Zeno's therapy thread

[Zeno]

Thanks for the replies. I'll keep using the Caldera while I get a taller one, since it does seem to provide some benefit.

I had a full lab-based sleep study in 2018 with AHI 8.6 and prescribed 9cmH2O CPAP (Can't find the full report right now, but don't remember CAs being prominent)
Second WatchPAT study just last month. pAHI 9.6,  pAHIc (I think this is Centrals?) of 1.5  and prescribed APAP 5-15 cmH2O

I did have bad dry mouth when I used a nasal pillows mask and had mouth leaks, but now I use full face it's got way better and very little leak.

I'm going to be travelling in Europe for the next 2 weeks so will not be looking at OSCAR data. In the meantime, thanks for any further comments / suggestions.

[Zeno]

It's been a few weeks since my last post and in that time:
1. I've changed from a Caldera collar to a 4.5" Coreflex. It took a while to get used to that but I now I don't see any positional clusters.
2. I changed the pressure to a constant 12 rather than variable.

I'm still getting a few obstructive events and I'm guessing that if I nudge the pressure up a bit, they will reduce.
However I'm getting many more CA events than obstructive and the number of them varies from night to night.
I'm not happy with the quality of my sleep and I'm finding it hard to get going in the mornings and experience increasing sleepiness from mid-afternoon onwards.

Here are a some Oscar charts from the last couple of weeks - the best, the worst and a typical.
What should I try next?

           

[Jay51]

Tough situation.  When you turn off EPR, no CA's, but higher flow limitations.  With EPR on, the higher you go, the more CA's you get.  With the collar, it should help with positional clusters.  

Which do you feel the best with:  EPR off.  EPR 1 full time.  EPR 2 full time.  Or EPR 3 full time (do you feel better in the morning with more CA's?  more OA's?  or kind of a balance of both?  

You are getting very close to optimizing this current machine.  The VAuto is the next step up because it can provide higher pressure support than EPR 3; and it has a trigger setting to help stop CA's.

[SeePak]

Jay51, "tough situation" , where did you see EPR=0 in zeno's charts?

I do not think that was tried here.

My take on this, is 9 cm prescription must be pretty close.
I dont think it could be under titrated so much that 12 cm constant would be a good choice.

My thinking is to do 9 cm min. to 10 cm max with EPR=0

See how you feel at that point Zeno

What do you think of that?

Give it a try?

[Jay51]

Good point SeePak.   I stand corrected.  These OSCAR charts only show EPR 1 and 2 full time.  I assumed that you have already tried 0 (EPR off) and EPR 3.  Well then, you now have 2 other sets up to investigate as well.  

SeePak's suggestions look good as well.  Give them a try and see which of your many different set ups gives you the best OSCAR results and best feeling in the morning after sleeping all night.

[Deborah K.]

I would do what is suggested but make the range slightly wider: 9 to 12.  Also, since your sleep quality is not good I suggest using some EPR, which should make your breathing more comfortable.  It will also lower your flow limits.  They are short, unreported apneas, and I think lowering them is perhaps more important than worrying about the AHI number.  I would try EPR at 1, then 2, then 3 and see how you feel.  Sleeping well and comfortably is more important than chasing numbers.

[SeePak]

I agree I would always go by how you feel and I don't think the numbers tried so far give you a chance to feel your best

[Zeno]

Many thanks for all the comments and suggestions.
Until recently I was doing APAP and I tried all the EPR settings. At EPR 0 or 1 the flow limits were high and the APAP algorithm sent the pressure high pretty quickly. I found EPR 2 resulted in lower AHI and lower average pressure. Also increasing the min pressure to 10 helped.
EPR 3 increased didn't make much difference.

Throughout the APAP experience I found a lot of variation day to day ( don't know whether everyone finds this) and that partly why I switched to CPAP.

Based on many APAP charts I guessed that 12 to 13 might be a good pressure, but I actually started at 9 with 0 EPR and the obstructives were quite high. Over a couple of weeks I stepped up the pressure to 12 ( and I increased the EPR at the same time). At 12 obstructives are generally pretty good and CAs dominate. That's where I have got to.

The original prescription for 9cm was back in 2018 so thing may have changed since then. In August of this year when I resumed treatment I started with an old nasal pillows mask and I got pretty good AHI at constant 9cm. But I couldn't continue because of mouth leaks and nose pain. Switched to a full face which I find comfortable, but it does seem to need higher pressure. No idea why but the data does seem to show that. Also I found EPR 3 feels very different to no EPR with the nasal pillows, but the difference in feel with the full face is much less 

I do think maybe I should now explore EPR more fully in CPAP mode because in CPAP the flow limits don't drive the pressure up so the APAP experience might not be relevant. So I could basically titrate the pressure for each EPR setting. That would take a few weeks to do because CPAP does not appear to have reduced the day to day variability.

I'm also tempted to try a couple of weeks without the machine entirely, but keep the collar. I've been monitoring 02 Sat all along so if I don't see a drop in that, then it just comes down to how I feel and it might be worth reminding myself how I feel without therapy, especially now that I know the collar definately improves the obstructives.

Sorry for the long post but I felt I should fill in some of these details. I really find everyone's comments and suggestions so incredibly helpful so please let me know what you think of the above. I'd also like to know how much variability from day to day others experience. And whether different masks is just about comfort or is mask choice important to the effectiveness of the thereby?

[Jay51]

All great points Zeno.  Try all of the things that you are thinking of trying.  A trend is usually established by a couple of night to a week or so at least.  Try to get a clear trend with each experiment.  

The type of mask and style can provide a different therapy.  The basic types are traditional full face (over the nose); hybrid full face (under the nose), nasal pillows and nasal cradle, and there is even one mask that only goes over the nose (like a full face mask that covers the nose only).  

Take a look at ApneaBoard reviews section where masks are reviewed if you decide you want to try a different mask.  There may be some reviews for that particular mask.

[Deborah K.]

Using Apap is advantageous unless the variability makes your sleep uncomfortable. No one breathes exactly the same all night, so it is beneficial to have different pressure levels available to meet your changing needs.  For some folks, big changes during the night disrupt their sleep.  In that case, the range of pressure needs to be more narrow, but still large enough to meet their needs.  That's why I suggested a range of pressure as a place to start, but since your median pressure while using Apap was 11, I now suggest you set Apap at 11 to 14 in case you need a little more.  It's your choice, but I think a small range of pressure is better than static pressure.  I don't think you will feel the 3 number pressure range at all.

I think you would sleep more comfortably with this narrow range of pressure and EPR set at 3.

Best of luck with getting your best sleep!