Requesting input on CPAP settings and therapy

[kettle101]

Hi, I am looking for input/guidance on my CPAP setup as I have been using CPAP consistently for about 5 months now. I was diagnosed with mild moderate sleep apnea a few years ago and had a lot of difficulty with the machine, and felt it made my already limited sleep much worse. I was constantly waking up during the night and eventually stopped using it in 2019.

At the end of 2021, I woke up with lancing pain in my right ear and it was determined to be a TMJ issue, which the doc thought was due to clenching my jaw at night. Thus, I sent in my Dreamstation 1 that had been laying fallow to be exchanged for a Dreamstation 2 Auto (the Phillips recall) and started using it in January. I have been using it fairly consistently but my sleep still seems pretty garbage. More recently, I have been waking with extreme dry mouth and asked my sleep doc about it. He said I had high leak, and recommended (on May 11th)  I switch my machine from CPAP Mode, 12 pressure to AUTO mode, 5-12 pressure. That felt like I was getting no air at all so I moved up the minimum pressure to 7. I'm not sure how the RAMP works on this mode but I have that set at 8 to give me "enough" air to feel OK going to sleep. The tooth sensitivity and TMJ issues have continued to come and go, and now my jaw muscles are consistently tired and I've been having tension headaches. I am also seeing a TMJ specialist who has prescribed a bite deprogrammer for the next month. 

I welcome any input on the above, and specifically I also have questions about my OSCAR data and CPAP setup:
-are my pressure settings looking good
-I still seem to have AHI and hypopnea (probably accompanied by jaw clenching) issues, especially after switching to AUTO mode - any recommendations?
-Is my data before AUTO mode unreliable, because my leak was high (many nights seem to be above the upper leak threshold dotted line)?  Was I just not getting therapy?
-I assume the leak issue was due to mouth breathing? Is that problem still apparent?
-What is going on with periodic breathing and variable breathing? Some nights those seem to be quite high, especially VB, and that is concerning
-Should I change my FLEX settings? Does EPAP matter?

Sleep study and some OSCAR data attached. Let me know if I should provide anything else. I know this is a lot to read but I'm at my wits end and appreciate any info. Thanks

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Data from before I switched to AUTO mode

[kettle101]

OSCAR summary data

[kettle101]

Initial sleep study

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Titration study (I just noticed the limb movement events which my doc has never mentioned, but I see the sleep tech made a comment about PLM)

[Sleeprider]

Your sleep test shows mainly hypopnea events, and this has continued with CPAP a much lower rate.  I don't see the PLM issue in the test which seems to show all zeros. The DS2 data shows a generally low number of events, mainly hypopnea.  There is a lot of variable breathing going on, but it's hard to say whether that has any significance without looking closer at the respiratory wave form to see if there is flow limitation or just tidal variation. With pressure 7.0 to 12.0 and A-Flex at 3 your results are pretty good, but hypopnea has increased since you lowered the minimum pressure and moved to auto pressure. 

My suggestion is to drop Flex to 2 and see if that stabilizes the variable breathing.  I think you should increase your pressure range to use a minimum pressure of 8.0 as your hypopnea have uncreased at the lower pressure. On the other hand you seem to tolerate the lower pressure better and have increased hours of therapy.

There is a discrepancy in your reported pressure levels and the chart in this example that I'd like you to bring to the attention of the developers in the Beta forum. Your graph shows your pressure is 8.0 but the summary suggests 7.0.

[kettle101]

Just wanted to say thanks for the reply, I tried out the 2 FLEX setting and my sleep doc seemed to support that as well. I looked into the min pressure setting readout and I think that is due to the RAMP being set at 7 while the actual min pressure is at 8, not due to the OSCAR beta for Dreamstation 2. Though if you think I'm misreading that will take it to the beta forum.

My sleep doc recommended I increase pressure again, and actually recommended 10 but I've just stepped it up to 9 thus far. I've attached the last two days - do you think these look ok? Should I be concerned about the amount of time the line is above the Upper Leak Rate Threshold?

Settings: 
Pressure: 9-12 AUTO
FLEX: 2
RAMP pressure: 8 (30 min)

Thanks

[Sleepster]

I think that is due to the RAMP being set at 7 while the actual min pressure is at 8,

I have found that the RAMP feature can be good for beginners, but is not really needed once you start adapting to the therapy. Try turning it off and see if you get along okay.

[Sleeprider]

It seems the revised settings are more comfortable and effective. What do you think?

[kettle101]

It's tough to say, there seem to be "good nights" and "bad nights" and I'm not sure what's different. Jun 1st was a "bad" night and though I felt more rested from Jun 3rd, apparently I was clenching my jaw enough at night to have headaches all day (both attached). Any thoughts? Does it look like there are leak issues (dotted line is upper leak threshold). It's just so frustrating as the doc promised CPAP would stop the night time jaw clenching (which is leading to TMJ problems, exhausting even to chew food, etc) and after using since January it doesn't seem to be helping - to say nothing of still feeling exhausted all the time.

Thanks

[Sleeprider]

I don't know what the relationship is between CPAP therapy and bruxism or jaw-clenching. As far as I know, CPAP is not prescribed to deal with this issue, and it's a bit unfair to judge your therapy based on a problem it is not intended to treat. Let's assume your CPAP therapy has been successful in treating your obstructive sleep apnea as designed. Bruxism is a completely external problem that may need intervention by your dentist or specialist with TMJ issues. There is nothing in your graphs that would suggest a modification of your therapy settings to address a problem that can be addressed by CPAP.

Your sleep and comfort are clearly compromised, but you will need to consult a Oral and Maxillofacial specialist or surgeon to address the bruxism.

[hh9797]

Hi, I am looking for input/guidance on my CPAP setup as I have been using CPAP consistently for about 5 months now. I was diagnosed with mild moderate sleep apnea a few years ago and had a lot of difficulty with the machine, and felt it made my already limited sleep much worse. I was constantly waking up during the night and eventually stopped using it in 2019.

At the end of 2021, I woke up with lancing pain in my right ear and it was determined to be a TMJ issue, which the doc thought was due to clenching my jaw at night. Thus, I sent in my Dreamstation 1 that had been laying fallow to be exchanged for a Dreamstation 2 Auto (the Phillips recall) and started using it in January. I have been using it fairly consistently but my sleep still seems pretty garbage. More recently, I have been waking with extreme dry mouth and asked my sleep doc about it. He said I had high leak, and recommended (on May 11th)  I switch my machine from CPAP Mode, 12 pressure to AUTO mode, 5-12 pressure. That felt like I was getting no air at all so I moved up the minimum pressure to 7. I'm not sure how the RAMP works on this mode but I have that set at 8 to give me "enough" air to feel OK going to sleep. The tooth sensitivity and TMJ issues have continued to come and go, and now my jaw muscles are consistently tired and I've been having tension headaches. I am also seeing a TMJ specialist who has prescribed a bite deprogrammer for the next month. 

I welcome any input on the above, and specifically I also have questions about my OSCAR data and CPAP setup:
-are my pressure settings looking good
-I still seem to have AHI and hypopnea (probably accompanied by jaw clenching) issues, especially after switching to AUTO mode - any recommendations?
-Is my data before AUTO mode unreliable, because my leak was high (many nights seem to be above the upper leak threshold dotted line)?  Was I just not getting therapy?
-I assume the leak issue was due to mouth breathing? Is that problem still apparent?
-What is going on with periodic breathing and variable breathing? Some nights those seem to be quite high, especially VB, and that is concerning
-Should I change my FLEX settings? Does EPAP matter?

Sleep study and some OSCAR data attached. Let me know if I should provide anything else. I know this is a lot to read but I'm at my wits end and appreciate any info. Thanks

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Data from before I switched to AUTO mode

1) "He said I had high leak, and recommended (on May 11th)  I switch my machine from CPAP Mode, 12 pressure to AUTO mode, 5-12 pressure. That felt like I was getting no air at all so I moved up the minimum pressure to 7" - 

If it is in auto mode with a set range it will go to the pressure it feels is correct at the time, it is perfectly fine to "feel like you were getting no (forced) air", the point isn't to feel like you have your head out the window in a car going 80 down the highway it is simply to have the pressure when the pressure is needed if it thinks 5 is too low it will auto adjust to the proper level at the time, for example my current setting is at auto 6.0-12.0 and almost every night so far it has averaged 11.8 for the entire night so even though it can go down to 6 when it feels 6 is appropriate most the night it feels 12 is appropriate. 

2)"I still seem to have AHI and hypopnea (probably accompanied by jaw clenching) issues, especially after switching to AUTO mode - any recommendations?" 

Anything under 5 is normal, don't expect to be able to get to 0, specially when it is just hypopnea and not a full on apnea.

3)"-Is my data before AUTO mode unreliable, because my leak was high (many nights seem to be above the upper leak threshold dotted line)?  Was I just not getting therapy?
-I assume the leak issue was due to mouth breathing? Is that problem still apparent?"

Two parter here, which I have to ask a few questions, what type of mask do you use? If it is just a nasal one, if you know you mouth breath then you should definitely be using a full mask. And if it is a full mask have you actually made sure you have the right size to properly fit? And if that is a yes have you properly adjusted your straps?

4)I'm not sure how the RAMP works on this mode but I have that set at 8 to give me "enough" air to feel OK going to sleep. 

The ramp setting has the air start out at a lower level then your prescribed settings and then slowly raises up to your prescribed settings over the (based on your settings 30 minutes) to allow you to fall asleep before the high pressure kicks in, literally to avoid that feeling that you said you were not getting in question 1, that is the point is to allow you to sleep BEFORE that higher pressure kicks in so you don't feel like you are being forced air.

Based on the fact your sleep doctor basically told you "hey your pressure is to high, turn it to where it will adjust the pressure as it sees fit" and you basically replied "well now I don't notice it when I am not suppose to notice it I am going to turn it up so I notice it totally ignoring your suggestion, my wager would be that you have the settings too high because you think you are supposed to feel something that you are not. For example my current settings are ramp set to auto starting at 4.0 and pressure set to 6.0-12.0, with those settings the first 5-15ish minutes it runs at 4.0 until it thinks I am asleep based on my breathing pattern and then ramps up to the prescribed settings, after that 5-15ish minutes it runs at about 8.6-9.2ish till I actually fall sleep because it senses I don't need that much pressure because my breathing is still normal because I am still awake and then after I fall asleep it goes up to 12 and stays there pretty much the rest the night because that is the pressure it thinks I need while still falling in the 6-12 range. Even though the range is set 6-12 it is pretty much always in the 9-12 range because that is what auto does is adjust the pressure to what it thinks you need based on the data it is generating.

As far as the TMJ goes, yeah that is no fun at all, I have issues where if I allow myself to fully yawn my jaw locks open and I can not close it, while if I moved it in just the right way basically using one hand like a nail and the other a hammer whacking the jaw at the right angle I could close it but it was extremely painful and if I accidently allowed myself to yawn again there would be no way for me to actually close my jaw because the pain from getting it to move again the first time is so painful it is terrifying to think of what the pain would be if I tried again while the pain is already there. I luckily never had chronic pain from it but holy **** if the pain is even a fraction that of when my jaw would lock open that would be horrible. I hope all goes well for you with that. Luckily it sounds like you just have the pain symptoms and not the locking joint part, that is absolutely terrifying when that happens, you can't really swallow, you can't really talk, it is no fun when it happens.

But yeah the few questions is what style mask are you using and is it actually the proper size for your face? The numbers are great and all, but the numbers mean almost nothing without knowing what type of mask at the very least, for example if you are using a full mask and mouth breath you shouldn't be having any leaks unless it is either the wrong size or the straps aren't on tight enough, but if you are using just a nasal mask then the leaking could be coming just from mouth breathing because the air will leak from your mouth if you are using just a nasal mask. So that is the most important question before anyone can really answer anything based on the numbers. It is kind of like saying it is 40* outside without giving a scale, if it is 40*c then it is hot, if it is 40*f then it is chilly and if it is 40*k then it is ungodly cold, the numbers are basically going it is 40*, the knowing what mask style you are using gives the actual scale wither it is F/C/K.


EDIT: BUT with that said, I do agree with the previous poster that the poor nights sleep sound more like an oral issue then a apnea issue, the apnea looks like it is well managed being under 5 which leads me to think that the poor sleep is due to the TMJ and not the apneas, but that is not to say stop using the machine, the machine is doing what it is supposed to, it is just you have two separate things effecting your sleep, you have one well managed and you need to get the second managed as well.