Tobiathan therapy thread

[tobiathan]

Hi all, I'm new here. I was diagnosed in 2019 and prescribed a ResMed Autosense 10, 5-20cmH2O, with a P10 mask. Therapy was uneventful up until this spring, when I started occasionally seeing AHIs above 5, when they used to be below 3. This month I've had a few nights in the AHI 8-10 range. I could really use some help figuring out what's going on.

I switched to an F20 full face mask in early June when I had COVID and was too congested to use nasal pillows. These are the differences I've observed from the P10:

• Once I got the F20 dialed in, my leak rate was zero for days on end, which I've never experienced with the P10.  Once in a while I do get a massive air leak that wakes me up.
  
• I'm seeing centrals and RERA episodes and hypopneas with the F20, not so many OAs. If I switch back to the P10 it's mostly OAs. The Events graphs look so different!
  
• The machine is going to considerably higher pressures with the F20, maxing out at various points in the night. With the P10 my pressures are lower.
  
• At this point I've had good and bad AHI numbers with both masks
  

I am sleeping on my back way more than I used to. My preference is stomach sleeping but I can't manage it with the F20 (I can with the P10 by turning my head, which I realize is not optimal). Runner-up sleep preference is side but my hips and shoulders are acting up, so I'm on my back a lot now. In my sleep study, my AHI was worse on my back but not hugely so.

I just installed OSCAR late last week so I don't have a ton of data, but I'll attach two representative samples (I've been switching back and forth between the masks, always changing the setting in the clinical menu accordingly). July 19 I used the full face mask, July 21 I used nasal pillows (and raised the minimum pressure to 8 because otherwise I feel like I can't get enough air when I start). I don't have detailed data much before that, unfortunately. I noticed that while my AHI was better on the 21st, I actually had more than twice as much total time in apnea.

I've been experimenting with different pillow heights, trying to avoid chin tuck (one complicating factor is I've developed some vertigo recently, and elevating my head seems to help with that, so I'm reluctant to go too flat). I've also tinkered with EPR. I have trouble exhaling without it but I've been reading it's associated with central apneas. At the moment it's set at 3.

I'm probably going to set up an appointment with a sleep medicine place — it's been about four years since I've had any contact with the original place I went that did my (home) sleep study. FWIW, my sleep study in 2019 indicated AHI 35.9, a mix of central and obstructive apnea, pre-therapy. The doctor didn't really say anything about the centrals and I didn't know enough to ask at the time.

Appreciate any advice!

   

   

[Old Steve]

It appears that you are having Positional Apnea (clusters of apneas). Get off your back, use a flatter pillow, sleep on your side (use a higher pillow) or use a soft cervical collar.  I tried all of the above, sleeping on my side was the only thing that worked for me.   Pressure will not help with Positional Apneas.  You need to get you positional problem under control to see what you real AHI is so your pressure can be adjusted if needed. 

Did your sleep test show Central Apneas, if not you are most likely having Clear Airways.  Clear airways are caused by having an arousal and then holding your breath. Not unusual.  If you enlarge the Flow Rate section where you had a CA and you had an arousal just prior to the CA it is most likely a Clear Airway.

[Deborah K.]

You would feel better and have better therapy if you raise your minimum pressure to 7 and raise your EPR setting to 3.

Also, as Steve said, the positional apnea needs to be dealt with.  With your vertigo, you might be most comfortable using a soft cervical collar to control your positional apnea.  That way you can sleep in any position while still solving the position apnea problem.  Good luck!

[tobiathan]

Thank you Steve and Deborah! 

My sleep study showed AHI 35.9, with 6.9 being apneas and the rest hypopneas. Of the apneas, it showed 4 central and 2.9 obstructive. But for  some reason the diagnosis was OSA, not mixed. 

Regarding settings — I actually did raise the minimum pressure to 8 and EPR to 3 after taking the July 19 screenshot. Last night was somewhat better, 3.6 events per hour.

It sounds like I should look into that cervical collar. I already look like Muppet Darth Vader in my F20, so I guess I needn’t worry about how I look to my spouse. 

Odd thing though, even if I take the FFM and supine sleeping out of the equation, my numbers are still noticeably worse than they used to be. My machine has 13K hours on it but I assume/hope it’s still working right. The only medical changes are that my blood sugar’s gone from slightly prediabetic to solidly prediabetic  , and also I went on BuSpar.

[tobiathan]

I'm ordering a cervical collar, but while I wait for it, I found one of those U-shaped travel pillows from an airport and thought, "Hmm?"

Tried it (with the U in front and the opening in back) and managed to keep it in place all night. Looks like some improvement compared to the previous night, but this pillow was probably not an adequate substitute for a cervical collar.

[attachment=67435]

[tobiathan]

Update: I thought "I used to get numbers under 4 or 5 every night, I'm going to try what worked then."

Back to the P10 nasal pillows. Wasn't liking the flat pillow, so I stacked two pillows—I seem to sleep on my side more comfortably with two. Jettisoned the makeshift neck pillow. Did this for the last couple nights and results were 3ish like the OSCAR screenshot below. 

Honestly, I miss the full face mask. I miss how easy it feels to breathe with it, compared to waking up and turning over periodically to try to clear one side or the other of my nasal and sinus passages. But my results with the F20 were really uneven and it was putting a little pressure on my lower jaw with the large mask (and, with the medium size mask, on the lower front teeth) which is a problem with some periodontal issues I'm having with my lower teeth. So I'm going to have to save the F20 for nights when I'm sick and so hopelessly congested that breathing through my nose is too difficult. 

I mean, I'd like to get these numbers lower, but 3 is an improvement over what I was seeing for a while. 

[attachment=67881]

[Old Steve]

Looking at your most recent chart, it appears that you need more pressure.  I would try 10cm minimum and leave your EPR at 3 for now.  Post some new charts in a few days.

[tobiathan]

I’m curious what pointed to a need for higher pressure, I assumed the machine adjusts as needed. I raised the minimum from 5-8 because I was noticing I felt air-starved when first turning on the machine, especially with the nasal pillows mask.

[Old Steve]

In  APAP mode the machines do adjust the pressure, after your apnea. The reason I suggested 10cm is because your average pressure is 10.56cm, so 10cm is an obvious pressure to eliminate the Obstructive Apneas before they occur. 

[tobiathan]

Thanks Steve! It’ll be interesting to see how this goes.