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Dialing in first-time therapy - rfburns - 06-19-2021
Hello,
I've been using my CPAP for a little over a month now and would like some advice on dialing in some of my settings.
Untreated AHI of 41.4, no mixed or central apneas in PSG, largely hypopneas, RERAs and obstructive events (ordered from most frequent to least.)
Was prescribed a treatment pressure of 8 - 9 with humidity, and have been using my CPAP at 9 with EPR set to 1.
I've attached a screenshot of my most recent night. My sleep schedule is very disordered, and after struggling with sleeping (and the neurodegenerative effects of chronic, untreated apnea) for the better part of the last decade, I'm trying to work on my sleep regularity and hygiene.
I'd appreciate some advice on getting my AHI down to 2 or less.
Edit: I raised my pressure to 9.2 for just the last night, to see if it would make a difference. Probably best to sit the pressure setting out for a week or more before I can draw any meaningful conclusions, though.
RE: Dialing in first-time therapy - Ratchick - 06-19-2021
Hi and welcome to the board! My sleep is ALSO all over the place so I feel your pain!
It looks like you already have a dramatic improvement in AHI. You have a low level of centrals which are almost certainly normal while you get used to the more effective respiration at night while on CPAP (or potentially as a result of waking up/rolling over etc).
Your leaks are a little high in places, so make sure that your mask is fitted correctly, or try to figure out what happened to cause that big leak at around 1 pm.
Moving your pressure up just 0.1 of a cm won't make a huge difference. Normally people will shift their pressure by at least one or two cm at a time. Unfortuneately, because you have the fixed CPAP version of the Resmed, we can't use the APAP to calibrate what pressures work best for you but generally speaking, you need to raise the pressure up to treat obstructive events. That's assuming the hypopneas are obstructive and not central.
I suspect that people who are more experienced than me will suggest putting your pressure up a bit to see how it goes and maybe test without the EPR to see if that reduces the central events - but hopefully the rest of the people will jump in with suggestions for you.
RE: Dialing in first-time therapy - rfburns - 06-19-2021
Thank you, Ratchick, I appreciate the welcome!
Yes, I feel much more well-rested than I ever have before, and am not tossing and turning as much as I used to. And though I've been using the CPAP for just over a month, I feel like in order to make accurate extrapolations from the data about long-term pressure/mask choice adjustments, I need to have a more regular sleep schedule.
The Elite was the only option that fit my budget; import fees are exorbitant in my locale, and the AutoSet would have cost me double the price of the Elite unless I purchased used or refurbished. I paid for everything out of pocket, and figured I must at least get something with some form of data reporting, rather than the brick CPAP trim of the AirSense 10. But absolutely, the AutoSet would be fantastic, and I might upgrade in the future.
I should mention that that large leak event is an anomaly, and I probably knocked the mask loose by turning over in my sleep. This has only happened once before in the last 30 days, according to OSCAR. I'm trying to maintain a supine sleeping position, but I've been a lifelong, restless side/stomach sleeper and breathe mainly through my mouth, and those aren't easy habits to break.
And yes, I'd quite like to see if someone interprets my situation to suggest experimenting with a higher pressure. I'm not quite sure about what causes central apneas, and they didn't find any during my titration study. Maybe a pressure of 10, EPR of 2 or 1?
RE: Dialing in first-time therapy - Ratchick - 06-19-2021
OK good to hear that the leak isn't relevant. And I understand, and for sure this is better than a brick, for sure. It just means that it might take a little more time to dial in the right pressure as we can't set a range.
Central apneas are different from obstructive apneas. Instead of your airway collapsing and blocking the airflow, even while you try and breathe, central apneas happen when for some reason, your brain doesn't tell you to breathe.
If these weren't present on your sleep study, at all, then it's most likely that it's as a result of the CPAP. This is pretty normal. You've been used to sleeping with poor breathing and your body has adjusted to having higher levels of carbon dioxide in your blood. This is important because in the majority of people, the trigger to breathe comes from rising carbon dioxide rather than falling oxygen levels.
Because you're now breathing more effectively with the CPAP, your body is able to blow off more carbon dioxide than it was doing before, so the levels are lower in your blood. As a result, this means that your brain goes for longer stretches of time before it's triggered enough by the higher level of carbon dioxide to take a breath.
This leads to the typical breathing we see with this kind of treatment-emergent central apnea - you will see breaths before the apnea gradual grown smaller and smaller until the apnea happens, then the breaths start up again, at first small, but then larger and larger as the carbon dioxide continues to build up in the blood and your brain is triggered to breathe more and more deeply. Then you get to the top again, and the levels start to fall off, the breaths get more and more shallow again until another apnea happens, and the cycle starts all over.
You can see a slightly different pattern while you're awake, or at least disturbed by something or rolling over, etc. Usually, in that case, the chart will show you taking a much bigger breath followed by the apnea, before you then start to breathe normally again. It's like when you sigh heavily and then you just take a little longer before you need another breath.
I hope that makes a little bit of sense (it can seem very counterintuitive at first).
If you zoom in on some of those centrals, we can take a look at them and see, especially if they're happening in clusters. Maybe take a 10-minute and 2-minute zoomed-in screenshot.
RE: Dialing in first-time therapy - rfburns - 06-19-2021
Thanks so much for the detailed explanation! That's very helpful.
I've put together a graphic with all of the events in that first OSCAR screenshot. I've included the leak rate graph where it seemed to vary during, before or after the event, in case that helps you draw any conclusions. I've also numbered the events for easier referencing. Hope this is helpful!
RE: Dialing in first-time therapy - WakeUpTime - 06-19-2021
I'm not an expert analyst, unlike many of the experienced users here, but I noticed many of your events are quite short lasting just 10sec or so - with a quick return to 'normal' breathing. You may already know this, but they're perhaps in a different category than longer lasting events, or events that don't have a quick return to 'normal' breathing patterns. Personally, I would skip over my short blips and just focus on events that are more significant.
RE: Dialing in first-time therapy - rfburns - 06-19-2021
WakeUpTime, being relatively new to CPAP therapy, you're probably right - the shorter events may not be significant. I've put up all of the events for that sleep session because it may help someone more experienced than myself draw conclusions about what I should do to optimize my therapy. More data tends to help, right?
I do notice now that I've had a closer look at the waveform that the flow rate graph that should characterize normal breathing have a chair-like shape, rather than a bell curve, for most of the night. Could this signal a flow limitation, that could be perhaps ameliorated with higher pressure?
RE: Dialing in first-time therapy - Ratchick - 06-19-2021
OK so this is just my best guess (and I'm definitely not the expert at this, plus I'm about to go to sleep) but here's what I would think based on just these short strips in isolation:
1) arousal because of the irregular breathing.
2) the first one looks arousal, but after that, it looks like that triggered a small trail of periodic breathing for the second couple of apneas
3) arousal because of the deeper breath at the start.
4) a bit harder to tell but I think may be irregular so I'd guess arousal.
5) it's a hypopnea but there's some irregular breathing before it so could be arousal, would need to see the normal graphs for that.
6) arousal.
7) again, hypopnea so would need other charts too, really
8) arousal, I'd guess, with the second one triggered by the first.
9) I think the arousal from the hypopnea might have triggered the central on its heels.
10) looks like the leak triggered some arousal which caused the first central, and that then maybe set up again a couple of cycles of periodic breathing and the second central before everything evened out.
11) arousal (and again, triggered a couple of cycles of periodic breathing and a short apnea that wasn't long enough to be marked as such.
12) looks like a series of increasing length apneas until it finally reached long enough to be marked as such which could have been triggered initially by a larger than normal breath, and then took a little while for your body to adjust back to regular breathing.
13) looks like again, the leaks triggered arousal, and that then triggered some minor periodic breathing and eventually an apnea, but I think it's probably just SJW from the leak disturbing you at the start of the strip.
Hopefully some of the other folk can give their opinion too.
RE: Dialing in first-time therapy - Ratchick - 06-19-2021
Flow limits tend to be helped with more EPR - but that can sometimes worsen centrals. That said, if your centrals are (as I would guess) just some minor and quickly resolved stuff based around arousals, you might find raising the EPR helps with the flow limits. The only way to find out is to give it a try.
RE: Dialing in first-time therapy - SarcasticDave94 - 06-19-2021
Worst case scenario is leaving EPR at 1 and trying to ride out the possible treatment emergent CA. I'd try EPR off and see what impact that shows on the CA. My reason to focus on those is they're the highest event right now.
A small bump in pressure could be also done to have a bit better result on the Hypopnea. Maybe a few clicks up towards or equal to 10.
As noted, this elite model has a few less settings than the AutoSet, but we'll suggest what's available.