[Pressure] New to CPAP - trying to titrate

[grubsztyl]

Hey there. Back with some awesome news... ya'll gonna like it.

I've managed to reduce my total OAs to just 2 during the whole night... 

As you know from my previous posts, I've struggled for a while with varying AHIs ranging from 2 to 8 with no real explanation as of what I was doing wrong. The best AHI I got was about 1.5 which made me feel pretty good. I'm still getting used to the therapy.

I switched to P10 mask from F20. I wore soft cervical collar and tried to sleep on my side exclusively. I lowered EPR from 3 to 1.

Attached screenshot is from last night. Notice that I woke up two times during the night. My nostrils were irritated and I suffered from significant aerophagia that I needed to get rid of. First night with a new mask was tough. 

I didn't experience any mouth leaks. Overall the pillows were quite comfortable, didn't move during the night. I sleep with ear plugs and I could hear the air being pushed into my nose, a very weird sound inside my head but I got used to it quite quickly. 

Seeing as my med. pressure was 9.4, and my min. pressure was at 9, I'm going to lower the min. pressure to 7 cm and max. pressure to 12 or 13. I hope lowering min. pressure will make my aerophagia less painful.

I don't know why P10 works for me so much better than FFM. But it does and I'm happy.

[grubsztyl]

I really need your input. I think my titration process has reached its natural end.

My current pressures are: 11-20, EPR 2, I'm using P10 pillows, soft neck collar. I try to force myself to sleep on my side and position my tongue on the roof of my mouth.

I don't feel rested at all. The initial enthusiasm has worn off and my AHI seems to be completly random. Sometimes it's below 1, other times it's 4. The higher AHI the crappier I feel.

I need at least EPR 2 to keep my flow limitations under control. I'm able to tolerate higher pressures and 11 cm is not a problem for me on pillows, however, there's no improvement anymore in raising pressure. I don't want to touch the settings till I get some feedback.

I'm attaching a series of screenshots. Some of them show what I think is palate prolapse (that would be not surprising, my soft palate is incredibly long...). Interestingly I haven't seen this pattern in my OAs (or it was very slight) before I attempted higher pressures to improve my AHI.

On some of the screenshots I think there are some arousals without flow limits associated... I wonder if they're physiological arousals or perhaps there's something else disrupting my sleep...

I don't have that many OAs events per night. I should sleep well...

I think changing the settings is a hit-or-miss now. I could up the EPAP to see if that keeps my airways more open and prevent OAs and possibly RERAS? Or I could try going back to EPR 3 but that means either lowering EPAP by 1 or upping the inhale pressure as well.

I'd really appreciate your feedback on this one... not sure what's the next step.

[grubsztyl]

Last night I had over 8 hours of solid sleep. No awakenings, no aerophagia. I still don't feel rested. I've settled at 12-20 with EPR 3. This range makes me feel best but I'm still tired. I've noticed my flow pattern and respiratory rate is rather erratic throughout the night... It makes me wonder whether perhaps I'm suffering from UARS and BiPAP would be more beneficial for me? I'm willing to spend the money if it makes me feel better... This would explain why despite AHI under 2 I don't feel all that great.

Please see second screenshot I've attached. It shows Class 2 flow shape followed by a period of not breathing... this doesn't get flagged as any event by Oscar, even as a flow limitation. I've studied my flow charts and this is a recurrent situation throughout the night. I have lots of these weird patterns and quite a bit of Class 2 flow shapes. Perhaps they result in micro arousals and that's why I don't feel rested?

[grubsztyl]

Im attaching some more screenshots of weird events I get... wondering whether they affect my sleep quality.

[Sleeprider]

Sorry for being absent from this thread several days. Going back to February 2, that looks really encouraging with a pressure range of 9-12 EPR 1. Remarkably quiet until some flow limits raised pressure. Moving to Feb 7 and actual pressure ranged from 11-15 EPR 2 with an AHI of 2. The anomalous breathing in that chart looks like an oral exhale, and the other zoomed segment there looks like an arousal and may have involved some movement. On Feb 10, pressure ranged from 12-15 with EPR 3 and AHI 1.7. The zoomed segment there looks more like a hypopnea and does not appear obstructive. On Feb 10 you are at 12-15 EPR 3 with AHI 1.6. Several segments of irregular breathing feature "cardioballistic artifacts" where the flow rate seems to pickup heart pulse, especially during expiration or periods of low flow. At 2:32:10 you have a large inhale and breath-hold as the flow does not go negative. This looks like a change in position with expiration happening at 02:32:20, then some irregular breathing until you resume a normal sleep pattern at 02:32:40. At 02:58:00 there is another non-obstructive reduction.

I don't see any artifacts that are of health concern, and looking through zoomed images of breathing will uncover similar artifacts and anomalies with most people. I certainly count myself among those. If you are experiencing aerophagia from time to time, it seems you can cap your pressure at a maximum of 15. Your lowest AHI was actually using a lower overall pressure and EPR, but without repeating the settings used on Feb 2, we can't say whether that was significant or not. Your event rate is normal and shows good airway control compared to where you started. All of your results show a rock-steady tidal volume of 440-460 mL and minute vent around 7 L/min. That suggests the therapy is working, and changing settings is no affecting your respiratory physiology in a significant way. At this point you should be pursuing comfort while maintaining this good AHI between 1 and 2 per hour. You might want to make some journal notes of your qualitative impression of sleep before you actually look at data. I have often found, there is not good correlation between how I feel and what Oscar looks like.

[grubsztyl]

Thank you for your input, Sleeprider. I really appreciate you taking your time to look over my posts.

This is very interesting. You're right that EPR 1 results in fewer OAs but introduces some flow limitations... and higher EPRs with consequent increase of IPAP to make up for the difference reduces flow limitations but appears to cause more OAs.

I was never able to achieve AHI of February 2 again. I ran 9-12 EPR1 for two consecutive nights but I do recall feeling worse on these nights and I blamed it on flow limitations. This is why I started raising pressures and EPR again.

You're right that I should be taking notes. I can't tell what setting was more beneficial. I usually get aerophagia after changing the settings, I quickly get used to it and don't experience it anymore.

I will be experimenting more, perhaps going back to 9-12 EPR1. I'm wearing a Knightsbride chin strap now and no longer wake up with air escaping through my mouth.

[Sleeprider]

I use the Vauto bilevel. Like you, I found flow limits were more disruptive to my sleep than the events. My pressure on bilevel has been 13/9 to 18/14, so fairly close to what you are experiencing with CPAP at 12/8 to 15/12. Your maximum pressure is set to 20 cm but the machine is not using that higher pressure, so your flow limits with EPR 3 seem well controlled. It is the bilevel deliver of air, with higher inspiration pressure that resolves flow limits for most people, and leads to much more steady pressure. When flow limits are not controlled, the Resmed Autoset algorithm will push pressure higher very quickly. I think you can set a slower response to flow limits on some machines, or restrict the maximum pressure.

[grubsztyl]

Interesting. I could rent a Vauto bilevel for a week or two and see if it makes me feel more rested. It's not a big cost compared to getting a new machine just to test it out. If it really does, I will buy it straight away.

What settings would you recommend if I went that route?

[Sleeprider]

The European model of the Vauto is slightly different from the U.S. in that there is no trigger sensitivity setting, but for the most part very similar otherwise. EPAP manages obstruction and IPAP manages ventilation, flow limits and hypopnea. Your current EPAP is at 8.0 and ranges upward about 3-cm. So, in Vauto mode: EPAP min 8.0 Max pressure 15.0, PS 4.0

[zaienk]

Well Aircurve 10 Vauto in germany has all parameter accessible and also a backup rate off 10 in BIPAP-S mode with easybreath desactivated, I trust in holland also, maybe it is also the case in all "germanic" country like swissland, austria etc. I'm sure for germany as I leave in France close to germany and manage to get one from there to get the trigger parameter available.
I try to know is recent model in france has also all these parameters now available but I still not receive the answer.