[Treatment] New CPAP user, help with settings

[tleish]

I was diagnosed with Mild OSA in 2022.  I shrugged it off as it was diagnosed as "mild", AHI was somewhere in the low 5's.  About 6 months later I decided that maybe I should do something about it.  Like many others, I tried multiple methods OTHER than CPAP (mouth taping, mouth appliance, force sleeping on side, etc).  I eventually purchased a ResMed AirSense 10 and tried it out for a few nights, but gave up as I felt my sleep was worse.

In the meantime, I suggested my wife get a sleep study because she often wakes up tired.  She never got a sleep study.

Fast forward to 3 weeks ago, I decided to give the CPAP with nasal pillow mask another go.  The first few nights were rough again.  I would wake up multiple times with air screaming out of my mouth (oral mouth venting), or sore nostrils, adjusting to the mask or something else.  With some research, I now wear a cervical brace to help keep my mouth closed.  I use a salve on my mask which cuts down on the soreness.  I also don't skimp on the amount of distilled water in the reservoir.  At one point I adjusted my EPR from "Off" to Auto at 3 cmH2O and that seemed to help.  

Then something happened.  After keeping the mask on all night I woke up 2 hours earlier than my normal alarm time.  Not only was I wide awake, but I felt amazing.  In fact, I had one of my best workouts that morning, smashing several of my workout metrics.  This continued to happen, waking up earlier than normal but feeling much better than I had in a while.  I wasn't sleepy during the day (at least I didn't think I was), but I felt great most days.  Some days I feel better than others.  Surprisingly (or not), my AHI score seems to correlate with how I feel.  For example, the day I felt great and smashed my workout I had an AHI score of 0.66.  

Another surprise is that my wife now sleeps better at night and wakes up more refreshed.  Turns out, I was the cause of her not sleeping great.

However, this past week my AHI has fluctuated between 2.59 and 7.96 (last night).  I understand it's normal to fluctuate, but is a 5.41 and a 7.96 from this past week while wearing the CPAP all night an acceptable score?  Last night I "slept" longer than I normally do (9 hours), and yet my AHI was 7.96 and I feel very tired today.  I can see in my report that I had 62 CA events last night (I usually average between 10 and 20).  At one point during the middle of the night my wife said she woke up and thought I had stopped breathing, she waited until she could tell I was then went back to sleep.  I feel groggy today, much more than usual.  I'm  new at this and hoping I might get some help with making some adjustments in order to have more good nights of sleep.

Note: Reading through some of the forums today, I realized that my CPAP mask settings were incorrectly set to "nasal", when they should be "pillow"?  I use ResMed AirFit P30i.

What other settings should I be considering?

Thanks

NOV 8 OSCAR DATA

       

---

NOV 4 OSCAR DATA

         

[tleish]

OCT 24 OSCAR DATA (the day I felt great)

         

[tleish]

Looking at my screenshots, I now realize a difference in settings before/after

Setting 1: Oct 24

• Pressure Min: 5 cmH20
  
• Pressure Max: 12 cmH20
  
• EPR: Off
  

Setting 2: Nov 8

• Pressure Min: 4 cmH20
  
• Pressure Max: 10 cmH20
  
• EPR: Full Time
  
• EPR Level: 3 cmH20
  

However, I'm pretty sure I didn't sleep well with EPR Off.  I remember waking up in the middle of the night feeling like I was gulping air.  I read somewhere to enable EPR, and it seemed I slept more through the night after that.  I've had many days on Setting 2 with an AHI below 1, so I don't know that the EPR setting is the cause.

[tleish]

I made the following adjustments last night:

• Pressure Min: 4 => 6
  
• Pressure Max: 10 => 12
  
• EPR: 3 => Off
  
• Ramp: On => Off
  
• Mask: Nasal => Pillows
  

I was surprised that my pressure climbed to the max 12 around 3am (not sure what caused it).  I thought going from a max 10 to 12 would be plenty of headroom.  I woke up around 3am (I don't know if the pressure woke me up, or whatever was causing the pressure to go up).  Upon waking, I felt the pressure in my throat and some air in my stomach.  I got up for about 15 minutes and the laid back down.  Took me a bit to fall asleep again.

My AHI went from 7.96 (the night before) to 7.08.  There are still lots of CA events, but this time they seem to be clustered and might be caused by what I've learned is called sleep-wake-junk?

Reading other posts and charts, I believe I should now consider adjusting the following?

• Pressure Min: 8
  
• Pressure Max: 14
  

or

• Pressure Min: 9
  
• Pressure Max: 15
  
• EPR: 1
  

The good news is, I feel better this morning then I did yesterday morning.

   

[Jay51]

In this last OSCAR chart you post, the CA's occur at the beginning of sleep (falling asleep) and the end of sleep (just before waking up).  This is characteristic of sleep wake junk since that is the time it occurs (as opposed to the CA's being rather evenly spread out during the night).  

In sleep wake junk, the brain doesn't perfectly hand of voluntary control of breathing to involuntary sleep breathing and vice versa.  Not that uncommon. 

As for EPR, basic titration says to keep raising EPAP pressure until all OA's are resolved ( if you have positional apnea - clusters of OA's, etc. then you may need to lower your pillow height, side sleep vs. back sleep, or even try a soft cervical collar to prevent your chin from tucking into your chest during sleep (kinks the airway like a garden hose).  

Then, after you get EPAP set just right, adding in EPR slowly (I would suggest only going 1 EPR at a time - so you could try EPR 1 full time to further decrease hypopneas (H's) and any lingering flow limitations.  It takes a little time for most people to adjust to EPR (going from off to EPR 3 full time all of the sudden can cause CA's).

[tleish]

Jay51, thanks for the response.

Reading other posts I thought when the Med was higher than the Min, then it's good to bump up the Min.  And when you bump up against the Max, you should increase your max.

Based on what you are saying, I don't need to adjust Min/Max anymore with zero OA's, I just need to adjust my EPR to decrease my H's?  If so, I also remember reading a thread that suggested when bumping up EPR you should also bump up Min/Max.  For example, I would set EPR: 1, Min: 7 (previously 6), Max 13 (previously 12).  Is this how I adjust EPR, or I only change the EPR without changing Min/Max?

[Jay51]

Good thinking.  Since your OA's are under control, time to try EPR.  Yes, you can increase epap by 1 every time you increase epr by 1 if you want to.  You can also just try increasing EPR by 1, etc. and leaving your epap alone and comparing the results.  

Then same strategy with EPR 2 and #3 (if they are necessary).

Your H's are spaced out (apart) vs. clustered (could indicate positional apnea).  This is a good thing.  There are techniques for positional apnea, but hopefully you will get optimized with the EPR experiments.

[tleish]

Great feedback!  I'm going to try some adjustments for the next few days and see how things go.  I'll report back.