Zeev - Therapy Improvement?

[Zeev]

Hi All,

I had posted over on reddit but was referred here. 

41yo male, large build, sleep on my back. I was diagnosed with Sleep Apnea back in August via an at-home sleep test (took a few to get a good result) and started with CPAP (Airsense 11) on Sept 3. Tried the first mask (F&P Vitera full face) for a couple nights but it was obvious it wasnt going to work. Uncomfortable and high leaks. Switched to an F&P Evora full face and its been great since. I took to it much better than I thought and immediately found that I was more able to get a "full" nights sleep more regularly and found it easier to focus at work. Its not perfect and, lately especially, feels like Im waking up a bit more often but with young kids and a stressful (at times) job, waking up in the middle of the night isn't uncommon so not sure if that's CPAP or "life".

My AHI on my sleep test was 51. 40% of the time, my SP02 was dropping below 90% and 10% of the time, it was dropping below 85%. The respiratory therapist I saw was pretty clear that I needed to start CPAP and I'm glad that I did.

With CPAP, I've been seeing an average AHI of 8.5 (74 days of data) and haven't made any adjustments since I started besides ramp pressure (6) and ramp time (recently dropped it from 30 mins to 20 as I get used to it). I am wondering if there's something I could be doing to further lower that number. I've attached a few of my latest charts - hopefully got the screenshots correctly formatted.

Also - I dont really like wearing my smart watch to bed, but I have a few times and have found that my SPO02 stays above 90% now.

Thanks in advance!
- Z

[staceyburke]

I have quite a few things you can do that will help you.  First all of your nights show positional apnea.  You can see positional apnea where either H or Oa events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.  Just stopping the positional apnea will help a great deal.

You need a higher min pressure, I would try min 8.

Any time you use the ramp, you are not getting therapy.  We always suggest it be shut off.  If you just can't get along without it, make it as short of a time you can.

EPR is used to help with flow limits and your flow limits are very high and we should try to get them down.  When you have flow limits your cpap raises pressures (that is why your pressure graph looks like a mountain range). The smoother the pressure graph the better the sleep...  To use EPR you need the min set to 8 - already suggested that - and the EPR needs to  be set to full time and EPR 3.

I hope you will make those changes and post again.

[Zeev]

Thank you for the detailed reply! I really appreciate it.

I guess my first question is whether I should try these all at once or try em one at a time to see the effect?

I use the same pillow i've been using for... wow. years. I've been thinking its time for something new, so I think that's the first thing I'll try.

I've been working on lowering the ramp this week as I've been thinking about trying to improve my therapy. Im going to try dropping it by 5 mins every few nights.

Should I try a new pillow and reduced ramp first or are the other suggestions (min pressure to 8 and EPR settings) going to help anyway and I should do those at the same time?

[Zeev]

Well. I decided to just try a couple simple things first. Last night I changed my minimum pressure to 8, my ramp pressure to 7, and my ramp time down to 15 mins.

5.7 is one of my best AHI's yet!

Should I bump it up again or try EPR?

[Deborah K.]

After 75 days on your machine, you don't need ramp at all. Turn it off.

You also need to raise your EPR setting to 3 full time.

See how those changes work, then if you are comfortable raise your starting pressure to 11. That's roughly the pressure you are at for most of the night.

[Zeev]

ok, thanks. I appreciate the help! 

I think i'll keep trying to lower the ramp 5 mins at a time and see how that goes.

For EPR, is the goal to turn that on and then raise the minimum pressure to make up for it? I guess im not really understanding how lowering the flow with exhale is supposed to help?

[Zeev]

Turned EPR to full and 3 for last night. Definitely didnt feel like I slept well though.

[SarcasticDave94]

The chart agreed. You didn't have a good night.

To answer the EPR question, this makes your CPAP a bilevel, and the diminished exhale can add comfort while giving a slight boost when your AutoSet bumps back to the inhale. Much like PS will do with a more expensive bilevel.

You had a lot of CA this time, plus some first half of the session mid level leaks. I'm thinking those leaks are based moreso on the mask itself, especially as the Evora full being used.

You may want to trial the Standard Response versus the currently listed Soft Response.

My recent VAuto trial was with this same Evora Full. You'll probably want to fiddle with strap tension, making it probably lighter/less. I used the top of head strap to determine where the overall mask sat in the up/down placement on the face. Emphasize comfortable under nose for the cradle, plus paying attention to the lower full section below your mouth, to make sure it's going to seal at the bottom.

Next is lower set, having just enough tension while CPAP is on not to pull mask tightly onto mouth.

Final is the middle set. This should pull towards the nose some but again not over tight. I've also found that after adjusting, sometimes I'd pull mask up off the face with all straps still connected, just to reset cushion, getting it to push outwardly.

Next up you seen to have a clustered event look, a strong indicator of what we users recognize as Positional Apnea. This is not a back or side sleep body position issue specifically. It's more a possible too thick pillow pushing your chin to tuck towards your chest. It will kink off your airway just like the kinking garden hose will hinder water flow. Attempt to pay attention regarding this probable chin tuck aspect.

You can use a thinner pillow if applicable. Maybe a corner of the pillow tucking between chin and chest to block this. Final alternate will be a proper fitting soft cervical collar to physically, externally block the chin tucking. And unfortunately no CPAP built will have enough pressure to air stent internally this extra external chin tuck force.

A link to the Apnea Board wiki regarding Positional Apnea below. Read please to learn more about this. And best wishes it helps.

https://www.apneaboard.com/wiki/index.ph...onal_Apnea

[Zeev]

Thanks! Yeah, i have definitely been fiddling with the straps a lot and last night, i think about half-way through, i adjusted them and think that it helped. Definite balance between all the straps and, when i get a leak, it is always in the same spot. Right nostril. And i can feel the air coming up and hitting me in the eye. I'll keep adjusting. 

As for the positional apneas, thanks for the link! Im wondering if i can try a cpap pillow or cervical pillow to try to open up that airway before resorting to the collar. I really dislike things around my neck (eg. scarves, turtlenecks, tight collars), so Im not excited about trying that. I generally sleep low on the pillow, if that makes sense, shoulders off it completely. I think it would make sense that my head would kink forward and close that pipe. My pillow is an embarrassing number of years old at this point, so its probably time to try something different. 

I think for tonight, I'll try to keep the settings the same and just work on the mask leaks, see if i can get them down. 

I appreciate all the help so far!
- Z

[SarcasticDave94]

You're welcome.

Certainly try other pillows to see what happens.

The mask, not sure which size you've gotten, but I went with small medium which was like the default I think. I'd used large with other masks models beforehand. Size change maybe some want to consider as well. I really like my Evora Full, the VAuto just didn't fit my over complex needs.

Anyway best wishes on success