[Treatment] New to CPAP but keen to learn - Please could you help with results and Q's?

[JustinWoods]

Hi folks,

Very grateful to be here as sleep apnea seems to be a confusing and slightly scary place so having a warm and knowledgable community is a great comfort.

I have a few questions/clarifications I'd love your thoughts on, please.

Context

I'm a UK based, 43 year-old male, 5ft 11inches, 190lbs, 26.9 BMI, mouth breather, big snorer, mild asthmatic, non-smoker, very low alcohol intake, in moderate pain with a herniated disc in my back requiring surgery in a few weeks. I have a few other comorbid factors which are likely a result of having sleep apnea rather than causing them.

I seem to be caught between private healthcare (BUPA who don't want to treat sleep apnea) and the NHS (sleep apnea doesn't seem well understood and massive delays make treatment difficult). I guess many of us are!

I did a private sleep study (Intus Watchpat) in March '23 which confirmed a mild sleep apnea (9.7 AHI) so I self-funded a ResMed Airsense 10 with a ResMed AirFit F30 Full Face CPAP Mask. 

I'm slowly trying to get used to CPAP therapy and better sleep hygiene. So far I'm able to sleep with the machine on for 4 hours or so but then wake up and can't fall back asleep with it on so take it off for the rest of the night. I'll keep at the frequency and duration of using the machine but for now I would like to share last night's OSCAR charts and validate some thoughts....

1. Mask Leakage
In general my mask leakage rate I believe is good but last night's was awful. I sleep in the recovery position and tend to push my mouth and mask into the pillow. I never sleep on my back. I woke with the mask blowing into my face so thinking I need to re-adjust the mask, tighten straps and perhaps change my pillow height or pillow position. I'm using a hose lift already which is helpful.

2. Mask choice
I'm liking the Airfit F30, it seemed the obvious choice for a mouth breather. Interestingly when I wear the mask I'm finding I become more of a nose breather. I've used a snoring recording app on my phone and it also *sounds* like my snoring is more nasal these days with the CPAP on. Should I stick with the F30 full face for the moment and seek the perfect fit or look into a nasal-style mask?

3. CPAP Pressure
I'm just starting out self-titrating so Min pressure is 4 and Max is 9 (up from 7 over the past few months), 30 minute ramp, EPR is off as I just don't seem to like it varying!. I suspect I need to raise both Min/Max based on what the flow limits are showing. Would you agree? By how much should I tweak these and over what timescale?

4. Current aggravating factors I think affect my Sleep Apnea
- Back pain causes problems falling asleep or going back to sleep when I wake in the night - I'm hopeful that surgery and subsequent recovery will make this easier but at the moment it likely doesn't help matters
- Pain killers are largely a necessary evil. I'm only using over-the-counter medicine (paracetamol, diclofenac, ibuprofen, codeine). Codeine is often the only thing strong enough to help with my back pain and to fall asleep but then I pay for it during my sleep with increased snoring, central apneas, and less deep/REM sleep. How do folks balance this vicious cycle (at least until my surgery/recovery are completed).
- Bad sleep hygiene - I'm really focused on improving this right now, including consistent bedtime/wake time, no bright screens, magnesium, a separate bed to my wife etc. I do think I carry a level of anxiety and mild insomnia about going to bed and falling asleep. Is there anything else I should be considering?

What do you think? Is there anything else I should be changing, thinking about, or considering?

Thanks for your help and reading this far.

   

[Jay51]

Hello Justin.  Welcome to ApneaBoard.  If you say the leaks last night were a "one - off" thing, then everything else looks ok to me IMO.  You can try raising both your min and max pressures.  Do it slowly (by 0.2 if you can here; if not then by 1.0).  Take note of any changes to your OA's, CA's and H's, etc.  Usually higher Epap treats obstructive events.  See if your central apneas stay the same or increaser or decrease.  You have some CA's.  With a 3 AHI that doesn't seem too terribly bad, but how do you feel in the morning after sleeping all night?  
Try to find your own sweet spot that gives you the best therapy and feeling well rested.  Go slow.  One night does not make a trend.  A trend consists of multiple nights.  The more the better.  
If leaks get worse with the higher pressure, just post here again and we can give you some mask tips.  Any other questions just post also.

[Gideon]

Welcome to the forum

Your leaks are mostly fine, at the end of your night your leaks are right at the borderline of being too bad. You sent his in the grayed portion on the chart where you have exceeded ResMeds stated max leak rate of 24 lpm. That is, based on your description, your mask being displaced causing a marginally high leak rate.

Based on your chart I think you could use a nasal mask, I suggest ResMeds P10 Pillow mask. This mask has 2 pillows connected together and the pillows rest on, not in, the nares, openings, of your nose. This is the smallest quietest most unobtrusive mask out there. Get a roll of tape designed to go on skin to help with mouth breathing should it occur. Taping is controversial so make sure you can easily take it off. It will not keep your mouth closed as you wi) be able to open your mouth with or without the tape.

Pillow. Be aware of your neck alignment. You need enough height so your neck does not drop down. Also, especially with a full face mask, need the mask to hang over the edge of the pillow to prevent the pillow from pushing it off your face.

Pressures.
IMHO a pressure of 4 just isn't enough. Your pressures are increasing almost solely because of your flow limits. Your 95% FL is over 0.10 which while there is no standard value for it, we consider too high with a much better value being 0.03. don't worry if we can't reach it. The best tool for these flow limits is EPR, or specifically a differential pressure between inhale and exhale. This feature makes your AutoSet effectively a BiLevel that is limited to a PS of 3.

Settings, try these
Mode:auto
Min=7 (allows maximum use of EPR and usually is more comfortable.)
Max=15 (with the addition of EPR below I don't expect pressure to go this high)
EPR= 2,Fulltime. (To manage your Flow limitations better.)

We will watch you central apnea to see if it increases.

Try then repost your charts

[JustinWoods]

Hi Jay51 and Gideon,

Thanks for taking the time to reply, that's some great advice.

Some responses and a new graph from last night (just for info, I don't need an analysis unless something jumps out!). Note: I stop/restart the machine if I'm not asleep after the 30-minute ramp so those are the "breaks" on the graphs.

1. Mask Leaks
I re-adjusted the mask straps to be symetrical using a mirror and I'm back to what I consider my "normal" leak-rate (below 10lpm average which I think is pretty good?)
You guys reminded me to reconnect the MyAir app so I have a "mask fit" score to keep track of too.

2. Mask choice
Great suggestion on the ResMed P10 Pillow mask, @Gideon. I like the style/comfort of ResMed masks. I think it's certainly worth an explore in combination with mouth tape (I did try just taping before getting the CPAP machine as it was quick to try and easily accessible). I may try that for increased comfort after I've fine tuned with my current setup.

3. Pillow choice
Also some great advice, @Gideon. I think I'll use a mirror/phone/wife to give me a perspective on how my body/head/neck align. I seem to have a tendency to sleep in the recovery position (so more on my front than side) and then move my chin closer to my chest. This "twist and tuck" is likely awful for my airway alignment as well as nuzzling the mask into the pillow. I'll see what I can do to improve my airway alignment and perhaps get a CPAP pillow so the mask can hang over the end.

4. Pressures
Thanks for the pointers, @Jay51. It's tempting to rush settings but you're right it's about finding a balance. I felt okay this morning but the issue is that I'm sleeping for c.2-4 hours with the mask (3 AHI), taking it off and then having untreated sleep until morning (? AHI). I need to work on wearing the machine continuously through the night as a control and baseline for experimentation (and obviously treatment). Then we can tune.

@Gideon, you're right. Pressure of 4 seems to equate to "normal breathing effort" for me so likely no discernable treatment.

Full-time EPR makes me focus way too much on my breathing timing and then I manual breathe and don't fall asleep. I do understand the benefit of EPR for Central Apneas which aren't necessarily about higher pressures.

I'm (respectfully) going to try the following unless you specifically say it's a terrible idea:

Mode: Auto
Min=7 (allows maximum use of EPR and usually is more comfortable.)
Max=15 (with the addition of EPR below I don't expect pressure to go this high) - Wish me luck! My ears start to pop a bit at 9+
EPR= 2, just not on Ramp. (To manage your Flow limitations better.)

Let me know if this is NOT a good combination of your collective recommendations!

The below was very good/interesting information. I'll research more to better understand about FL itself. I do understand at a technical level what you are saying about making the AS essentially a PS of 3 BiLevel.

Your 95% FL is over 0.10 which while there is no standard value for it, we consider too high with a much better value being 0.03. don't worry if we can't reach it. The best tool for these flow limits is EPR, or specifically a differential pressure between inhale and exhale. This feature makes your AutoSet effectively a BiLevel that is limited to a PS of 3.

Priorities are 
- Wear CPAP as much as possible throughout the night, every night
- Adjust slowly and find balance between obstructive and central apneas
- How rested I feel is just as important as the numbers
- Get my other health issues fixed (back surgery)
- Keep up / improve sleep hygene

Thank you again.

   

[Gideon]

I just received a Trial SCS, Spinal Chord Stimulator for my back pain. What surgery are you having?

I found muscle relaxants and codeine helpful in breaking pain cycles, but with me it would li[really knock me out for 6 hours. I found that a tens unit helped me a lot, I liked the irelieve model better than others, search for it if interested.

[JustinWoods]

Hi Gideon,

Sorry you've been having back problems too. Pain and lack of sleep are really miserable! I'd not heard of an SRS before, I wish you well with it!

I've certainly loved my tens machine (Med-Fit 3) and a Theragun both used more for muscle stiffness than neurological pain which the tens didn't seem to help with.

I have a bilateral disc prolapse in L5/S1 and a fracture in the vertebra. Been suffering with it for the past year and a half and so after some unsuccessful alternatives I will be having a fusion. Codeine is definitely helpful but it aggregates my sleep apnea badly, makes me sleepy during the day, but not so much at night!

I adjusted my CPAP settings last night (slightly differently as I mis-remembered how the config works):

Mode: Auto
Min=4* (allows maximum use of EPR and usually is more comfortable.)
Max=15 (with the addition of EPR below I don't expect pressure to go this high)
EPR= 2, Full time
Ramp pressure = 4*
Ramp time = 30 minutes

*Setting min to anything above 6 makes my ears pop and I can't seem to fall asleep. Having the Ramp Pressure at 4 and Min pressure at 4 means I get 30 minutes to fall asleep on 4cmH20 with no ramping up. I understand this means I may be initially under-treated when the machine starts to work but that is a mute point if I'm not falling asleep in the first place.

Is this still okay? At least for now whilst I get used to the machine? I don't want to hate it!

My graph from last night is enclosed. Observations:

- I struggled to fall asleep until late 1.50am after many attempts (not shown on graph)
- I took the mask off again and fell back asleep at 5.30am - need to do better but will come with practice/time
- Max pressure (95%) is 11.12 cmH20 - so this (at least for one night) was my maximum treatment pressure?
- Flow limit (95%) is 0.22 which, to your previous comment, is higher than preferable. I need to read up on what affects/treats FL if it's an important thing to tweak.
- Leak rate has increased over my "normal" to 32.8 (which is over the recommended) and likely due to increased pressures overall. So I should explore better mask fit, different mask, sleeping positions, CPAP pillow (I have one coming today)

Anything else that stands out? I think I'm happy with these settings for now and need to just increase adoption and usage. Agree?

   

[Gideon]

Your reason for using a ramp is sound so OK. You can try the Ramp on Auto and see if that is better or worse.

On Flow Limits, its the 95% we look at which is 0,09 OK but could be better.
Also Try EPR=3, see if you like 2 or 3 better.

In the future I'd like to see if a fixed pressure (8) works for you.

On leaks the "critical" value is 24, Spikes like you have ignore.

Just to give you a feel of the pressures you are actually using get a Tall glass of water and a straw. With the straw near the bottom, blow bubbles. Yes, I want you actually to do this. Assuming 8 inches of depth you just exhaled against the maximum pressure your machine can produce, 20 cmw

[JustinWoods]

Hi Gideon and AB Forum,

I am so excited to let you know that I used my CPAP machine all night for just over 7 hours (beating my previous record of 4 hours). I feel tired but not exhausted and that's a great first indicator. 

I attach my results for your interest/comments .

Responding to Gideon:

Your reason for using a ramp is sound so OK. You can try the Ramp on Auto and see if that is better or worse.

On Flow Limits, its the 95% we look at which is 0,09 OK but could be better.
Also Try EPR=3, see if you like 2 or 3 better.

In the future I'd like to see if a fixed pressure (8) works for you.

On leaks the "critical" value is 24, Spikes like you have ignore.

Just to give you a feel of the pressures you are actually using get a Tall glass of water and a straw. With the straw near the bottom, blow bubbles. Yes, I want you actually to do this. Assuming 8 inches of depth you just exhaled against the maximum pressure your machine can produce, 20 cmw
Posted by JustinWoods - 06-23-2023, 04:03 AM

Cool. I will try Ramp on Auto just to see. I will increase EPR to 3 because that may help with the non-obstructive events.
Happy to try a fixed pressure in future, I won't do that just yet.
Interesting exercise in blowing air into a depth of water (which is ofcourse where the PAP units of pressure are derived). I used a tube and a cafetiere as they were the things I had to hand 

What has helped:

CPAP pillow - Cutouts each side stop me from burying the mask into the pillow when I sleep on my side increasing comfort and reducing mask leaks even further
Changing my settings - Staying with Ramp, increasing pressures, turning on EPR
Just sticking with it - Using the machine every night. Celebrating my wins and not punishing myself for any challenges or failures.
Measuring and analysis - Being able to measure and interpret what is actually going on thanks to OSCAR and the people on this community


Going forwards:

EPR - I'm going to try EPR changes and pressure changes based on feedback from folks here.
Mask - I may tray a different mask but the current full face is working well, especially with the CPAP pillow
Frequency - Just keep going. I can see and feel results (although it's early days)

Let me know what you think about my latest OSCAR charts and if anything else stands our or I should consider.



   

[Gideon]

Min pressure should never be less than 4+EPR to allow the EPR to work.

[JustinWoods]

Good catch, Gideon!

I find pressures of 5/6+ when I’m trying to fall asleep make my ears pop which then keeps me awake. Even a gradual ramp (start of 4 up to 7 after 30 minutes) makes me focused on “when my ears will start popping” and creates an anxiety that prevents sleep (at least right now).

My ideal would be a constant pressure of 4 to let me fall asleep and then the machine adjusts from there up to my regular CPAP settings with EPR but this doesn’t seem possible with my current machine.

I’m trying to balance getting used to to the machine and not hating it vs effective treatment.

Am I strange? Does anyone else get this?