[Treatment] The Fox's Therapy Thread (plus help with Dad)

[The Fox]

Hi Apnea Board!

Wanted to start by saying thank you for the wonderful repository of information and expertise you've built here, it has been invaluable in helping me get started with my CPAP and finding good settings for myself as I get started with my treatment. With your (indirect) help, I believe I've gotten my AHI and flow limits down to a fairly decent amount, and while I'm still lacking the "wow" factor of feeling refreshed sleep, it has been waaaaay better than life before I was diagnosed. I am feeling optimistic and hopeful for the future.

My Dad also has sleep apnea, and I conveniently have the exact same model of machine that he does (the ResMed Airsense 10 Autoset). Being the "tech savvy" good son that I am, I bought him an SD card and have been analyzing his data in OSCAR with mine, figuring that I could help improve his sleep. While I have been successful in calibrating my own settings, I now have to admit that I need your help to make sense of his, as I fear that I may have only made his sleep worse with my changes (though he initially liked them).

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Some background and current settings:
I started with CPAP on April 11th. I am presently at a minimum of 8.6 with a maximum of 11.0, and EPR set to 3. I still have ramp enabled, but it starts at 6.0 (and as of last night, 7.0). I'm currently using a full face mask because I found my nose was getting congested during my first nights with CPAP, and I am afraid of breathing through my mouth while I am asleep. After some teething issues the fit is now mostly okay (I had to use a larger mouthpiece than what Philips recommended otherwise it would rub my nose raw) and while I get the occasional leak annoyance, I am mostly sleeping the whole night. My AHI and FL seem pretty good but if you have any recommendations to try to hit more restful sleep, please let me know. Otherwise I'll just keep getting used to the machine and making up for lost sleep.

For my Dad, I believe he's been using the machine for over a year now. He's found a nasal mask that he likes and has commented that he sleeps better with the CPAP than he did before he was diagnosed. He stated that nobody has ever changed his settings, and his machine was set to min 6.0 / max 11.0 with EPR off and ramp at 4; I don't know if these settings were chosen for him by a provider but I saw somewhere (probably OSCAR) that they'd been that way for about a year. His pre-OSCAR AHI varies a lot, but trends to 4-6, with some occasional nights as high as 12 or as low as 1-2 depending on how long he kept the mask on (more on that later). Given this, as well as his 95% pressure easily hitting 11.0, I figured increases were in order.

I initially tried to slowly raise his pressure by changing it to min 7.0 / max 12.0 with EPR 3, and he said that these settings felt better than before (particularly the EPR), but after one night with a huge cluster of hypopneas and another with a large cluster of OAs, I set max to 20.0 for a few days to see how much pressure he "needs." His 95% easily reached 19, with some nights at 18 and one with 17.4. However, he started to find the massively increased pressure difficult to sleep with, and I noticed he started taking his mask off far too soon (one night after 3 hours, another night after an hour and a half). Last night I raised his minimum to 9 and dropped his maximum to 14 to try to help compliance, and it seems to have worked (almost 7 hours of sleep), but his numbers seem like they can use a lot of improvement. Both pre-OSCAR and now, he's also had leakage between 2-13%, but I don't know if this significantly affects his sleep (still something to solve). 

That leads us to now. Rather than try to keep figuring it out on my own and potentially worsen his sleep, I wanted to see if you guys had any ideas. I don't understand a lot of the finer points of the data and I'm worried that I might be missing something that can't be corrected with simple settings adjustments. Here's my current thought process:

• Keep trying to (slowly) raise his maximum pressure higher.
  
• Pick up some of the cream I've recommended to help with his mask's seal.
  
• Perhaps pick up a SCC, chin strap, or mouth tape for him in-case he's mouth breathing at night (I don't understand the charts well enough to confirm or deny this); he doesn't like mouth masks so finding a way to make his preferred one work better is best.
  
• Look into bilevel machines in-case it's the EPR of 3 that isn't adequate.
  

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If anybody has any ideas, please let me know! I've learned a lot from this forum and the wiki, but his numbers definitely evade my current understanding. Thank you a ton for reading my too-long-thread!

[Jay51]

Welcome to Apneaboard, The Fox.  It seems like no matter how high you set the epap max, he either hits it or comes really close (like the 17 and 18 and 19 with apap max set at 20.  The "clusters" might be mitigated by lowering his pillow height, possibly changing his sleep position, or even trying a soft cervical collar.  For the collar, just measure the distance in inches from his sternum to his chin with his head in a normal, straight position.  Chin tucking or twisting of his airway can cause pressure increases to very high levels that may not even open the obstruction.  

Please post some more charts when you can and hopefully with improvements from the decrease or eradication of the positional apnea.

Soft Cervical Collar

[The Fox]

Thanks for the reply Jay! I'll see about getting him a collar and seeing if that helps. I'll also talk to him about his pillow height. If it is positional apnea (which would make sense), does that mean that the high APAP pressures are artificially high as a means for the machine to try to compensate? I figure that means I should wait until investigating the PA before adjusting the max more.

Also, I realize I forgot to include any pictures of the clusters I mentioned. Here's the zoomed out view of the OA cluster night and the H cluster night, along with a zoomed in view of the H cluster (this is when I had his max set to 12.0). Let me know if you'd like any other charts, otherwise I'll collect more data and get back here soon. Appreciate the help!

[Jay51]

Good points.  The machine is trying to compensate with higher pressure to "break through" the hypopnea clusters and OA clusters.  At a certain point, no amount of pressure can break through an airway that is too positionally closed.  You can keep the pressure higher for better results, but you can lower it if he can't tolerate the higher pressures.  Yes, attacking the positional apnea would be the 1st thing to try IMO.  

Great job of posting charts.  Several good long term and short term charts.