Poor sleep quality because of CA events?

[Hypoxic]

Hello Board,

I was diagnosed with sleep apnea in 2017. The sleep study (without cpap) revealed 22.6 AHI during sleeping on my back and 8.4 AHI on side. Totally, it counted 119 hypopneas, 4 OAs, 2 CAs and 4 “mixed apneas” (not sure what that means) over a 7.5 hour sleep.

I went through a 2nd sleep study in 2021 with virtually the same results.

I use the “ResMed AirSense 10 AutoSet For Her” and successfully mitigated both the hypopnea index and the obstructive index.
The problem is that the residual AHI is still around 2, mainly due to Clear Airway events. I uploaded screenshots of 2 typical nights.

I know that an AHI around 2 does not seem high, but I wake up feeling really terrible.
Rarely, once in month, I wake up refreshed and full of energy. The difference is profound. Wondering what happened, I check the last night’s index. Miraculously, the CAs are almost zero! I haven’t found out the cause, but I really need these nights to occur more often.

I did my homework reading many valuable posts on board forum and Wiki, trying to reduce my CA events.

I gradually reduced the pressure by the minimal step of 0.2 making sure to try the new pressure for several days. I now use min4.4/max12 from the initial min8/max13.
This definitely made my sleep more comfortable, but it didn’t reduce the CAs. Actually, they were marginally increased. I uploaded the monthly statistics (last screenshot).

I reduced ERP from 3 to 2 and even to zero, maintaining ERP only during ramp. This didn’t improve the CA events, either.

I also changed the “for her” algorithm to the classic one, noticing no effect on CAs.

Wondering whether my Clear Airway events are in fact positional apneas due to chin tucking, I followed the suggestions about Soft Cevical Collars. I tried both the Caldera and the Futuro SCC (the other two reviewed collars are no more available). Wearing a collar made me feel uncomfortable and hard to fall asleep. On the other hand, I'm not sure there was noticeable improvement in the CA events. So, I abandoned them after some days.

Then, I set my hopes on trigger sensitivity. I checked out the Resmed Aircurve 10 VAUTO, but unfortunately the trigger sensitivity option is not available in EU machines.

Do you have any other suggestions?
Could you, please, help me on improving my sleep quality?

[CPAPfriend]

hi hypoxic

1) There is a concerning amount of leak in the screenshots you shared, as well as somewhat significant flow limitation.

2) I've heard many patients note a discernible difference between AHIs ~1-3 and being below 1, so I don't think you're crazy nor is pursuing further improvement unreasonable.

3) Sometimes, with nasal / pillows masks, patients open their mouths and wash out the anatomical dead space, which in turn can induce central apneas. This fact, taken together with your not unremarkable leak profile in the shared screenshots, raises this suspicion.

4) Have you tried a fixed pressure?

Share the screenshot of the night where "CAs are almost zero!", and share zoomed-in screenshots of the CAs which you believe might be positional OAs, please.

[paulag1955]

I think you could try a fixed pressure of 9 with EPR set to full time on 2 or 3.

[Hypoxic]

Hi CPAPfriend


Thank you very much for your help.

You are right about the leak. The truth is that during the last weeks, I experience large leaks. I don’t know how this occurred suddenly. I used to have the leak under control the last two years (as shown on the monthly stats).

Two weeks ago, I changed my mattress and pillow to a softer and fluffier. Perhaps this is the cause, since the other parameters are the same. Anyway, the feeling of bad sleep was present way before this change.

4): I have never tried a fixed pressure. I’ll do so this night and post the results tomorrow. I’ll use the pressure that paulag1955 suggested above.

I share here the last three “good nights”, where the CAs were minimal.


I’ll share on next posts some “bad nights” CAs, hoping I’m not wearing you down.

[Hypoxic]

These are some typical nights with multiple CAs. Sometimes the CA events seem evenly distributed during the night and some other times they are clustered.

[Hypoxic]

...and these are some more recent nights:

[Hypoxic]

Let me zoom in the clustered CA events of the three above screenshots:

---

[Hypoxic]

I think you could try a fixed pressure of 9 with EPR set to full time on 2 or 3.

Thank you Paula!

I'll try the settings tonight.

[PeaceLoveAndPizza]

A few random comments…

On the 11/12/2023 night, the CA’s at the end look to be SWJ (Sleep Wake Junk). Ignore them as you were likely not asleep.

On 15/12/2023, the clustered CA’s are likely from a chin-tuck. As you relaxed in REM your muscles relax as well, so this is a typical issue for many of us. A soft cervical collar (SCC) is most helpful.

On 16/12/2023, ibid…

On the early charts EPR is doing a decent job with flow limits, but there are some big FL spikes that could be from any number of things. I’ll go back to the SCC as something worth considering giving a go. It is a simple thing to try, just be careful with the sizing.

As CPAPFriend and Paula suggested, fixed pressure 9 is worth a try, but you may need it higher to handle the hypopnoea’s. Possibly 11 or 12. Experiment and see how things go.

It may be that EPR will work for you at higher pressures, probably worth trying a pressure range of 9-15 EPR 1 or 2 full-time at some point, but for now go the fixed pressure route as they suggested. I would do it first with no EPR, then reevaluate.

Good luck mate!

[Hypoxic]

I tried the fixed pressure. Fell asleep on side. At some time in the night, I woke up from loud leak noise and found myself lying on my back.

In the morning I was feeling worse than usual. Almost dysfunctional until noon.