Need advise on treatment

[iPal]

Hello, this is my first post so thank you advance for all your help and apologies if this post doesn't meet the rules of this forum.

I am a 260 LB 5 ft 7 inch tall male and I got diagnosed with sleep apnea earlier this month. My AHI was 62. I had 14 apnea events and 297 hypopnea events in 304 minutes of sleep time during my sleep study. During the sleep study I spend 2% time under 89% of O2 saturation.

I am currently on a C/APAP trial with a local agency, my device is Resmed Air-sense 10 Autoset for Her and my pressure settings are 7-15 (used to be 5-15 but I asked them to up the start pressure to 7). I am not using ramp. I also use distilled water in a humidifier and a heated hose. My mask is dreamwear nasal. I have a few questions about my treatment and I am looking for some answers before I discuss with my doctor/respiratory therapist:

1. In my treatment, starting from day 1 until now (about 3 weeks now) my AHI measured by the CPAP machine has been consistently under 1.0, and most of the nights it is under 0.5, one night it was 0.0. Numbers show that treatment is working, but it seems too good to be true and I don't know if I am missing anything? Can I trust these numbers? I can now sleep on my back which I couldn't before, and overall energy levels are much better.

2. In my OSCAR charts I see that there are snore events and flow limitations. Is the goal of CPAP therapy to eliminate them as much as possible, or is it acceptable to have these events as long as AHI is under control? Do I need to increase the lowest pressure more to eliminate them? The pressure seems fine otherwise (i.e. I don't feel suffocated)

3. Prior to starting CPAP therapy, I used to sleep only 6-7 hours a night and I used to be awake at ~5 AM and couldn't get back to sleep after that on most nights. I heard most people with severe apnea slept 10-12 hours a night prior to starting therapy, that wasn't the case with me. After using the CPAP machine, I'm still sleeping for 6-7 hours and waking up at ~5 AM on most days. Some of the days I do get back to sleep and sleep for another hour or so, while other days I try and don't get any more sleep. On the days I don't get that extra sleep in the morning, I feel sleep deprived throughout the day, become excessively sleepy before bedtime and the cycle continues. Although I feel much better than prior to starting the therapy in terms of energy, I don't feel refreshed on these days. However, on the days I get that extra hour of sleep in the morning, I feel like a different person, not sleep deprived at all and fully refreshed (the ideal state). What could be going on and how can I get myself to sleep through to the point of feeling refreshed? I have attached 3 oscar screenshots - August 25 is when I was able to sleep the extra hour and August 26/27 is when i couldn't. I don't find the mask uncomfortable so I don't think it has anything to do with getting used to the mask/treatment.

4. My dreamwear nasal mask (size: M) seems small for me. I tried the size L frame but that is too big for me (isn't snug on the head). Any recommendations for other masks that have the hose connecting on the top of the head?

I do have a sleep doctor and a respiratory therapist I'm working with but I found that the community here is fantastic when it comes to advise, and I want to be prepared before I talk to them in my upcoming appointment. I am really thankful to the community for all the help and I am looking to return the favor wherever I can.

[Gideon]

Trust the numbers. From a therapy point of view you are in excellent shape.
Are you in Ontario by any chance?
You have the best APAP out there. Make sure you keep it.
Ontario has misclassified the for Her AutoSet as a CPAP.

At this stage adjustments are made more on how you feel than the numbers. I'd recommend you lose weight but you've heard that before.

[iPal]

Trust the numbers. From a therapy point of view you are in excellent shape.
Are you in Ontario by any chance?
You have the best APAP out there. Make sure you keep it.
Ontario has misclassified the for Her AutoSet as a CPAP.

At this stage adjustments are made more on how you feel than the numbers. I'd recommend you lose weight but you've heard that before.

Thank you. Yes i am in ontario and plan to keep the same for Her Autoset! And yes loosing weight is the next step for sure.
I think the issue described in my question #3 is really the one keeping me from feeling great. I want to address that as it makes a difference between a decent day and a great day!

[Sleeprider]

Your therapy is outstanding and the way you feel will follow. The objective of your CPAP therapy should not be based on an AHI, event count or the minor presence of flow limitations or snores. You are practically at zero with 95% flow limits at 0.01 to 0.03. That's pretty amazing. Your pressure is staying near the minimum pressure, and moving within a small range that should not be disruptive. As a rule of thumb, I try to optimize the minimum pressure to be high enough that pressure will not vary more than 3-cm, and you are there.

At 3-weeks into therapy, you are still awakening with less sleep than you would like from time to time. I think awakenings and sleep time is somewhat habitual, and you are still unlearning the habits from before therapy. There does not seem to be any respiratory or therapy issues to explain early arousal, although there are some leaks that seem to precede the awakening. I think arousals will diminish as you acquire more time on the therapy. You are working on issues with your Dreamwear nasal mask and you should continue that, and perhaps request a size L nasal piece to give that a try. I think the Resmed Airfit P10 is far less disruptive and is a solution you should eventually try to compare. Your therapy is doing great, and as bonjour says, you need only focus on comfort at this point.

[staceyburke]

Resmed P30i is a pillows mask with the hose on top of the head. One of the best to stop leaks

[iPal]

Thank you all for your feedback and I already feel more confident. I will make sure to work on the comfort now.

[Cpapian]

The only comment I have to make is with respect to your awakening earlier than you want to.  It might be an issue with sleep maintenance which is a type of insomnia.

As Sleeprider said, this has become a habit from before PAP.  

One way to deal with this would be, when you wake too early,  give yourself a little time (you decide  10 - 20 minutes) to get back to sleep.  If not successful, get up.  And stay awake for the day.  The next day you will be more tired and might sleep longer.  Daily repetition of this strategy should help you to break the pattern of waking earlier than desired. 

This suggestion is along the lines of sleep hygiene.  Sleep hygiene is an actual thing, you can search those terms for more info or ideas.

I use the P10, the N20 and something P30i?? and find them all pretty good.  The N20 ends up being my goto mask because the headset is more stable and adjustable.   The P10 gets stretched out quite quickly for me.

Looks like you are off to a good start.

[Sleeprider]

Cpapian, have you ever tried to connect the P10 to the N20 headgear? There is some more substantial head gear that is supposed to work with with the P10, but I don't recall what it is.

[iPal]

This is excellent. Thank you. Do you recommend I seek help for CBT-i? If yes, do you know of any online resources to try it myself?

[mesenteria]

I would guess that you're somewhat open-minded, hopefully at least insofar as getting control of your body is concerned.  I would offer some suggestions for weight loss if you are interested.  I'm not a health pro, but I recently admitted to myself that I had to get a grip on my own corpus, and I took steps to lose 10 kg over the next three months.  I would encourage you to carefully consider all well-meant advice, including my own, and figure out what you know you can do, and live with for at least four months. 

As an example, calorie counting.  Don't.   Another example: snacking.  Don't.  Yet another, go on a diet.  Don't.  You only need to change some things, some of it a bit of a challenge, and to do more of some things and less of another.  The weight will come off, and with it you will shed some of the impediments to sleep, pancreatic function, liver function, brain function, and heart function.  

I am not offering to mentor or to coach you, or to offer you advice.  I'm merely offering to provide you with references to four different people, maybe five, who talk the same tune and who know how to describe a durable and salutary change of lifestyle.  From there, it's a search for videos, pondering what they say, and then synthesizing all else you learn and glean from your exploration and developing a plan.

It's part of a holistic path to getting you back to a younger and more healthy self...hopefully.