New Here, Been using OSCAR, Need Advice Regarding Adjustments

[FrankReality]

        [attachment=60559]Need some guidance regarding CPAP adjustments.  Working with my sleep doctor has not been particularly helpful.  Here's what we've tried with little success.  Have arthritis in shoulders and back which means I have difficulty confining sleep to any one position.  I also do not have a colon due to cancer surgery which requires several toilet trips nightly.  I take 3mg melatonin ~ 30 minutes before bedtime and 7.5mg Remeron ~ 90 minutes before bedtime.  The Remeron is prescribed to help return to sleep when awakened by a toilet run.  Times were set via testing.

Reviewed sleep hygiene - made minor changes.  Screens off time before bed, electric heater off during sleeping hours.

We have bumped pressure from 8 to 9, then from 9 to 10 over several months which didn't significantly help.

Based on OSCAR and myAir data, I tightened the mask - this helped with leaks caused by movement, but caused facial irritation.  Have since loosened it a bit.

I tried various pillow heights - no change.  Added soft mattress pad for comfort.

Tried a soft collar - no change.

Tried sleeping on back - the more on my back, the higher the AHIs (typical of obstructive apneas) The more sleeping on either side, the lower AHIs.

Ramping my head end higher per doctor suggestion increased AHIs proportionally to the angle of inclination. A 40 degree angle bumped the AHI's to above 34. We dropped that idea real quickly.

Currently trying a half dose of Benedryl - it can help with the facial rashes/skin sensitivity and also may help keep the sinuses clearer.

The sleep doctor gave me three options: 1) live with it as is with AHI's bouncing around 10-12, 2) continue adjustments, and 3) get a sleep study.  I asked him to do option 2 making changes quicker and to look into how long it would take to get an appointment to do option 3.

I'll post a couple of recent screen shots so you forum experts can weigh in.  Thanks in advance.



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[TechieHippie]

Great job working through different ideas. One you didn't mention was Flonase or generic equiv. Non-addictive topical steroid nasal spray.

Option 1 is not a great solution; that's still not ideal and you would be slowing down the problem but not addressing it fully. Option 3 probably won't get you a lot of value for the cost compared to advice you will hopefully get here. I would add a fourth option, 2A, work with this board and adjust settings yourself after letting him know you will try this; it's your therapy and the process of it will help you know what works for you. Home plus Knob for several seconds will give you the options.

I'm not the expert but can help with some basics. First, have you ever tried EPR? Because you have some centrals, you may have to go slowly and see how they react, but it might help the flow limits a lot as well as making therapy more comfortable. 2nd, you could find out a lot by going to the Autoset which you currently aren't using. It will auto adjust within your given parameters, and that will let us see what the machine thinks you need as far as pressure.

My best guess is to make your way toward EPR 2, autoset range 10-15 to start so the machine doesn't go ballistic, and then post new charts. Other experienced folks hopefully will refine more.

As far as back sleeping, many of us can't do so no matter what we try. I so wish I could. Given your other health issues, you might consider a PulseOx such as the SleepU from Supplier #40 . It has a configurable buzzing alarm (I think the larger CheckMe has an audible alarm) that can wake you off your back when needed. When I'm desperate for another sleeping position I rest in my not-great position in half sleep until I feeling my oxygen dropping (I can feel it at about 92-93 now) and then turn back to my norm. What the alarm helps with is breaking the cycle of all those events crunched together and makes for a better night of sleep.

[FrankReality]

Thanks for your feedback. 

Yes, I use a generic Flonase, have just gotten away from it recently, so I'll restart using it regularly.

I do think the 2A option is a good one given how unresponsive my sleep doctor is, which is why I posted here.

I'm also stopping by my equipment provider tomorrow and checking out a different mask type and/or mask liners to reduce the skin irritation.

Thanks again for the assistance.

[Expat31]

Hello,  I agree with Techiehippie that in Autoset mode with EPR would be a step in the right direction.
However, when look at you graphs, I see the results of positional apnea, (the small but frequent clustering of events). 
I believe this is the first  priority to resolve so as to get a clearer picture as to what settings are actually needed, so as to avoid unnecessary adjustments that could muddy the waters later on. 

My guess is that you are moving around quite a big at night, and  spending these frequent periods on your back. In your case, this is what could be happening :-
 
In the deep sleep phase during sleep, when there is a sort of "semi paralysis" of the muscles (loss of muscle tone), the tongue can, under the force of gravity, fall back against the phalanx wall, and consequently block the airway. (See attached image).

As you have already tried a collar, and if was a suitable size and fit, it is perhaps unlikely a problem of misalignment of the trachea, hence a collar may not work. 

I personally found a collar would not work for me also, . I had to make a chest belt with 3 tennis balls to get me off my back, but at least with excellent results. It took 6 months to train myself. Now I find all is well

Just a short video demonstration to show practically what is going on :-
Positional sleep apnea blocking airways 

Hope this may help.

[FrankReality]

Thanks for the reply.  I'm pretty certain there is positional apnea.  The times I have tested sleeping on my back have been awful.  The last 2 days, I've gone back to experimenting with the neck collar and trying to sleep as much as possible on my side.  AHI numbers look better,  but forcing side-sleeping seems to have caused significant mask leakage - I don't trust the AHI numbers from the last two days.  Also have no idea how to determine how much sleeping is done on my side - I have no way to record/review a overnight video to monitor it. I also have added naproxen to be taken with my evening meal to help with arthritic pain - effect on sleep is an unknown.  

Because of the face irritation, I got a new mask today (AirTouch F20) which has memory foam on the points of contact, not silicone.  It seems more comfortable and is much quieter, but it will get its first test overnight.

I'm a bit concerned with changing so many things at once, but I can always do more testing to isolate each variable.

I've heard of the chest belt with 3 tennis balls method, but I'm not quite there yet. 

Thanks again for your reply

[TechieHippie]

You can start with a fat pillow or other things placed where you would roll onto your back. I really find having a pillow up tucked up against my back when I lay on my side to let my nervous system relax. Maybe I'm weird!

[FrankReality]

OK, I can try that.  Thanks

[Expat31]

Hi,

I forgot the possibility of suggesting a wedge pillow, which would be more comfortable than my own  "nuclear option" of tennis balls, but that's all that was effective in my case. These pillows are less expensive on AliExpress compared to Amazon. 

One extra thing, for the F20 Airfit, best to run mask fit programme a couple of times to drive out any resudial humidity accumulated during the night. The cushion can degrade if not cared for properly. Clean only with baby wipes, no water.

[FrankReality]

Got it.  Thanks.

[FrankReality]

Putting a large pillow behind me to keep from sleeping on my back caused significant pain in the shoulders/collarbone - while the numbers got slightly better, my overall sleep quality was awful - no deep sleep, little light sleep and almost entirely REM sleep per my fitness tracker.

Net - I think not sleeping on my back is out of the picture due to pain.  Numbers were still unacceptably high, so I restarted using the soft collar to see if it helps and removed the pillow.

First night with the F20 there was some leakage which it appears I corrected by strap adjustments and was excellent the second.  Normal teething pains of a new mask.  The F20 is much quieter than my previous F30i and doesn't vent into my eyes.

Adjusted the CPAP to autoset with a range of 8 to 12 and turned EPR on and set it to 1.  Also corrected the time so it syncs with the fitness tracker and I can remove the time offset from OSCAR.

For the record regarding EPR, I'm pretty certain my previous CPAP (also an Air Sense 10) had EPR on.  When I got the new machine I noticed it was much harder to exhale than the old one.  Didn't know there was a setting for that.  Surprise.

Will use it a few days like this and report back.