[Pressure] New to CPAP - obviously questions :-)

[mayuh]

Hi there,

first post :-) I was recently diagnosed with OSA (just got the results yesterday, I thought my AHI was around 40, no it was actually north of 60) and had my machine fitted on the 19th June. I was sent home with a Dreamstation BiBAP with EPAP19 IPAP24 (!) pressure and a ResMed Quattro FFM. I think I generally accept the therapy very well, as I think it will help me a lot. 

The first week I had 2 nights with AHIs under 2. But I was far away from feeling rested. I felt like run over multiple times to be honest. 

I tried to educate myself as quick and profound as possible. I learned about sleepyhead and started to analyse things there. What I saw was that in the night they tried to dial me in, their last pressure adjustment was from 16 to 24 within 1 hour -- something I interpret as they were losing their patience and just went up to prevent any further apnoeas...

Anyway I must have to ability to scratch my nose or I get nuts  Also my mouth was very dry... So I got a new mask, the very comfortable new DreamWear FFM. A wonderful piece of engineering, I almost don't feel it anymore after 10 days.

I had to tighten the new bugger so much, that I woke up with several different aches from the neck, mouth and worst - my septum. Then I checked a few instructional videos from Philips (and also asked my supplier), and came to the conclusion that it should not be fitted so tight, but rather comfortable. Guess what - it leaks like crazy when the pressure goes over 20. As I already think my pressure is way too high I decided to alter the prescribed pressures so I can wear the mask comfortably and achieve good results.
From the sleepyhead data I saw that I already sleep rather well at IPAP 16-17, when the ramp hit that range. At the max pressure of 24 I tend to wake up after 10-40 minutes - of course hitting the ramp button again.

With a little help I decided to try AutoBiPAP EPAP 10, MaxIPAP 25, MinPS 2, MaxPS 5 and see how that will turn out.

Now, I'm still no expert, so I seek for a little advice from you. I'd greatly appreciate any advice, help or comments :-)

My AHI is now between 1.3 an 4.4 - my snores rose (yet my wife didn't hear a thing) - also, I think I read somewhere that the Dreamstation does not record/flag snores when the pressure is over 16, so I take that with a grain of salt. What I really don't get is why I sometimes have less events at lower pressures and other times vice versa. Maybe you can have a quick look? :-)

Maybe it's worth noting, that I sleep for about 4.5 hours (brain decides that I have had enough), then wake up for an hour, and go to sleep again for a second round of about 2 hours again.

Thanks so much in advance,
Mario.

ps. I'm not allowed to post with attachments yet... so, let's try this: 
imgur.com/a/a8oCDm7

[Sleeprider]

Actually your settings are Mode AutoB, EPAP min 10.0, IPAP max 25.0 and PS 2.0 min, 5.0 max. That is not such unreasonable pressure as a fixed 24/19 might suggest in fixed BiPAP-S mode. Your results for starting out are quite good, and generally your obstructive apena seems to be well resolved with a few clusters that suggest a positional issue may be responsible.

I would like to see your minimum pressure support raised to 3.0 (PS min), to help with the hypopnea, snoring and flow limitations. Your minimum EPAP seems fine. You do not need IPAP pressures higher than 17, but the machine seems to be regulating that fine without changing settings, so really the only machine tweak would be to change PS min from 2.0 to 3.0.

I think you should consider using an aid to prevent your airway from being obstructed by your sleep position, and particularly where your chin tucks toward your chest. A soft cervical collar or partial collar like the Dr Dakota Snoring Stop or Snore Eliminator has proven both effective and comfortable many times over to forum members. You can wait a while to see if obstructive events self-resolve, but this has been surprisingly effective. A good experiment is relax and breath through your nose as you allow your chin to drop. If this causes airway restriction or a snore while you're awake, you can imagine what it does when you sleep.

Welcome to the forum. New members can post charts as attachments as shown in my signature. It is the links to off-site images that will cause problems for you until you have member status after 4 posts. You did a good job with the images, and your therapy looks pretty good. I think you will find the higher pressure support more comfortable, and we can look at limiting maximum pressure if you continue not feeling rested.

[mayuh]

Thank you for your comments. I wouldn't have thought of a positional issue, but now thinking of it, the Dreamwear FFM allows me to sleep on the side (at least I fall asleep that way). So this may very well be true...

I will try the "snore experiment" with the dropped chin in a more relaxed environment tonight - just now when I tired, I wasn't even able to get a snore from that, no matter how (hard/relaxed) I tired :-)

So this night I will raise the PSmin to 3 and report back. I will have my next appointment in the sleep clinic in mid October and I really want to have my therapy as optimized as it can get by then. I already feel like a little criminal for altering the therapy    but it made no sense to me at all, that I woke up every 40 minutes (after a 30 minute ramp time) and hitting that ramp button again and again.

Thank you so much for your time!
Mario.

ps. this is what it looked like with 19/24 - I felt like hit by a train in the morning (or 5)
imgur.com/a/kvp8QHk

[mayuh]

Newest chart with PSmin3 - it seems the RERAs have almost disapeared. One was flagged in my second sleep session, but I doubt that one is real - or is it? (close up screenshot attached)

Also, I slept for almost 5 hours continuously... a big gain from the last 4 to 4.5 hours. Still somewhat tired after lunch, but hey, I try to be patient :-)

imgur.com/a/AsqF2Qm

[mesenteria]

Hi.  This is encouraging.  The 'learning' applies to both your brain and your 'system', so it will take time for things to settle down.  Even when you make minor changes, it might take as much as five or six days before you can call what you see rendered in sleepyhead a reliable and consistent result.  That's because all of us see variance in our data from night-to-night.

BTW, isn't this fun?! 

[Sleeprider]

Looks better. You can give this a day or two, but we are going to PS 4.0 pretty soon. That should knock off the flow limitations and remaining hypopnea.

[mayuh]

Thank you so much for your replies. It really helps me (as a noob/beginner) tremendously...

Yes, this is kinda fun :-) patience is the key - as well as give every change a few nights. I try to learn that and I think I already did the last weeks. In my job I’m more the pilot than the passenger ;-) but I promise I will - as i already feel a big change for the better. Still tired, but at least the people around me tell me I’m more relaxed, and generally I’m better company than I was before. That’s motivation ;-)

[mayuh]

A few days in I get (for me) non consistent results... All I see is that the higher the pressure, the more leaks, the more apneas. Still no audible snores according to my wife despite the machine flags a few. Any suggestions?

ps. I got a stuffy nose the last 3 nights too...

[Sleeprider]

You might try to limit IPAP max setting to 17.5. This will stop pressure increases that seem to produce leaks and actually result in higher AHI. The apnea events may still remain, but at least you will be more comfortable. I think increasing PS min to 3.5 will also help. So my suggestion is a narrower range of pressure, EPAP min 10.0, IPAP max 17.5 PS 3.5 to 5.0.

You have made nice progress, and this should retain that and perhaps build on it for flow limits. You may want to turn off VS2 in your Sleepyhead charts. It really doesn't provide any useful information and kind of clutters up the events.

[mayuh]

Yes, sir :-) I'll give that a try... Thank you for your help!

Today is the first day (after 4 weeks of CPAP) I don't feel tired the whole day. I just received the full diagnose - - Things work out great - everything lower than my initial AHI 86,1 (and O2 under 60%) is good - I now know what the staff at the lab meant when I woke up and they said they are happy to see me alive... geez...