1st week on APAP down - Am I on the right track & flow restriction?

[HokiEd]

First off I want to thank everyone in the community. It was this board and the other online resources that enabled me to start this journey with a positive attitude and the determination to succeed. 

Background: 
My wife has always said I had sleep apnea but about 3 months ago I started to feel symptoms of extreme fatigue, fogginess, my lungs feeling strained after sleeping, in addition to some other typical symptoms. After some experimenting with recording my sleep sounds in various positions I confirmed I had sleeping issues which were worse on my back and better when sleeping inclined. I visited my primary Dr. for various bloodwork and a cardiologist which all came back negative so I requested a referral to a sleep specialist. 

About Me and Sleep Study Summary: 
I am a fairly active early 30s male with a BMI of 19. I suspected UARS but was surprised to see numerous OAs and hypopneas recorded by my home sleep test results (performed while sleeping inclined). The overall AHI was 6.1 per hour. A total of 13 apneas (OAs) and 43 hypopneas were recorded and was worse when supine. Longest apnea was 49 seconds (!!) with an average of 27 seconds. Oxygen saturation averaged at 96% with minimum 92%. 
I suspect this could be worse when sleeping flat. Everything looked pretty good on paper but I decided to pursue this to see if my symptoms would improve.

The doctor gave me a prescription for an APAP with pressures ranging from 4-12.

Optimizing Settings
Below is a summary of how I've been tinkering with the pressures and why. It's cut off in the screen shots, but I've had EPR and ramp off all of the nights except the last. I've been getting around 6+ hours with the CPAP most nights and felt really awake the first few days (maybe adrenaline) and am still feeling fatigued otherwise. Previously my lungs felt worked from what I suspected as working against the resistance and now they feel worked breathing against the pressure.

Nights 1&2: 4/12; AHI 2.3 & 0.9; I attached one of the Oscar days, but it was a bit of a mess as to be expected  . I noticed trends of waking up as the pressure rapidly built up. I experienced mouth leaks, chipmunk cheeks, and aerophagia. Average 95% pressure over first two days was 10.4.

Night 3: 6/10.4; AHI 0.87; Reduced pressure to help get used to sleeping with CPAP and started taping mouth. Only a single hypopnea this night and some chipmunk cheeks. Had central apneas for the first time (4 total and not sure if they're all real). 

Night 4: 6/9.4; AHI 0.16; Reduced max pressure some more. (1) hypopnea all night! Reduced aerophagia.

Night 5: 6/9.4; AHI 1.16; Changed masks from F&P Brevida to F&P Evora. Had a couple drinks for the first time since symptoms started and pressure was on the higher end most of the night. Not sure if its a good data point. The new mask resulted in even less leaks but felt harder to breath against due the smaller exhaust holes. 

Night 6: 5.4/9.2; AHI 0.17; Oscar attached

Night 7: 5.4/9.2; AHI 0.66; Tried EPR 1 because it's been pretty hard to breath against the pressure the whole week and I read it could help with flow limitations. My wife said my breathing sounded more natural but the respiration rates appear the same. Saw (4) CAs ranging from 10-23 seconds. 

Questions:
1. I've been lowering the pressures to help get used to the device. Should I start bumping it back up as I am able to allow the APAP to do its thing or am I not hurting anything by creeping down since my AHI seems mostly un-impacted. My goal was to tighten the range so the large swings didn't wake me up and to eliminate TECAs.

2. Am I on the right track? I still feel really fatigued but realize the process will take time. I was wondering if my approach of messing with the pressures is productive or if its too early to be making these micro-adjustments. My hope is to give my lungs a bit of break by lowering the pressures but don't know if i'm doing more harm than good.  

3. Should I be concerned with the flow restrictions? Each night has had a similar density. Please see the sample screen shot which shows my flow rate at the higher end of the pressure spectrum. I was wondering if I should try EPR at 3 but wasn't sure how compatible it was with my current pressure settings or if I should just stick with the current settings for a while per question #2. 

Thank you! I plan on posting my side by side experience with the F&P Brevida and Evora masks so stay tuned.

[SarcasticDave94]

Welcome to the Apnea Board,

It appears you sometimes mouth leak, which can disrupt sleep and cause therapy to blow out. Just be aware for now, but a later action might need to take place, something like a chin strap to keep your jaw pulled up but not back.

Bigger issue, I'm seeing shaggy grass in the flow limits chart. Make your minimum 5 so you can use EPR 1 full time. For each EPR setting, you must add this to 4, the lowest PAP pressure, for it to work properly. 4 + EPR 1=5, 4 + EPR 2 =6, 4 + EPR 3=7. It does need on full time.

EPR can combat the FL shaggy grass issue. I'm suggesting EPR 1 for now, but higher will likely be needed. Deferring to aerophagia for now. Maybe try left side and/or slightly elevated head area of the mattress to combat the aerophagia.

[HokiEd]

Hello Dave, 

Thank you for the advice. I actually tried full time EPR of 1 last night with min pressures of 6 (Oscar attached to this post) and it looks like the grass may have thinned out a little but is still mostly there. 

I will try to bump up the EPR another notch using the principle you mentioned.

[SarcasticDave94]

OK copy, and you can see EPR 2 within pressure 6 cut some FL grass. That's the positive change that you want to see. FL represents the beginnings of an Hypopnea, a partial Apnea. The flatter, lower activity, the FL chart, then it's more likely you're resting with less disruptions.

Feel free to include an OSCAR shot tomorrow along with your answer to "How do you feel?" Take note to answer with critical descriptions involving sleep and therapy.

[HokiEd]

I was able to try the EPR 2 last night and actually feel fairly lucid and rested despite the limited hours! I imagine it will catch up to me in the afternoon but perhaps its quality over quantity at this point in my therapy. 

My lungs don't feel nearly as fatigued and my breathing felt much more natural with the EPR 2. I will try EPR 3 with a min pressure of 7 tonight to see if that provides any additional benefit and reduce the shagginess.

I woke up a few times due to heartburn and aerophagia but tried using some earplugs which really helped me take my focus off of the CPAP sounds and fall back asleep faster.  1.0 now, but still tired? Is it UARS, RERA, arousals or FL in your FR peaks?"

[SarcasticDave94]

The FL chart looks a lot better now. Next is getting more hours on therapy. You're getting there and there's progress so it's going right.

Reward yourself with a coffee.

[quiescence at last]

given your scores, and the feeling rested, that is a good sign you have effective treatment.

also, I think your question of whether it is ok to put an upper pressure maximum fairly low to combat leakage, but more importantly reducing wake ups and giving your lungs or abdominal muscles a break in the "getting used to therapy" mode - my answer is yes.

while it is good that the numbers also show as good, i would have still felt justified in reducing the upper bounds even if the results were less ideal, until the body makes peace with the machine. even in cases where AHI were > 5 the adaptation to the machine is more important in my mind as it results in restfulness.

i would estimate that 14 to 21 days or even more could be a rational peace making period.

for the record, the charts seem to be showing that the upper limit of 9.2 is ok, as the pressures do not automatically rise to the maximum and bump up against it a lot.

if this was my chart i would be happy. also, i would have picked either EPR 1 or EPR 2, and would adjust my start pressure to be [6] + EPR. 6 is picked from the average of the median exhale pressure for those 2 nights recorded (6.9 and 5.2). So, with an EPR of 2, the minimum pressure is 6+2=8.

QAL

add: after make peace period, you could erk the maximum pressure up just a little bit, in 0.6 steps from 9.2 to 10.4 just to see if the 90% pressure stays in the 9.8 range.

[HokiEd]

Good Morning Again! I got some espresso in celebration of the prior nights progress .

Last night I slept on an incline and tried EPR 3 but forgot to raise the min pressure. The change triggering some TECAs and I noticed the flow rate resembled more of a wave (screen shot attached) in many instances rather than a constant in and out rate. There were more instances where I stopped breathing with a clear airway but didn't get flagged due to the duration. 

I was able to log some good consecutive hours on the CPAP last night but woke up feeling more tired than yesterday. I'm hoping the extra hours will carry me later into the day before I crash. 

The flow limits and comfort improved with EPR 3 but that didn't manifest into feeling as rested during this particular night. Is it typical for someone to be able to raise their EPR without triggering TECAs or strange breathing patterns if done over a longer period of time?

I will revert to EPR 2 tonight and experiment with raising the min pressure per QALs recommendations over the next few nights.

Thank you!

[SarcasticDave94]

Now, you get to evaluate which felt better EPR 2 and flatter rate or EPR 3 a bit of CA, etc. The CA level is there but not a high enough rate to require action against them unless you're less comfortable.

Note that EPR 3 might look different the next time. You've not built a trend yet of what to expect, what's going to be your normal look. This isn't negative, it's what is just there with beginners.

You could try pressure Min 7 with EPR 3 and see if you like it but it may affect CA either via up, down, or possibly no change. CA of any sort are consistently inconsistent, they will naturally be up and down randomly.

Bottom line is settings go where you feel most rested and comfortable.