oral appliance in conjunction with cpap

[Dolpp]

I'm going to try to use my cpap with my oral appliance. I don't feel as good as I want to and lately i've been taking my mask off in the middle of the night. How do you think I go about doing that? I have an auto bipap machine, but don't know how to use it for the auto setting. I was never titrated with the oral appliance and cpap together. Here's my history from a different post of mine

" I started with CPAP about 2 years ago. After a sleep study that I had an RDI of 27. I was put on a pressure of 10. I spent the first year with a not very knowledgeable DME. I would unknowingly take my mask off every night. Every once in a while i would wake up with it off and put it right back on but it got to the point where I would put it on before i fell asleep and i would wake up with it off and the machine actually turned off and i would have absolutely no recollection of doing it. Every time I asked my DME what to do he would just tell me it is an "adjustment period". After a year i decided this isn't going to work. I was feeling no better. So I hooked up with a dentist who specializes in oral appliances. He fitted me with an oral appliance "Herbst Telescopic Appliance". He was very knowledgeable and really felt I had a good shot at feeling better with the oral appliance because I am 5'8" 160 lbs. and a neck size of 15 1/2". After about 4-5 adjustments I was actually feeling better but not 100%, but we were advanced as far as we could go. We did another sleep study and my RDI was 9.8 with only the oral appliance. I never used the oral appliance in conjunction with the CPAP. So discussing with my sleep doctor he suggested we go to a bipap machine. No reason to wear the oral appliance and a PAP if we can fix it with just the PAP. So I had to have 2 sleep studies done (for insurance reasons)one without the CPAP to confirm sleep apnea and one with the BIPAP. The first one I did half the night without the CPAP but since my RDI was 44 the technician put the CPAP on me for the second half. They gave me a pressure setting of 8 it only dropped my RDI down to 12 at a pressure of 8 but 6 and 10 were way worse. Then i had the bipap study done for the whole night. My RDI was 9.0 at 12/8. 8.4 @ 14/8 7.4 @ 16/10. He put me on 12/8 which didnt really make sense to me but I didnt question him. The part makes me nervous is that this study was the first of my 4 total that had any central apneas. They started at a pressure of 12/8. The sleep doctor assured me that they would go away when i got used to the bipap. Since I started the pressure of 12/8 gave me very few apneas besides centrals about 15.5/hr. felt like crap. I dropped it down to a straight 8 and that gave me good numbers about 4.4/hr split between obstructions hypopneas and centrals - still felt like crap even worse. I slowly increased it to 9 then 10 and my numbers were all over the place. Last night I was at 11.7 with 8.7 of it being central. No matter what the numbers were I never felt better than I did with just the oral appliance."

I want to use the oral appliance with the bipap because I felt pretty good with the oral appliance just need a little extra to feel really good I think. I was thinking of setting it at a setting of straight 4 and seeing how that goes and adjust up as needed. Any thoughts?
Is that too low? Should I put it on the auto setting? Like I said i'm not sure how that works. Recommendations? Thoughts?

[sleepmba]

That 4.4 number is looking pretty good. From what you describe, you may be having some tolerance issues. Are you comfortable with your mask? How is the leak rate during the night?

As far as the centrals...they may be caused by an uncomfortable mask and or leakage. Look at my blog: Sleep and CPAP (link in my signature), there is a topic called "Central Apneas....Normal?" You may find it useful.

On the night when you had the AHI of 4.4, you said you woke up feeling bad. You may have been experiencing REM rebound. That is you were in deep stages of sleep for longer trying to make up for previous lost sleep. I think you may want to stick with those settings for at least a few days to see how it goes.

[Mtnviewer]

I use an oral appliance in conjunction with my APAP with no real problems. Basically to me, it helps keep my mouth from dropping open and that's about it, but that can and does cause events for me, so I wear it. I don't know anything about BiPap, so I can't guess if your pressure is adequate, but I'd wonder if a pressure of 4 would be high enough if you were higher without the appliance. The appliance IME / IMO, isn't going to have a drastic impact, if any at all, on opening your airway or with keeping it open compared to PAP therapy. I'd suggest to expect that PAP therapy should be your goal and that the appliance "may" help a little more in "some" aspects of your sleeping anatomy and results.

I'd also suggest that you video record your sleep for a few nights and to analyze that to determine EXACTLY what is going on and when and match it up to your software data and or oximeter data as well. Then you may discover more about why your mask is coming off etc., and what you might do about it. As well, you'd discover WHY you might think that you need an oral appliance as well as BiPap. Without this proof you and we are only guessing and IMO you are wasting valuable time, sleep and days of feeling good. Guessing will drive you crazy eventually if you don't soon hit on a cause and cure, which video and software evidence could provide you ASAP.

My other thought is to analyze (best with video evidence) your sleeping position, supine vs. side, and match that with your data and the video evidence. My guess is that if you are like most people, your sleeping postion may be your worst enemy and that any extra pressure increase and or do dads such as an oral appliance, may not help you as much as getting yourself to sleep in a better position to lower or eliminate OSA and high PAP pressure.

If you choose to use APAP, then I'd suggest testing VERY narrow pressure ranges of 2-3 points. APAP is not very accurate as it chases events and too wide a range will have you guessing. Been there done that and it wasted so much time and energy for me. Finally the video evidence showed me my problem (supine position), and from there I worked on a cure, that being side sleeping and then I could easily figure out the best pressure range.

If you are adamant that you MUST sleep on your back (supine), then all best are off, as you will likely have to deal with high pressures in that case, with or without an oral appliance, especially in the long term.

[Dolpp]

Update. I'm going to video tape myself sleeping first chance I get. Thank you very much for your responses. Last night I went to bed before I got any responses here. The lowest setting my machine will go is 8 on straight c-pap so i switched it to auto which let me set it a 7i and 4e with a 3 swing between. I slept with the oral appliance and the machine all night. I woke up feeling okay, very similar to how I felt with just the oral appliance when I was using that but still pretty tired when I checked my results I was at 9.7/hr with almost all of my events as centrals. Before I could really look at the data my computer went dead and I can't get it up and running. I just bought a brand new macbook and can't get the software to install on it so i've been using my old computer to read my data. Any recommendations there?

I'm also curious about this REM rebound, When I was at my pressure of straight 8 I was absolutely exhausted for the two weeks I tried it. Most days I actually had to take a nap after work I was so tired I couldn't function. The naps didn't really help too much though. I was getting 7+ hours every night and my numbers were always between 2.9 and 5. Was this the REM rebound? How can I be sure? Does anyone know for sure they had REM rebound? Would it feel different than the regular sleep apnea tired? I hate to try this for months thinking it is REM rebound and I'll get better and not ever getting better. Why is it that getting REM sleep that I haven't had for a long time would make me more tired? It just goes against what I would think would happen. Any thoughts?