Opinions and help Re my usage data please

[Poolboy]

Hello.

 I have been using CPAP since August 2023.  The Respiratory therapist who handled my Resmed 11 purchase fairly quickly settled on a fixed pressure of 8 CM with no EPR. 
 
 I continued with these settings for three months,  but became more educated from this forum and some online videos and started experimenting in search of better results.  My first self adjustment from 8 up to 9 CM resulted in impressive AHI reductions.  That encouraged me to experiment more with the goal of reduced AHI, and at the same time, reduced flow limitations.  

For me,  EPR can produce a very significant 33% decrease in flow limitations,  but the trade off is significantly higher Open Airway events (OA events were observed during my sleep studies. Copies included in a follow-up comment).  At this point I feel the choice is to either shoot for low AHI numbers, and endure whatever sleep disruptions the higher Flow Restrictions may be causing, or to focus on achieving the lowest possible Flow Limitations and accept that a greater number of AHI events is the price paid to have lower Flow Limitations, and beautifully rounded inhale breath peeks. 

I realize I am comparing two extremes here,  and am very open to a compromise between the two,  and would sure appreciate some advice getting my machine  dialed in and providing the best possible results. 

Somewhere on the site there is info about an attachment limit, so a few are included here,  and I will include a couple more in a comment to this thread opener. The list of machine settings changes will be included. 

Thank You to all that respond!

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My Sleep Studies and machine settings changes attachments included.

[Deborah K.]

Since your sleep study showed some, but not a lot of CAs, I would focus on getting your flow limits down.  I suggest that you turn EPR on full-time, set at 3.  When you have higher CAs yours are mostly treatment-emergent and will lessen as time passes.  Don't try to chase a 0.0 AHI.  I get those sometimes, but many people whose apnea is well treated never get them.

You might like to consider trying Apap mode.  This allows you to find where you are comfortable and where you get the best treatment.  Then you can remain at Apap, which I think is best, or you can return to straight Cpap if you prefer it.  For now I suggest that you try Apap set at 8-15 and see what happens and how you feel.  Good luck!

[Phaleronic]

Your leak rate is down and more consistently lower when using CPAP mode (when juxtaposed with the apap mode you were on previously). I prefer this mode (CPAP) over APAP or AutoBipap, so I'd stay with it personally. What I would do is raise your CPAP pressure to 12cm and turn EPR on full time at 2 for a few nights to see how you feel and then post charts again.

[Poolboy]

Hi Deborah K. and Phaleronic.   Thanks for your suggestions.

I have tested APAP at 6 to 15 Cm with EPR 3 over two separate weeks, but was put off by the elevated CA events.  Considering the possibility the CA's may reduce over time, I should give that a go again.  All my EPR tests have been with APAP, so I decided to try fixed pressure at 12 Cm and EPR 2 for a few nights, starting last night.  Last night resulted in a big reduction in Flow limitation,  from approx. (95% numbers) .14 down to .09.  That was just the first night so I will update here in a few days once a consistent trend is visible. 

What do you think about my degree of flow limitations?  I can't find much info explaining their level of severity, and any impact on sleep quality that these numbers represent.

Thanks for your help.

(Screen shot for May 7/24 of a typical night at APAP 6 Cm to 15, EPR 3, attached)

[Dormeo]

Your numbers are pretty good, so as you try out little tweaks to your settings, pay a lot of attention to how you feel the next day. You might find it helpful to keep track of some variables on a piece of paper, e.g., your settings, your AHI and FL numbers, subjective feeling the next day, hours of machine usage, bedtime, rising time, other variables like noise, temperature, evening food/drink, etc. This could help you identify some correlations.

When you post your next chart, be sure to include the top bit of the left panel, which is quite useful. Also, if you can hack it, you might turn off your ramp. But if you need it to fall asleep, keep it.

[joeblough]

idk if i would worry about those CAs - they are extremely minimal. personally i have CAs when i change position, whether or not i'm using the CPAP. the CPAP @ EPR3 definitely makes these CAs a lot worse - i'll have a string of 10+ of them apparently because the CPAP clears out CO2 too effectively at EPR=3. at EPR=1 the cascade of CAs does not happen for me.

i guess the question is, would a single CA here and there cause an arousal? or do the flow limits cause arousals? i guess the answer to that question would indicate whether it's more important to attack the CAs or the FLs.

[Poolboy]

[attachment=65490][attachment=65494][attachment=65495][attachment=65495][attachment=65494][attachment=65490]

Thank-you everyone that responded to my post. 

Update:
-On May 25, pressure was increased to 12 Cm and I activated EPR=2 Cm. I stayed with these settings through to last night.
- Before the above change I tested 5 nights, May 20 to 24, at 10 Cm and EPR=Off.  Screenshots for that period are in my opening post of this thread.
-Screen shots of the Overview screen to current date, and Statistics screen for the 17 nights at my currents settings are included.  Also a screenshot of lats night,  which is one of the better ones in this period. The Flow limitations were at my lowest extreme on this particular night. 

To recap a bit,  I am trying to achieve lower AHI's while also minimizing my flow limitations.  EPR reduces my Flow Limitations by about 30% but it also causes an increase in my Clear Airway events.  At this point I think the focus should be finding a good compromise between the degree of these two conditions.  

On PAP therapy I feel fine in the morning with no grogginess, and I feel good over the day.  In the morning I am not aware of very many awakenings over the night.  Before CPAP (about 10 months ago)  I was checking the clock every 30 Min. - 60 Min. when sleeping, but felt like I was sleeping OK in spite of that.  I thought the frequent awakenings were just part of being me and accepted them as part of getting older .  Pre CPAP it took a long time in the morning to get past my groggy feeling and I needed much more coffee to get going.  So, I think my PAP therapy is very effective, but I want to get the most out of it.  

I wonder about the jagged appearance at top and bottom of my flow chart and will probably try a higher pressure to smooth it out.  

Any suggestions out there for what I might try next?

[Dormeo]

I'd suggest trying to minimize the FLs by trying EPR of 3.  Please also raise your minimum by 1 to compensate.  

The EPR of 3 may increase the number of CAs you experience, but I'll try to explain why I think that isn't important, unless the CA index is fairly high (e.g., an index of 2+).

CAs reflect a pause in your breathing that is 10 seconds or longer.  These pauses often come after sighs or arousal breathing.  (Those are the spiky bits at the top of your flow rate graph.)  Try zooming in to take a look; I've posted two examples of the kind of pattern you'll probably find. Raising your pressure will probably not reduce these arousals.  

Arousals during the night are completely normal.  You may be moving from deeper sleep to more shallow sleep or from sleep to waking.  The awakenings are often brief.  But sometimes arousals mess up your sleep architecture -- the sequence of sleep stages that repeats during the course of the night.  This can leave you feeling unrested the next day.

It isn't clear what the mechanism is for causing these arousal-associated CAs.  It might be a reduction in CO2 in your blood, or it might be a transmission to your brain from sensors in your chest wall.

Arousal-associated CAs often go away with time, as the body adjusts to EPR (and CPAP pressure in general).  But these CAs themselves aren't necessarily harmful; what might be problematic, though, are the arousals that trigger the CAs.  (And you may be having arousals that aren't followed by CAs.  I certainly do!)

So the goal is to try to reduce arousals.  One thing that might help is to reduce FLs.  Or not -- the FLs might not be playing a role.  But the only way to figure this out is to do a little experimenting.

[Poolboy]

Hi Dormeo.
Thanks for your feedback.

I should have mentioned in my update that my 12 Cm pressure is Fixed.  Not Auto.  So should I increase it to 13 Cm when going from 2 to 3 Cm EPR? 

I will try your suggestion tonight.

[Dormeo]

Yes, up it to 13.