BigTex wrote:Its been over a week.
I will fall a sleep with the mask on, wake up take it off.
Wake up again, put it back on.
Wake up take it off.
That seems to be the pattern so far.
After 9 nights on Cpap I am pretty much worn out.
This pattern of allowing yourself to take the mask off and then return to sleep is most likely one of the major factors in your adjustment problems. Every time you allow yourself to fall asleep without the mask on your nose, you allow a primitive part of your conscious mind, your unconscious mind, and your body to continue to believe that the CPAP machine is not really necessary and that if they are stubborn enough you'll give in and the necessity for doing something unpleasant will simply go away. In other words, there's some part of your mind (either conscious or unconscious) and your body that is behaving like an unruly two-year old and it's your job to not give in and let the two year old have what they want just because they're throwing a fit.
So you need to work on breaking this pattern of non-use as soon as possible. My advice? Never consciously allow yourself to fall asleep without the mask on. If you wake up and cannot stand to have the thing on your face for one more minute, force yourself to get out of bed when you take the mask off. Go to a different room and settle yourself down and relax. Only return to your bed when you are both
calm enough and
sleepy enough to mask up when you go back to bed. That's the only way of
not rewarding your unconscious mind and your body for waking you up to take the mask off to get back to sleep without the mask on.
I am concerned this will not work for me and I am concerned I am not using the mask enough to be compliant with the insurance company.
This pretty much sucks.
Attitude is important: If you convince yourself that CPAP can't work, then it won't work in the sense that you won't wear it enough for it to actually do you some good.
As for using the machine enough for the insurance company's definition of compliance: First, contact your insurance company and learn the rules from them. Chances are the rules are something along the lines of
at least four hours a night on at least 70% of the nights during the first 30 (or 60 or 90) days.. And chances are if you got off to a really rough start (because of bad choices of masks, etc.), a note from your doctor speaking to your continuing improvement with compliance AND the medical necessity of your becoming compliant may be enough to get you a grace period of a month.
During the sleep study they went up to 12 for the pressure but doc told me to use 8.
I am wondering if this is not enough using a full face mask.
Should I up the pressure?
This is a concern. Your signature shows that you are using an S9
Elite, which is a full efficacy data machine. So what does the data say? In the nine days you've used the machine, what do your AHI's typically run? And how are the leaks?
Let's tackle leaks first: The S9 records only
excess or
unintentional leaks. In an ideal world, your leak rate would be 0 L/min all night long. However, it is not realistic to expect an unintentional leak rate of 0 L/min for the entire night on a regular basis. The Resmed engineers know this. According to the stuff that Resmed has put out, Resmed believes the S9 can compensate for leaks that are under 24 L/min. For leaks that are greater than 24 L/min, the length of the leak is also imoportant. Mr. Red Frowny Face shows up in the short version of the Sleep Quality report on the S9's LCD when your leak rate is AT or ABOVE 24 L/min for at least 30% of the night. And Mr. Red Frown Face indicates that the Resmed engineers believe that your leaks are both LARGE enough and LONG enough to cause problems with the efficacy of your therapy and/or the data recorded by the machine.
On the two nights you've posted data for, the summary data for the leaks indicates that Mr. Green Smiley Face is showing up on your Sleep Quality Report. You still might want to look at the leak line itself. To my eye, the leak line on the two nights of data you posted indicate that you do have some periods where the leaks are bouncing all over, but they stay below the Red line of 24 L/min most of the time. Significantly, the periods of "bad leaks" occur right before you turn the machine off and right after you turn the machine on. And that raises two key questions about just the leaks:
1)
Are leaks waking you up? You say that you're waking up "gasping for air several times" during the night. But is it possible that leaks are what might be causing you to stir and then when you are in a half-awake stage that some part of your mind begins to panic because there's this THING on your FACE and a six foot monster hose attache to your nose? And the panic then triggers the gasping for breath? And the gasping for breath then wakes you to full consciousness?
2)
Are leaks keeping you from getting comfortable enough to get to sleep? In the limited data you've provided there are numerous "short" sessions of less than an hour in length. Is it possible that you never really got to sleep during these sessions? In other words, are you spending a long time dozing (being awake or in Stage 1 sleep) with the mask and then deciding to tear the mask off so you can finally get to Stage 2 sleep?
I raise these issues because it seems to me that if the leaks are what leads you to take off the mask, then you need to fix the leaks that are irritating to you---even though they appear to be "small enough" to not affect the efficacy of your therapy in the sense that they stay below 24 L/min.
And in looking at the limited data, it also appears that the worst of the clusters of events occur during these "bad leak" periods.
So lets examine your AHI data in more detail. As a general rule, PAP therapy is considered "effective" if your AHI with the machine is consistently less than 5. But in the data you provide, your AHI is significantly higher than expected on Tuesday night (AHI = 28.94 in a bit less than 2 hours of use) and higher than expected on Monday night (10.73 in about 5.7 hours of use).
If these AHI's are typical of what you've seen every time you've tried to use the machine, then you need to call the doc back and find out why the heck he prescribed 8cm when the titration study had you up at pressures as high as 12cm. Have you got copies of your sleep study results? If not, you need to get them---both the doc's dictation AND the full summary data including summary graphs. There may be something in the titration report that explains why your doc prescribed 8cm of pressure. Then again, there might not be anything there.
As I noted above, it appears that your worst AHI clusters are correlated to periods where your leaks are bouncing around pretty significantly, but staying below the Red LIne of 24 L/min for the most part. Do you remember struggling with leak issues during any of these time frames? You've expressed your dissatisfaction with the masks you've tried. Is part of that dissatisfaction due to leaks waking you up or keeping you from getting to sleep? If so, you've got more mask shopping to do. It's important to not get discouraged. Folks who need FFM seem to have a tougher time than the rest of us, but from what I've read, there are very real differences in how FFM actually fit on a person's individual face even when the masks look very similar to each other. So a trip back to the DME, as frustrating as that might be, is in order. Also, since you're currently trying out a Quattro FX, you should read through JanKnitz's
Taming the Mirage Quattro. While the Mirage Quattro and the Quattro FX are not the same mask, a lot of the same fitting tips apply to both masks since they both use an air-filled cushion to achieve the seal.
Next, any chance you were awake during the periods of the worst clusters? Wakeful breathing is much more irregular than sleep breathing in some people. And since you feel as though you're fighting the mask in the first place, it wouldn't surprise me that if your breathing is even more irregular than normal when you've got the mask on your nose and you are semi-awake to fully awake. And when you are breathing irregularly while AWAKE, a lot of the time the machine can score events that would not be scored in the sleep lab (because you are awake when they happen). Sometimes this can happen because you may have several minutes of larger, deeper, and possibly more rapid breaths (bordering on a mild form of hyperventilation) followed by settling back into a more normal breathing pattern. If the normal breathing pattern's inhalation peaks are much smaller than the "hyperventilation" peaks, the machine can, and often will, score a hypopnea. We often pause in our wakeful breathing for several seconds because there is a tendency to hold our breath when we're concentrating on something---even when the something is as "simple" as turning over in bed. That too can get scored as an event by the machine when it would not have been scored as an event in the lab (because you were awake when it happened).
And note: While intuition says that if you hold your breath while awake and while using the CPAP, the machine ought to score a CA, you may find that in practice that doesn't happen. The times that I've experimented with "hold my breath to see what happens" have lead to very mixed results: I always get an apnea of some sort scored, but in my data it seems to be at least a toss up on whether it will be scored as an OA or a CA. Maybe it has to do with the particular way that i hold my breath---I don't know. My point, however, is that if you were awake for most of the time during these clusters of events, then many of the events may have resulted from wakeful breathing irregularities.
Finally, it appears that you are using EPR set to 3. Is that correct? If your EPR = 3, then that means that on your exhalations, the pressure is dropping to 5cm. And while Resmed claims that EPR is a patient comfort feature that should not increase a patient's AHI, in practice EPR = 3 does adversely affect some people's AHI numbers. And since your titration had pressures up to 12cm, it could very well be that 5cm is no where near enough pressure to keep your airway open when it is threatening to collapse on your exhalations. So you might try reducing the EPR to 1 or 2 and see if that improves the AHI numbers.
