Next step?

[permabear]

Hi folks,

I've been lurking here for a while but this is my first post. I'm quite impressed by the level of knowledge here and the kindness to guide others who have just started their journey. 

As for myself I've been battling fatigue and brainfog for 20+ years and started CPAP therapy 3 weeks ago. My PSG came back with AHI of 17.0 (100% hypopneas and based on 3% AASM oxi criterium). 78% of hypopneas were scored based on the arousal criterium and 22% due to desaturation. Based on these outcomes I guess it might be the flow limitations that are ruining my sleep quality.

The hospital gave me my APAP with pressure settings 4-10, EPR1 (Resmed Airsense 10 Autoset/ Airfit P30i). After some initial experimenting I changed it to 7-10 EPR3. Happily enough sleeping with CPAP doesn't cause me any trouble and I manage to get around 8 hours of sleep without any nightly awakenings. Oscar showed excellent AHI figures between 0-1. No OA, no CA. However I still had quite a bit of brainfog (especially in the morning) and didn't feel better in general.
After a week or so I raised pressure to 10-13 EPR3 in order to see what it does to my FL. To be honest I don't think it did a lot, nor do I feel any better. Because of the higher pressure, I now experience some more leaks, especially when I don't wear a cervical collar. 

What next step would you guys advise from here? The hospital told me I could suffer from adrenaline withdrawal. But when I asked if this also occurs in people with moderate apnea with only hypopneas/ no OA, they didn't know. 

Should I be more patient and give it more time? I can imagine it takes time for the body to find a new balance and to begin to feel refreshed after a night's sleep. But does this also apply for the morning brainfog? Or is this a clear sign that things are still far from optimal?

Should I perhaps raise pressure some more?
At pressure setting 7-10 my 95%IPAP was 8,8 on average and hardly touched the max of 10. At pressure 10-13 the 95%IPAP comes at 11,2 and also doesn't come near the max of 13. 

Thanks in advance to hear your comments. If I need to post any Oscar charts please let me know.

[staceyburke]

Welcome - lots of very knowledgeable people on this site. To give you suggestions please post OSCAR. Download Oscar free from the top of the site. Check my link on charts (last link) in my signature. It also gives you guidance on OSCAR.

[Gideon]

We all need comfort, I cannot tolerate an EPAP of less than 10, Mine is at 11 for comfort. At 10 I tend to want to remove my mask. My AHI stays low down to an EPAP of 6 so theoretically I could go with a lot lower pressure. The point is you want to control your apnea AND be comfortable.

Definitely post your OSCAR charts. They will help;p us to dial in your therapy, otherwise we would be guessing, we'd rather not do that.

[permabear]

Thank you. 
Please find attached 3 Oscar charts of October 1 (pressure 7-10 EPR3) and 3 charts of October 5 (pressure 10-13 EPR3).
If you need anything else please let me know.

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and here are the October 5 charts:

[SarcasticDave94]

In my opinion, the higher pressures didn't benefit. The leaks were higher, with no real therapy increases. You could probably be OK with that lower setup.

The only thing needing attention is leaks. Your low pressure chart October 1 as an example, at time 0030-0100 the spikey leak pattern is what I associate with mask leaking. Later, the flatter, rounded pattern is seen about 0200 and 0300, and somewhat in other areas. I associate that with mouth leaks.

Mouth leaks may be addressed with a chin strap or tape or attempting to train yourself to keep your mouth from opening while asleep.

Mask leaks are typically incorrect strap adjustment, cushion not the right size, bumping the mask out of place.

[staceyburke]

looking at the 10-13 night the only time you had pressure increase, O and H events and increase in Flow Limits were all when you had large leaks.  If you can control them, this seems to be very good therapy.

[permabear]

Thank you. My first aim will be trying to get the leaks under control. 

Just one more question. 
Even without leaks my wave form looks flattened with two or three tiny peaks during inspiration. You can see them in the zoomed in 3-minutes screenshots (_3).
Are this flow limitations? And could they be the culprit of my brainfog?

Apparently higher pressure doesn't lead to a more rounded waveform. Could a higher PS possibly be of help here?

[permabear]

I can tell that some deviant waveforms are counted for as FL (followed by a pressure raise) but others are not. Is this a matter of inaccuracy when it comes to detecting?

[Gideon]

No. Not inaccurate. The FL chart represents a flattering index that ResMed uses algorithmaticacly to raise pressure.
We have to manually interpret for flow limits if they might be a problem. The number per Dr Krakow' is 90% good breaths as a target.

[Gideon]

That would be UARS