Second attemp at therapy

[Jonkier]

Two more nights data.

Night 1 - pressures 8min 10max EPR fulltime 3.

Couple of hours. Subjectively bad sleep as usual with plenty of awakenings, burping, general aerophagia.

Night 2 - automode but 9min and 9max (fixed) EPR fulltime 3.

2 stints with a long period in between without mask. Airsense 10 flagged CSR for about 15 mins (in image 14.05.24 B). Is this legit, or just periodic breathing. Something interesting about this...lastnight was the first night I have turned onto my left side and fell asleep with the mask on. This is due to wife seeing me when facing left so I always sleep on right so she doesnt see me with the massive mask and hose sticking off my head. I know, let the ego go. I'm pretty sure this CSR corresponds to being on my left, but can't be certain. Lots of centrals in the CSR period. In my at-home sleep study I showed about 9 total centrals, and about 150 H's, and was diagnosed with OSA (not complex).

Again, subjectively terrible sleep with the usual 53976 arousals/awakenings, and burping. 

I watched this video yesterday, and the 'EPAP is the therapy' really stuck out to me, hence the fixed pressure to avoid overly high IPAP and subsequent aerophagia. Am I wrong with this. It's like i'm battling with the war between having the pressure high enough to 'stint' my airway and provide therapy, and aerophagia. 

If anyone could offer any advice i would be greatly appreciative. I am starting to feel lost with this. Feel like I should go see a sleep specialist but cynically feel like it'll be a waste of time vs reading up on all the great advice and case studies found on here. I'm startung to buy into the idea that this SDB is having a massive effect on me physiologically, emotionally, psychologically. I am up and down with mood, maybe depressed, lethargic and have 0 energy or motivation to do anything, anxious.

Sorry guys, for the rant. Really want this therapy to work.

Best regards,

Jon

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This was the video I watched -

Dr. William Noah - Manipulating the PAP Circuit

https://www.youtube.com/watch?v=EWTzFXNUIZU&t=2050s

[40plus]

That video was intresting. That guy seem to say kinda what lankyleft and some others say that epap should be kept up and one should not use epr.

The strange thing is that if i have no epr i get higher flow limitations and flatter flow rate top combined with more snoring. Fixed pressure of 9 or raised to 15 doesent affect these issues at all but epr does. As soon as i start using epr flow limitations decrease, flow rate tops get rounded instead of flat and i snore less or not at all.

So how come some, incl experienced doctors, say that epr shouldnt for the most part be used while others like people here and my own experimenting show that it is very beneficial?

[Jonkier]

I read some posts yesterday stating that, and I paraphrase, it's the pressure support, or pressure differential that assists when EPR is on. 

I still don't know if I am understanding the concept correctly. More reading I guess.

[Jay51]

I will try to explain a little bit (and anyone can jump in here and correct or help also).  EPAP is the "stent" or "splint" that keeps the airway open. It increases oxygenation (mainly spo2).  With a wide open or nearly wide open airway, it is much easier to breath.  Mainly used for large, obstructive apneas.  

EPR (or PS) can and does decrease flow limitations and other mild resistance.  I have seen it here in many charts when a person starts using EPR, flow limits decrease.  Not in every single case though.  It gives a little extra "umph" or "boost" to each inhale.  And can suction out a little bit more CO2 on the exhale.  People start breathing so much better with EPR, that some develop CA's.  Not all though.  

3 is the max for EPR.  A VAUTO can go 4 or maybe 5 or even more I am not sure.  An ASV can go 5 or more for Pressure support (PS).  When pressure support gets really high, it is being used like a ventilator (to mechanically assist breathing and force inhales).  

Everyone would need to experiment for themselves to figure out their own sweet spot here (straight cpap pressure, or 1, 2, 3, EPR, or even more with a VAUTO or ASV, etc.

[Jonkier]

Hey guys

Been playing around with different pressures. Really at a loss at the moment. 

I've tried: 

pressure at 11 fixed with EPR 1
13 fixed with EPR 3
8-10 EPR ranging from 1-3

Even the high pressures I still woke lots and the flow rate shows periodic breathing with recovery/arousal breaths.

Do I try even higher pressure? After some reading I kind of fit the UARS template, healthy weight and fit, don't snore, AHI <5, but plenty of flow limitations leading to recovery breaths, subjectively terrible sleep with cognitive impairment and daytime sleepiness etc.

I did also purchase the Wellue o2 ring. What this has shown quite consistently is that when I have the mask on, even at lower pressures, my oxygen saturation is quite stable. Once I remove the mask, which most nights I do from frustration of waking up over and over again, my spo2 levels start to drop. 

I guess the more stable o2 levels is a good thing re: cardiovascular/ANS etc BUT im still waking up constantly, gasping for air sometimes, always tired, and my breathing is almost never consistent and always flat-topped. 

Have attached a couple of nights data. 

03.07.24 screenshot says 8-13 but this was only for a couple of minutes at about 2am, which I have unhighlighted. The pressure was fixed at 13 with EPR 3.

Any help would be massively appreciated.

[Jay51]

What jumps out at me the most in your charts is the large amount and frequency of movement during sleep.  Do you have PLM's?  (Periodic Limb Movement).  The movement alone could be the cause for all of your arousals. 

All of your other statistics look at least reasonable to me personally.  Flow limitation of 0.05 at 95%.  Good tidal volume and respiratory rate and I:E ratio.  You don't quite have clusters of H's., but close.  Lowering pillow height, side sleeping instead of on back, and possibly a soft cervical collar would combat these.  

If anyone sees anything else in these charts, please feel free to post.

[Jonkier]

Hey Jay51, thanks for your input.

It's an interesting question. I am certainly quite twitchy and get 'spasm attacks' as I call them sometimes when I'm very tired eg lying down watching TV and just cannot lie still, have to be moving. It's almost painful until I go to sleep. 

However, I do strongly believe the movement is driven by the airway restrictions. 

An interesting night lastnight. Decided to set the pressures at 10-12cmH20 with EPR 2, based on the prior nights 13 fixed not really seeming to be any better, and probably worse than lower pressures. I know it was only one night but went with the idea anyway. 

Took the mask off after about 45 mins as usual after restlessness and awakenings. Put the mask back on at 2am until 3:50am (my wake up time) and had what looks and felt like a great 2 hours. Spo2 is stable, little movement, nice consistent flow waveform(v rare for me), very stable respiratory rate and minute v. Still flow limits present however.

The flow rate does get a little inconsistent around 3:05am until I wake to my alarm, even though the pressured are driven higher by the autoset algorithm. I guess my question would be; does this indicate that higher pressures won't necessarily be better for me? Or, is this a period of REM sleep and things look more erratic due to that.

The dream is to get 6 or more hours similar to the time from 2-3am. 

Best regards,

Jon

[40plus]

Im in a similar situation where ahi is damn near perfect but sleep quality is crap. I only wake up once or twice a night that i know of but have lots of arousals.

Anyway i been experimenting a lot. Finally i settled on a mask, N30i. I cant stand it with nose pillows neither can i stand Dreamwear nasal pillows because the breathing feels too restricted.

If i have fixed cpap at 13 cm and epr 3 i have perfect breaths with nice rounded tops. Flow limitaion is 0.0. No snoring. The data in oscar show perfection. But i wake up feeling like a zombie, way worse than pre cpap (ahi 69). Lots of spikes in the flow rate.

If i lower the pressure to 12 or even 11, and lower epr to 2 or even 1 something intresting happends. Flow limitations increase but still somewhat ok. Snoring increase. Less rounded and more flat breaths. Data in oscar is not nearly as perfect as above. But i feel more rested when i wake up. AHI is even lower than with above settings and sp02 is higher and more stable throughout the night.

So try and not only look at Oscar and chase techincal perfection. Rather chase sleep quality and restful sleep at the expense of how the data looks and even ahi.

[Jay51]

Have you talked to your PCP about your muscles, "twitching" so much?  PCP might have a medication to stop these.  A Neurologist consult may even find something and even provide medication to combat it.  

You know your own body best.  I personally have never heard of flow limitation, etc. causing muscle twitching.  You may be right, but it seems like PLM's can cause a lot of arousals during sleep.  

I hope that you get this figured out.