Still exhausted after 8mo of CPAP -- is oral appliance better for me?

[mcrick]

Hi all,

I have an untreated AHI of 10.0, diagnosis of mild OSA, no major health issues (only thing is low ferratin levels which I am taking iron supplements for), and have been on CPAP for about 8 months now. I am a healthy young male in 20s at a healthy weight and physically active. I use the ClimateLine tubing with the airsense 11. I wear a P30i large pillow.

Despite my machine's reported AHI being around or under 1.0 most nights, I have generally been sleeping pretty poorly. In particular, I am conciously waking up 1-2x per night, and experiencing eye twitches, dry eye, brain fog, memory loss, speech issues, and fatigue throughout the day. I feel exhausted every morning and never wake feeling rested or restored.

I have tried many different settings on my CPAP with no clear improvements from any. When I increase pressure too much, I get minor issues with aerophagia. Below are links to various settings and results:

APAP, 7.6-10, EPR 3
https://sleephq.com/public/ca64e888-c626...451b08d676
https://sleephq.com/public/e1036edf-d924...5980c0651e
https://sleephq.com/public/f39947c5-466c...240293c5c5
https://sleephq.com/public/2a724f38-f046...7ebdf53682
https://sleephq.com/public/9a05e83a-1e00...ba58a42c2e

APAP, 9-10, EPR 3
https://sleephq.com/public/840717bf-1bff...19341d87f6

CPAP, 10, EPR 3
https://sleephq.com/public/5def8a63-2cb3...a0c38a1faa
https://sleephq.com/public/588015d1-e155...b031c32180
https://sleephq.com/public/857aca80-7572...fceb78d421
https://sleephq.com/public/5fbaf3b7-7f13...163dc4752c

CPAP, 11.2, EPR 3
https://sleephq.com/public/c9a91b43-54d9...5ef16f9d88

CPAP, 11, EPR 3
https://sleephq.com/public/9667828e-83f7...a4b6bf9ae6
https://sleephq.com/public/d55fb2a1-0492...ba73c42b8f

APAP, 6-10, EPR off
https://sleephq.com/public/19801ed3-0b36...43f0d85fd7
https://sleephq.com/public/3ac99e98-bbd8...d209d49c36
https://sleephq.com/public/7f42e8f5-185c...51738949de
https://sleephq.com/public/ca8d5ec2-2f68...1e2ed5aa3c

APAP, 8-12, EPR 2
https://sleephq.com/public/59e58b27-e618...0b26942520
https://sleephq.com/public/5140eaf6-203f...71f0f85c57
https://sleephq.com/public/159a447b-c739...de225d1260

APAP, 8.6-12, EPR 2
https://sleephq.com/public/766d5ea3-a550...fd8a4afb34
https://sleephq.com/public/43d9f1c0-0d65...d05ab5ba07

APAP, 9-12, EPR 1
https://sleephq.com/public/5efafbc9-1c87...3a40b01b17
https://sleephq.com/public/a5300580-3730...842d8928a9
https://sleephq.com/public/70bb0020-83a3...d510720375

APAP, 9-13, EPR 1
https://sleephq.com/public/446d1657-c00b...28276881c2
https://sleephq.com/public/2575c4fc-e1a1...6b644f0fbf

My graphs don't seem to look that bad but I am concerned about the symptoms. I have tried mouth taping but it does not seem to help, even though from my data, it seems like this event sequence happens a fair amount:
1) flow limitation causing decrease in tidal volume
2) leak occurs, maybe(?) from my mouth opening to take in air since my volume has decreased
3) apnea event and arousal

If it's relevant, I sometimes wake up with nasal congestion, dryness, and inflammation (my nose looks swollen and larger in the morning). My humidity is as high as possible without causing rainout. I had a functional septorhinoplasty in January 2023 to resolve a deviated septum and enlarged turbinates, so my nose breathing is very good generally, though often dry. Sometimes my mouth is dry when I wake up too.

I have seen two dentists who suggest I have a narrow palette and large tongue which cause my disordered sleep breathing. My Mallampati score is Class IV (or even worse). They of course want me to buy their oral appliances (a MAD plus a retainer I'd wear for 10mins the morning after to hopefully prevent shifting of my teeth). Their rationale: though my sleep apnea is being treated well by CPAP (as evidenced by the AHI reduction), CPAP is just not working for me and my body, as evidenced by my symptoms. They think that CPAP should not have been prescribed to me because mine is mild and I am a skinny guy, and they think the oral appliance will similarly treat the apnea but in a less intrusive way that my body will tolerate much better.

I understand there are concerns/risks with MAD and messing up my jaw alignment. I have a very slight overbite so I actually wouldn't mind a slight shift of the lower jaw forward over time. I also think this downside could be worth proper sleep breathing, but I am open to people's thoughts here.

My question to the board given all this context: would an oral appliance really be the next best step to try? Am I being duped? What other treatment options do I have?
Note that I have tried sleep drugs (trazodone, gabapentin, lunesta) and wakefulness drugs (modafanil) without success.

My sleep doctor has no idea what to do with me because they see good looking data from the CPAP and assume I should be feeling great.

Any help would mean the world.

Misc: I follow healthy bedtime habits, eat healthy, don't drink/smoke, am in therapy, hydrate well, take magnesium and vitamins, bedroom is cool, dark, quiet, etc etc.

Also, here are much more details from my sleep study... note that most of the night was on my back as instructed, though I still had (fewer) events on my side. At home I always sleep on my side.

https://imgur.com/a/UD0jeV3

[MikeR20]

I was also suggested to get a MAD device.
So I got a DISE in which besides looking at the upper airway, they simulated the effect of a MAD.
Result: the MAD is 0% effective, and the obstruction is caused by the epiglottis which CPAP can not fully solve.
It could also indicate if any surgery could help.
If you have the means, you could look into it.

I also had great CPAP stats with no leaks and an AHI of around 1.5. So I did a PSG with CPAP with resulted in a AHI of 5, and very shallow sleep.

[PeaceLoveAndPizza]

A few points below. I am not going to address the MAD, prescription, or surgical options, as I have no experience with them. You also said your sleep hygiene is good, so not going to address that either.

Firstly, every night is different. Even with the same pressures your AHI and other numbers can vary quite a bit. How you feel in the morning will vary as well. It is no different with or without any sleep aids. 

Next, your numbers and flow rate look good. The best seems to be when your pressure is between 8-10 with EPR 3. Flow rates are smooth for a good portion of the night. When your pressure goes up arousals creep in which will likely cause poor sleep.

Finally, I think if you stick with one setting for an extended period things should feel better. It takes some time to adapt to the right settings, but once there it can be most helpful. Some nights you will have poor sleep, but that becomes more a one-off than the norm.

If it was me, I would limit the range to avoid the pressure swings which can be disturbing for some. Start with something like:

Min pressure 8
Max pressure 10
EPR 3 full-time
No ramp
Response standard

That keeps you in your sweet spot and should hopefully feel better. You can make adjustments from there if needed.

Others with experience in the rest may want to chime in and offer help.