New APAP user need help interpret chart

[farmdog]

Background: 
Long history of snoring and occasional wake ups out of breath. Quit a sleep study early a few years ago. Recent few months suddenly worsening sleep. Waking up many times a night, usually gasping but not always. Feeling like I'm not breathing as I'm about to fall asleep, usually something in my throat clicking shut, and so suddenly having to inhale hard instead of falling asleep. Did a home sleep study, got a prescription. Study numbers were low I think because the doc assumed all the data was asleep, when in fact maybe half the data was actually sleep time, the rest was trying to sleep and waking up at the moment I'm about to fall asleep because I couldn't breathe. 

Current:
So first night on Airsense 10 I slept 4 straight hours. Chart seems to show the machine did what it was supposed to. Fair enough.

Second night, not sure...

For both charts, I could not fall asleep the first several times I tried, so I turned the machine on and off as I got up to use the bathroom or what not. I also have problems falling back asleep in the early mornings. So, the only actual sleep periods are in the middle. 

My concern is night two, where it looks like pressures hit and sustained my max setting of 10 several times, with matching spikes in flow limit. Hypopneas and an RERA flagged during these times. I woke up every single time, but managed to get back to sleep not long after. 

(Question 1: Is waking up every time the pressure boosts common for first time users as they get used to CPAP?) 

Question 2: Seeing night 2 with the pressure maxing out this many times, would it make sense to go ahead and bump up the max to 11 for tonight? 

Night 1 (good): 
   

Night 2 (?):
   
--
Airsense 10
Setting 4.2-10
Nasal mask

[OpalRose]

Welcome to Apnea Board!

The reason your pressure is bumping to the maximum is due to Flow Limitations. So it makes sense that you would wake up. Flow Limitations are helped by using EPR.

The use of EPR (Expiratory Pressure Relief) not only helps lower Flow Limitations, Hypopnea and Reras, but enables you to exhale against the pressure easier.

It makes little sense to raise the max pressure until you control the Flow Limitations, because the algorithm will automatically cause pressure to raise when it detects FL.

To receive the full use of EPR, you will need to use a minimum pressure of 6cm for now.
We may need to go up to 7cm, but let's start there.

Set EPR to 2 (full time).

Note: When posting charts, it's important for us to see the entire left sidebar along with all the statistics. Thanks.

Consider the changes above and repost in a day or two.

[farmdog]

Welcome to Apnea Board!

The reason your pressure is bumping to the maximum is due to Flow Limitations. So it makes sense that you would wake up.  Flow Limitations are helped by using EPR.

The use of EPR (Expiratory Pressure Relief) not only helps lower Flow Limitations, Hypopnea and Reras, but enables you to exhale against the pressure easier.  

It makes little sense to raise the max pressure until you control the Flow Limitations, because the algorithm will automatically cause pressure to raise when it detects FL.

To receive the full use of EPR, you will need to use a minimum pressure of 6cm for now.
We may need to go up to 7cm, but let's start there.

Set EPR to 2 (full time).

Note:  When posting charts, it's important for us to see the entire left sidebar along with all the statistics.  Thanks.  

Consider the changes above and repost in a day or two.

Many thanks. Will include the left column going forward. 

A couple follow up questions...

Would slight nasal congestion that switches between nostrils a few times an hour and a mild deviated septum be a factor in the flow limitations? 

Also, on night two, quite a few times on night two I woke up to my cheeks puffing out and air suddenly shooting out of the corners of my mouth, after which I'd close my mouth and try to sleep again. Eventually I did get up and tape my mouth shut. Would these events have fooled the machine into thinking I was inhaling successfully when in fact maybe my tongue was blocking my airway and the air was just getting redirected out of my mouth?

EDIT: Added snapshot of zoomed in flow rate during period of high flow limit. Looks like flow is being limited during inhale mostly? Does that mean anything? Thanks again.
   

[jwest]

We always want to be breathing through our nose. The mouth is the emergency hatch. In no way is the mouth more efficient at breathing. The soft-tissue lining on our turbinates naturally cycles through engorged and flaccid states, but if the congestion is being caused by allergens, other reasons, or if you just have underdeveloped nasal passages, then, yes, that could be an issue. In addition, a deviated septum could also be compromising your nasal airway, but it's whether the combination of different nasal structures is a problem versus just one thing, if that makes sense. You could try using nasal decongestants for a few nights (careful with these. Tolerance builds fast and causes a rebound effect, so they're for testing/emergency purposes only), nasal dilators, breathe-right strips, and so on.

Either your mouth is dropping open during REM when we have accessory muscle paralysis or you're opening your mouth to breathe when your nose isn't doing a good enough job/airway is obstructed. Did the taping make a difference? No, those events would show leak. This is all assuming you're wearing a nasal mask as noted in your bio.

To the flowrate, yes, those are blunted breaths. The top is flat, indicating you inspire to a certain extent and then obstruction prevents you from completing the breath = flow limitation. Use EPR to resolve these. Is it on?

[farmdog]

Welcome to Apnea Board!

The reason your pressure is bumping to the maximum is due to Flow Limitations. So it makes sense that you would wake up.  Flow Limitations are helped by using EPR.

The use of EPR (Expiratory Pressure Relief) not only helps lower Flow Limitations, Hypopnea and Reras, but enables you to exhale against the pressure easier.  

It makes little sense to raise the max pressure until you control the Flow Limitations, because the algorithm will automatically cause pressure to raise when it detects FL.

To receive the full use of EPR, you will need to use a minimum pressure of 6cm for now.
We may need to go up to 7cm, but let's start there.

Set EPR to 2 (full time).

Note:  When posting charts, it's important for us to see the entire left sidebar along with all the statistics.  Thanks.  

Consider the changes above and repost in a day or two.

The Chipmunk Cheek, Leaking Balloon Phenomenon
So what has happened on nights 2 and now night 3 is this: I wake up with the machine at full force and my cheeks puffed out like a chipmunk and then the tape peels back and CPAP air starts forcing out from both corners of my mouth like a deflating balloon. Why the air is not going down to my lungs, or if my lungs are already full, I don't know, but the source of the air really seems to be the machine, not an exhale. Maybe tongue is blocking air passage and thus air is rerouting out of my mouth? I think I'll need to order a full face mask. 


New Phenomenon: Air Pushing Into the Stomach
Waking up at full pressure and feeling like air is getting pushed down into my stomach instead of my lungs, or perhaps both. First time happening. 


Night 3 Overall 
In terms of settings, I initially upped minimum to 6, kept max 10, EPR 2. (Never used EPR before this.) Bumped up the humidity from 1 to 2. Woke up a few times with the chipmunk balloon leak phenomenon mentioned above, as well as the air pushing to the stomach. First wake up was around 12:30am, then a few more times after that, until waking up around 4am or so and I couldn't fall asleep again but felt somewhat rested. At some point in the night after enough chipmunk balloon episodes I did try changing the minimum to 5 and EPR 1. Don't think it made much difference. I put it back to minimum 6 EPR2. Beside that, there was a burst of snoring (I didn't see any snoring on nights 1 and 2, or anywhere else on night 3) around 1:40am lasting about 20 minutes. Only correlation I see is pressure being maxed out for an extended period. Also, I see a couple CAs, one of them being 23 seconds long. Does that seem alarming? 


I think I'll try another couple nights with the EPR at 2 (minimum at 6) and see how it goes, but would appreciate any advice on how to avoid the chipmunk cheek balloon episodes as well as the air getting pushed toward the stomach. (Though I'll take either of those over of waking up gasping for air three times a night like I used to.)

   

[staceyburke]

Your pressures are going up because of flow limits. Flow limits are obstructive apnea just like Oa and H events are. You need to use EPR to help with the flow limits. I would use Min 7 EPR set to FULL TIME 3