Ineffective therapy or something else

[sleeplessinky]

Hi all.

I received my sleep test because of some severe insomnia and poor sleep quality with what little sleep I was getting. I was diagnosed with OSA with an AHI of 75 and given a resmed air sense 11 cpap. A year and a half later I'm still having the same issues despite a very low ahi, in fact the fatigue has greatly worsened recently. I have insomnia most nights and very fragmented sleep. A "good" night of sleep for me is 6 hours with around 4 conscious wake ups. I am looking for advice on my therapy to try to determine if ineffective cpap could be the issue or to press my doctors about other medical issues that could be causing my severe fatigue. My original therapy was set at 8-16 with an epr of 2. I did notice my flow limits looked high so after browsing threads here about flow limits i adjusted my pressure to 12-18 and set the epr at 3. I am including screenshots of a "good" session of therapy from before I adjusted the settings, last night's therapy where I fell asleep for 1+ hours initially and then around 3.5 to 4 hours before I woke up and couldn't fall back asleep, and two close ups of the 2 flow rate patterns I see most often at times when I am fairly sure I was asleep. 

 [attachment=60712].       .     

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here is the second flow rate close up

   

[sleeplessinky]

messed up the screenshot from last night so adding here
   

[Plmnb]

Hi.  You might want to read my thread entitled: Plmnb's New Therapy ResMed AirCurve 10 ST-A

It is very long but at the end I have been referred to Mayo Clinic.  Praying they can help me.

I wish you the best with your own journey and hope your situation does not turn out as complicated.  I have been off and on therapy since 2003.

[BoxcarPete]

First, let me say that your chart doesn't look horrible, but there is definitely smoke there if you're feeling poorly and lots of room for improvement.

Looks to me like you have two primary options to work on your sleep quality from here. Most likely to be recommended here is a bilevel machine to add some more pressure support to aid in smoothing out your flow rates and eliminating the FLs that are plaguing your nights. Option two is to go see an ENT and have your airway evaluated for any obvious obstructions that can be dealt with one way or another.

How you proceed will depend on your age, general health, and personal philosophy. I went with surgery because I'm still relatively young and there were three things that could all get cleared up at once, on both sides of the nose, so the risk/reward was highly in my favor. The idea of a lifetime of mechanical ventilation assistance (above and beyond PAP) didn't sit well with me in comparison.

Best of luck to you.

[OpalRose]

Hi sleeplessinky,

The pressure increase from 8-16 to 12-18 with EPR 3 was a move in the right direction.
You were able to bring the 95% flow limitations down from .19 to .02.

High FL can cause many sleep arousals, some which you are not aware of.  
This may be why you're so exhausted during the day.  Not saying that's all of it, but does play a big part.

Your leak rate is a bit high, enough to also cause sleep disruptions.  How do you feel your mask fits?  Have you replaced the mask or cushions lately?  

Read through the Mask Primer as you may find some hints on mask fit.

[sleeplessinky]

Thanks Pete

If I am interpreting this right my flow limit patterns show some level of resistance/obstruction, correct? When I look though my flow rates I frequently see what looks to be several instances where it looks like an obstructive even too short to register as an OA event on the machine and they are not flagged as hypopnea either. I also see brief changes in breathing that are not flagged as arousals but appear to be affecting my "flow in" to me. I've wondered if these short obstructions/events are resulting in arousals that are not being flagged by the machine. I do feel like there is some structural issues affecting my breathing even when awake, especially through my nose. Luckily I saw a new primary care provider yesterday and she is trying to get me referred to a sleep specialist and ent. May I ask what procedures you ended up having and how your recovery went?

[sleeplessinky]

Thanks for the response opalrose

I actually thought I had my mask leak under control as at one point it averaged in the mid teens. It may be time for me to try a different mask. I have to wear a full face due to mouth breathing. I really wanted to use a nasal pillow mask and I have tried several nights to use one with a chinstrap but oddly enough the nasal mask makes me feel like I am suffocating. 

My mouth breathing seems to cause issues even with the full face mask. I've noticed in certain positions, especially on my back, my jaw will kind of fall away from the mask, causing periodic leaks from the corner of my mouth. I "fixed" this by tightening the mask quite a bit. I wonder if it would be better to try a cervical collar so I could loosen the mask without leaking from the corner of my mouth?

[BoxcarPete]

Yes, flow limits are typically associated with partial obstructive blockages of airflow.

My procedure was, as I noted above, something of a "slam dunk" for surgery. The ENT noted problems with the septum on both sides, with a deviation to the left and a bone spur protruding to the right. Turbinate hypertrophy present on both sides as well, with the inferior turbinate extending further back in the nasal cavity than normal. Those issues are both common enough, but the kicker was adenoid tissue occupying 50-70% of my nasopharynx. After tonsillectomy and adenoidectomy at age 8, having such large adenoids as an adult has an occurrence rate of about 1% according to my doctor. That's the part of the procedure that I am certain made it all worthwhile, so if it's just the other stuff your mileage may vary. I still think it's worth getting looked at, because you never know what's up there till it gets checked.