Increases in pressure not stopping OAs? Positional apnea?

[imtiqurr]

Hello everybody, 
I've started using OSCAR to optimise mine and my brother's CPAP settings because these last 3 months we were on the default range of 6.0cm to 18cm APAP which did nothing and we kept having events throughout the night. 

Although I've switched to a fixed pressure for both of us:
My brother is on: 11cm fixed with EPR of 1 on his Lowenstein Prisma SMART Max Auto CPAP Machine
I'm on a 10cm fixed with an EPR of 1 on my Philips Respironics DreamStation Auto CPAP Machine

Regardless, we are still having terrible sleep and waking up groggy every morning smh

My brothers daily data is below: 
   

Although I'm new to this forum, I'm assuming that he has positional apnea due to the cluster of events that he's having, he is wearing a mouth tape to keep his mouth shut. Should he look at getting a soft cervical collar or just to increase his pressure by another 1cm?

My data is below: 
   

I've increased my pressure and i'm still having OAs so I definitely don't know what's going on here, Should I increase again by another 1cm. There was one CA that occurred throughout the night.

Any advice would be appreciated.

[PeaceLoveAndPizza]

It appears he needs more inhale pressure to handle the OA/H events and lower exhale pressure for the flow limitations. 

How did you arrive at the current pressures you are both using? Doctor recommended, self-titration, or guessing? 

If not by titrating, I suggest giving that a try. Here is an example of the settings, but as you have two different devices this is a common language describing the changes.

Mode APAP
Min pressure 7
Max pressure 15
Pressure Support 2 (SoftPAP or Flex Level)
No ramp

Once you have a few nights you can decide whether to use the 95% as a CPAP fixed pressure, or possibly narrow the range for APAP mode to manage the pressure swings.

You may also just increase the pressure and pressure support for the current settings and see how it goes.

[imtiqurr]

Thank you so much for your reply. 

Well it really came out of the blue but I just thought we should start from a fixed pressure and work our way up, knowing that his OSA is a lot worse than mine I started us at 8cm (me) and 9cm (my brother) and just added 1cm as I saw the data these last 1-2 nights. Having a CPAP titration study is just too long and expensive for us so here I am self monitoring mine and his treatment. 


Although I don't mind APAP, I just find it to be hella annoying and tbh prefer the CPAP, is that an issue if i just increase by another 1cm?

Some questions I do have though:
What are flow limitations and how does EPR help to reduce them, I read about them on the apnea board wiki but still can't seem to grasp my head around what to do when you do see a flow limitation?
How long do you need to keep yourself on a certain pressure setting before you can make changes? 

I would also love if you could explain how you came to those conclusions, I'm learning a lot through this forum and one day would like to contribute as well so it's a good lesson for me as a beginner!

Again, thank you so much!

[PeaceLoveAndPizza]

Without knowing what you have already tried, it is impossible to guess what may or may not work. Starting from a good baseline helps with controlling the variables. You can do it with fixed pressure changing it and pressure support every few days, but it will take time to find what seems to work, for now at least. Your choice.

If you had issues with APAP it likely was either not quite properly configured or not explained well. Too often devices have default configurations with wide ranges and no fine-tuning, which leaves a negative impression of how APAP works. We typically start with a wider range, then narrow it down as more data becomes available from usage. Once the proper pressure and pressure support range is found, having max pressure a bit above the 95% seems to work. It gives the headroom needed.

What I see in the charts is that you both have some OA and H events at your current pressures. Your brother has many flow limitations (basically mini-apnoea not long enough to get counted), but you have none that are registering. I expect that if we would take it down to the individual waveforms you would see flattened peaks on the inspiration typical to FL’s. A bit more pressure and pressure support is warranted to my thinking.

Regarding how EPR helps flow limitations, I have no idea of the physiology of it all. Just that properly tuned pressure support reduces flow limitations, which smooths out the respiration and flow rate graph, and helps lead to better sleep.

[imtiqurr]

Thank you for your reply!

I do understand and I've noticed reading the forums that people with APAP who haven't configured their settings properly like my brother and I are stuck in a loop where everybody says that their data is perfect but in reality it's terrible haha!

I might keep it at CPAP at this stage just because we seem to find it more comforting, I suppose. 

I think I'm seeking to make these changes to both my brother and my machine: 
My brother 13cm fixed CPAP with 2cm EPR 
Myself 11cm fixed CPAP with 2cm EPR 
NO ramp on both. 

Hopefully I'll monitor these next few nights and seek to establish if this works. 

Thank you!

[quiescence at last]

I am noticing on your brother's chart that his tidal volume (depth of each breath) is wildly varying. Try to set the range of the flow graph to +80 and -80. Try to set the range on the Pressure graph of 0 to 14. Try to find a way to show a graph of flow limitations and echo off the limitations on the flow chart as it can obscure meaningful data. Try to get the pressure, flow, and other charts to be somewhere around 70 percent of the current height, so we can see all important factors on the snapshot. We may also be able to help if we get some close ups of problem areas, so see if you can zoom in on about 6 minute wide chart. We will ask for certain things as we progress.

You're doing great.

If either of you start feeling bloaty and burpy you may be ingesting the extra air, which is not very comfortable. It takes a little while to get used to higher pressures. 13cm might be high enough to really increase that effect, called aerophagia.

Error on a lower pressure if that occurs. Even though not ideal, it may be better to get less issues and a few extra apnea to get sleep that you need.

Good luck,

QAL

[imtiqurr]

Hey there!
Thank you for your reply! Highly appreciate it! 

I've tried to make the changes that you recommended for my OSCAR settings. I did some research and found out that flow limits are only applicable to APAP modes not CPAP. A fix I could do is seek to set my min and max at the same pressure on APAP to get the flow limitations chart if you reckon that would be helpful. 

   

That's what my new graphs are looking like, for some reason I could not change the tidal volume setting as seen in the screenshot. 

I've also attached below a 6 minute screenshot of where a hypopnea occurred. Looking at this, from my beginner observation, could this be due to the leak as seen below, or am I wrong?

   

"Error on a lower pressure if that occurs. Even though not ideal," are you advising that if my brother and I get too burpy we should seek to drop the pressure correct? 

Also please advise on how you came to the conclusions if you do come to any, I would love to learn off everybody in this forum and maybe seek to be as helpful as you guys are for me right now!

[quiescence at last]

yes. temporarily reducing pressure to minimize the aerophagia can be a good move. if you do, just keep a watchful eye on the number of OA and H as they might increase a little. It's a trade off. Having an OA increase from 0.11 to 1.0 and H from .76 to 2.0 may well be worth the reduction in discomfort.

QAL

[imtiqurr]

Hello Everybody! 
My brother and I slept with our new settings yesterday, and these is our results!

My brother: 
   

Now I understand that FL needs to be kept off to get a clearer picture. But there's two points as a beginner I want to get your advice on: 
First of all, looking at this data would it be recommended to increase the pressure on his machine to seek to lower the RERA's and flow limitations or move to an APAP range that may help? 
Second of all, after reading the wiki page on UARS is it that he may need to switch to a biPAP machine at this stage? As his flow limitations aren't getting any better 


Myself: 
   

My two points out of my data is that, there was too many leaks throughout the night for meaningful data to be produced, although it looks promising in the reduction of OAs correct? And that my sleep duration was too short again for data to be meaningful. 
Although some hypopneas are visible, maybe increasing by 1cm2 would be able to help? As I was on 12cm2 for last night. 

Please let me know your advice, and please explain how you got to those conclusions. I want to learn off everybody in this forum!

[quiescence at last]

what you suggested about showing the flow limitations on their own chart is definitely worth doing. so, you should go to APAP with min 13 max 13.

can you supply us a 10 minute close up of brothers chart the first 10 minutes of the night.

Thanks,

QAL