[Treatment] Out of Ideas (any help appreciated)

[Snoozer76]

Hi Everyone,

I firstly want to say how much this forum is a blessing in terms of the support and guidance it provides, particularly for those of us who are struggling with treatment and just need that encouragement.

I've been on CPAP for around 5 years now.  I was diagnosed with mild sleep apnea with around 7 events per hour (combination of OSA and Hypopneas).

I had never woken up feeling rested and was starting to become more anxious and was wondering why anxiety was happening given that I had always been a relaxed person.

Following the diagnosis, I starting on CPAP.  It has been a constant battle since that time as I have never felt much improvement following compliance - this is despite my AHI figures being very low.

I started looking more deeply into what might be stopping me from feeling better and my suspicion is that, even though my AHI events are low, I must be having some disruptions during sleep which preclude me from feeling rested the next morning.  

Traditionally I have stayed on Fixed pressure of 10 with EPR of 2.  However, last night I road-tested increasing the EPR to 3 as I read on this forum that this can address Flow Limitations which might be causing disruptive sleep.  I slightly increased the pressure to 11 (which I am aware you need to deduct the EPR of 3 to give a net pressure figure of 8).

The screenshot of last night is here.

To be honest I don't feel any better, even though the Flow Limitations, Leaks, AHI look great.  

Any help would be really appreciated - 5 years is too long to be battling with this.

Many thanks team!
       

[Gideon]

Welcome to the Apnea Board Forums Snoozer76,

Your numbers look good.  

Your breathing stats are somewhat abnormal
Your exhale time is approx. equal to your inhale time (exhale is typically twice your inhale)
Your Tidal volume is a bit low.  I'm guessing you don't weigh 125 lbs.
I'd suggest posting 2 different 2-minute zoomed in screenshots so we can see what your breathing looks like on a breath by breath basis.

Sleeprider?

[Snoozer76]

       

Hi Bonjour

Thanks very much for your reply. 

I weigh approximately 90 kg (190 pounds).

I have attached two separate screenshots for 2 minute intervals.  Are these screenshots the ones you are after?

---

P.S. I forgot to mention that I am male 5'11 height.  Thanks.

[PoolQ]

"I must be having some disruptions during sleep" this describes me a couple years ago. turns out I was very sensitive with disruptions in my air flow, not enough to wake me up fully but enough to stop me from fully resting. My last sleep study the Doctor said that I really didn't "sleep" at all that night.

Someone on this forum gave me some suggestions about settings that I have on my ResMed AirCurve (BPAP) that change how sensitive the machine is to detecting my inhale and exhale. I have a very slow exhale and the machine was cutting me off right at the end additionally the trigger level for detecting the start of inhale and start of exhale both had to be adjusted. Now I sleep fine.

Think of every time you inhale, the machine just delays you a bit. Just enough to disturb your inhale every single time and then when you exhale the machine tries to adjust for the pressure change for a second and then lets you exhale. totally frustrating and hard to see, adjustment by trial and error. Did not even take over night. I would put the mask on change a setting, try it and after the last change it was like "oh that's so much better" if this is it with you, you should be able to tell quickly, assuming you have the settings on your machine.

[Snoozer76]

"I must be having some disruptions during sleep" this describes me a couple years ago. turns out I was very sensitive with disruptions in my air flow, not enough to wake me up fully but enough to stop me from fully resting. My last sleep study the Doctor said that I really didn't "sleep" at all that night.

Someone on this forum gave me some suggestions about settings that I have on my ResMed AirCurve (BPAP) that change how sensitive the machine is to detecting my inhale and exhale. I have a very slow exhale and the machine was cutting me off right at the end additionally the trigger level for detecting the start of inhale and start of exhale both had to be adjusted. Now I sleep fine.

Think of every time you inhale, the machine just delays you a bit. Just enough to disturb your inhale every single time and then when you exhale the machine tries to adjust for the pressure change for a second and then lets you exhale. totally frustrating and hard to see, adjustment by trial and error. Did not even take over night. I would put the mask on change a setting, try it and after the last change it was like "oh that's so much better" if this is it with you, you should be able to tell quickly, assuming you have the settings on your machine.

Thanks PoolQ / Fred Bonjour - yes I suspect there is something going on as my numbers all appear pretty good but I wake up feeling as though I haven't slept.  Any ideas what I can do with my settings to tweak things in the meantime to see if it can make a positive difference?  

I've got the Resmed Airsense 10 Autoset.  Currently on fixed pressure.  But I am definitely open to what you guys can help me with.  I am also open to changing machines if need be!

[PoolQ]

I know you would need at least access to an Air Curve level machine to access and try these settings. I know nothing about the Respironics product line, but I would think that they would have some way to "fine tune" the algorithm on their products.

[Snoozer76]

"I must be having some disruptions during sleep" this describes me a couple years ago. turns out I was very sensitive with disruptions in my air flow, not enough to wake me up fully but enough to stop me from fully resting. My last sleep study the Doctor said that I really didn't "sleep" at all that night.

Someone on this forum gave me some suggestions about settings that I have on my ResMed AirCurve (BPAP) that change how sensitive the machine is to detecting my inhale and exhale. I have a very slow exhale and the machine was cutting me off right at the end additionally the trigger level for detecting the start of inhale and start of exhale both had to be adjusted. Now I sleep fine.

Think of every time you inhale, the machine just delays you a bit. Just enough to disturb your inhale every single time and then when you exhale the machine tries to adjust for the pressure change for a second and then lets you exhale. totally frustrating and hard to see, adjustment by trial and error. Did not even take over night. I would put the mask on change a setting, try it and after the last change it was like "oh that's so much better" if this is it with you, you should be able to tell quickly, assuming you have the settings on your machine.

Thanks PoolQ / Fred Bonjour - yes I suspect there is something going on as my numbers all appear pretty good but I wake up feeling as though I haven't slept.  Any ideas what I can do with my settings to tweak things in the meantime to see if it can make a positive difference?  

I've got the Resmed Airsense 10 Autoset.  Currently on fixed pressure.  But I am definitely open to what you guys can help me with.  I am also open to changing machines if need be!

Hi PoolQ - I am currently using a Resmed machine with a Phillips mask

[Snoozer76]

I can see that my Tidal Volume is quite low for a person my size.  I am wondering whether this is causing the tiredness given that my AHI is so low?  If that is suspected, what suggestions would you have to tweak settings to see if a positive impact can be made?

[Sleeprider]

We get into slippery slope when we try to affect tidal volume with CPAP or even bilevel. The respiratory system has a way of balancing out, and we often see increases in tidal volume accompanied by a decrease in respiration rate resulting in the same minute vent. Unless tidal volume indicates a likely or obvious problem, I usually ignore it. Your therapy is very good and there is no medical necessity to modify it in any way. That is why any change to a higher level device is likely to come at an out of pocket cost, not insurance. That said, many of us have done exactly that, buying our first bilevel and demonstrating the efficacy and better sleep quality through some experimentation and self-titration. Documenting the benefits of a purchased bilevel with your doctor is the alternate path to bilevel coverage in the future. It starts with having bilevel experience and that won't likely be on the insurance company's dime.

PoolQ points to the use of inspiration timing and sensitivity for IPAP trigger and EPAP cycle. These along with pressure support are features we have on the Resmed Aircurve 10 Vauto or VPAP-S, but you won't get them on the Philips Respironics BiPAP which is limited to pressure support, BiFlex or rise-time adjustments. There is a significant difference. I have no idea if this is a solution that will produce noticeably different results for you, and the price of admission varies by the deal you find through a private party or Craigslist, Offerup, Facebook Marketplace, DotMed etc.