a “bad” night, two are from “average/good” nights (Oct 11 and 12). One chart (Oct 12) also includes SPO2 data that I collected from my Contec pulse oximeter. I don’t tend to wear the oximeter very often (I find it uncomfortable), but these results are fairly typical. It shows about 20 desaturations per hour, although there is almost no time below 88%. The software that comes with the Contec device reports only 7 desaturations/hr, using the 4% drop criteria. I’m not sure what to make of these numbers, and whether I should be concerned about the number of desaturations or whether it's more important that my O2 level doesn't drop below a threshold for very long. My sleep specialist wouldn’t opine on this subject, instead gravitating back to the fact that my AHI is good so I’m fine.

I’m looking forward to any suggestions the community might have.

Thanks
Ed.

[Deborah K.]

Your charts look good.  I wonder if you are one of those who find their sleep disturbed by pressure changes.  I suggest you set your pressures at 9-11.  See if that helps you sleep and feel better.  If not someone here will likely have another suggestion.

Again, welcome, and good luck!  

[Phaleronic]

Welcome to the forum Grateful Ed!

I'd change min pressure to 7.8cm and max pressure to 12cm and turn EPR down to 1 please, this should help your CAs a bit and let you regain some apnea control as you do not need to have EPR @ 3 at this time.

[Grateful Ed]

Thanks Deborah K and Phaleronic for the advice.

Last night I changed my min to 7.8 and max to 12, with EPR 1. I could definitely feel the effect of lowering the EPR - it was slightly uncomfortable, but I'm sure I can get used to it. My AHI looked great (0.14) but my flow limits (0.05) were on the high side of what I typically experience. My Oscar chart is attached.

Unfortunately my sleep quality didn't improve. I woke up twice in the first in the first three hours, but did manage to get about three hours straight from about 3:30am. I woke up tired, as per usual. I'll see how the day goes. I appreciate that there is going to be variability in sleep quality from night to night, so I'll stick with these settings for a bit and see how it plays out.

Ed.

[Deborah K.]

I would put the EPR back at 3.  It's not just more comfortable, it helps lower flow limits which are short, unreported apneas.  Lowering EPR can lower CAs a little, but I think controlling the flow limits is more important than the slightly higher AHI.

[Grateful Ed]

Thanks Deborah.

I did a second night at the new settings (7.8/12, EPR 3) and it went much like the first one: Good numbers (see attached) but poor sleep quality and sleepiness the following day.

I have a couple of questions:

1. Roughly how long should I try out new settings for before moving on and making further adjustments? Is it reasonable to expect that clinical symptoms will improve on the first night of changing settings, or does it take longer? I'm concerned that since I need to optimize based on how I feel rather than my numbers, there might be a lot of night to night variability that has nothing to do with my pressures. I'd be interested to hear what others have experienced.
   
2. I understand how narrowing the pressure range (you suggested 9-11 instead of 8-14) will reduce pressure changes, but I don't understand the logic in reducing the maximum pressure value. If at some point I'm experiencing apneas or flow limits that are driving pressures higher than 11, and I'm maxed out, won't that just lead to an arousal and disrupted sleep? Intuitively it seems better to me to just raise the minimum and allow the machine to move to higher pressures if required. Of course by that logic everyone should just leave their max pressure at 20 and let the machine do its work, which clearly people don't do. So I think I am missing something here, I'd love some clarification.
   

Thanks
Ed.

[Deborah K.]

If you are not sleeping any better try my suggestion. Then you can compare.

[Grateful Ed]

I tried it last night, with pressures 9-11, EPR 3. The data look good, but my sleep was still poor. Multiple awakenings, though I managed to get maybe three straight hours. I was tired today. So overall not much difference in symptoms, although I did find the the EPR 3 to be more comfortable.

I'll give it another few nights and see how I feel.

Ed.

[Expat31]

Hi,

I have just come across your graphs and found something very familiar to me personally, great AHi numbers but still poor quality sleep, for no apparent reason.

What I suggest is set your minimum pressure up further to say 10, which should hopefully smooth out constant  pressure changes provokimg arousals.

The second benefit may be that there could be some undetected micro events that you are currently ultra sensitive to, and these could be taken care of by this further increase in pressure.

It could be worth a try at 10 to see what happens.

Concerning your graphs, you don't need the snore graph, or the tidal volume, however the respiration graph may help, just to check for any hyperventilation.

[Grateful Ed]

Thanks Expat31.

Data are included from last night, with the respiration rate graph. I'm not sure if there is anything unusual there. As with the previous night, my AHI and flow limits look good but still had disrupted sleep.

I'm happy to try bumping the minimum pressure to 10. Do you think I should still keep the max at 11, or increase it a bit?

Ed.