OSA and CPAP Titration Help Needed

[tiredpanda]

Hello. Please help! I am new to this forum and relatively new to using a CPAP. I have been using my CPAP machine since February 2023 and am still feeling quite fatigued, anxious, etc. I am scheduled to have my first titration study this Thursday (July 20, 2023) and am curious if I should do that or work on this stuff myself on the forum or with a consultant (like Jason, aka the LankyLefty).

Diagnosis: Moderate OSA, AHI of 17 (diagnosed in Dec 2022 from an in-lab sleep study in Nov 2022).
CPAP machine: Resmed Airsense 11 with a heated tube and heated humidifier. Currently on Auto-pap, pressure set between 5 and 15.
Mask: Full face mask (F&P Vitera, Large) because I am a mouth breather. I have a beard and I think it can sometimes leak a fair amount around the chin area, which is a concern. 
AHI since using CPAP: 1 to 3. But I'm still tired. 
Other notes: I have TMJ issues, so I'm sensitive to things that move my jaw a lot, like chin straps. 

Screenshots of OSCAR are below and attached for the last few days. Questions are numbered below:
1. Any thoughts on why I'm still feeling tired? 
2. Should I go through with the titration study this Thursday or hold off until I get a better idea of what's wrong? 
3. What could the titration study help me with that I couldn't do on my own?
4. If I do the titration study, what questions should I ask and what should I look out for/advocate for?
5. Should I use a consultant like Jason, the LankLefty, to help me on this stuff instead of doing a titration study?

Please let me know what other info you need to help me out. Any help would be much appreciated, as this is greatly affecting my quality of life. 

   
   
   

[tiredpanda]

I’m posting some updated information here since I’m still tired and fatigued and anxious, and I could really use some help.
 
I had a titration study done in July of this year (2023). The study noted the following:
“SLEEP: Normal sleep efficiency, short sleep latency, increased N1, increased N2, decreased N3, decreased REM. REM latency is prolonged.
RESPIRATORY: CPAP titration started from CPAP 5 cm H2O to 10 cm H20. Events were controlled with all
pressures. Patient was observed in supine and REM sleep with CPAP pressure of 10 cwp with good  control of respiratory events.
The AHI at the recommended pressure is 0.6.
Snoring was eliminated with CPAP.
Position: 27.8%
PAP tolerance was acceptable
EMG: Normal. PLMI 8.0. There was a short period of leg movement which lasted less than 5 seconds as patient appears to be walking, at the epoch 719. Please correlate clinically.”
Recommendations: CPAP 10 cm H20 is recommended. Pressure change will be ordered.”
 
The sleep tech mentioned that my two main concerns were periodic limb movement and RERAs. He said the limb movements went away after the pressure was increased to around 8. The tech and doctor said that a fixed pressure of 10 should fix my issues.
 
I tried CPAP at 10 (EPR 2/aka EPAP 8) for 2 months and CPAP at 10 (EPR 3/aka EPAP 7) for one month and I didn’t really notice any improvement. I met with my sleep doctor one month ago and she recommended that I increase the pressure to CPAP 11 (EPR 3/aka EPAP 8). I brought it up to that one month ago and still haven’t noticed really any improvements in the past month. I’m still tired during the day and fatigued. I also still wake up with sore legs and lower back muscles like I have been moving my legs all night.
 
Medications: I currently take an SSRI and anti-depressant, which may affect my sleep. There are studies showing SSRIs affect Periodic Limb Movement, so I'm curious about that.
Other medical conditions: I have mild asthma, moderate anxiety, and mild depression. I have pretty bad TMJ issues, and I see a TMJ specialist for it. This includes: a quality acrylic grind guard, weekly physical therapy (including dry needling), and local anesthetic shots (every 4-6 weeks). My jaw still hurts a lot when I wake up, and I think that teeth clenching and grinding are either causing bad sleep or a symptom of it.
Blood tests: My blood results were pretty normal earlier this year, but I’m going to get them taken again to make sure I’m not anemic or anything.
Cardiology: The titration study noticed some bradychardia and PVCs. I did an EKG, Holter Monitor, and echocardiogram, and all turned out to be normal, so I should have a pretty healthy heart.
 
I attached a screenshot of my sleep titration study and some OSCAR results from this past Friday, December 1.  

In terms of possible solutions, I'm curious if I should consider upping the CPAP pressure, switching back to APAP with a higher minimum than before, or considering Bipap.
 
Please let me know what you think. Any thoughts would be much appreciated, as no one responded to my first post. I'm happy to zoom in on any OSCAR data to give details. Thanks!



           

[staceyburke]

What I would try for pressers ....

max 12
min 7
EPR set to FULL TIME set at 3

[UnicornRider]

StacyB, is very knowledgeable, those settings look good. 

You will have to change your PAP Mode from CPAP that your Dec OSCAR Report shows to the APAP mode your July OSCAR Reports show.

Good job controlling leaks in your Dec OSCAR Report.

[tiredpanda]

Thanks for your help! I forgot to mention two other things:
1) I met with an ENT in October and they said that I have a narrow nasal passageway but no other issues to note. They figured that I would probably need higher pressures than I otherwise would, but apart from that there should be no other trouble with CPAP.
2) With the pressure I had at CPAP 11 (EPR 3, aka EPAP 8 ), I have been having a fair amount of gas/aerophagia. Not unbearable, but still annoying. Hopefully reducing minimum pressure will alleviate some of that.
Thanks!

[tiredpanda]

@staceyburke - I'm curious why you recommend a range of 7 to 12. The tech during the titration study said he didn't notice my sleep issues go away until a pressure of 10. Would the range allow for the ability to get the sleep issues under control if they arise but keep the pressure lower if the issues are not there? Thanks.