Feedback Request

[Amishboy51]

Although I've been using CPAP for many years, I'm still not happy with the functional results: despite taking the maximum daily dose of Armodafinil (generic Nuvigil), I'm still capable of falling asleep by late morning or early afternoon if I'm sitting too long.

My DME, Lincare, replaced my previous cpap about 18 months ago with a ResMed AirSense 10 Autoset; initially they gave me an N10 mask (and never advised that I could try the mask for 30 days and replace it if it didn't work for me). I struggled with it for a while, especially with air leaks and mask noise. I called the DME, followed their suggestions, but continued to struggle, so finally decided to see the DME again, with an additional complaint about my dry mouth. The RT decided that I must be mouth breathing and recommended that I try a FFM, so I replaced the N10 with an F30.

That happened about 6 months ago. During this time, I've also tried mouth taping (never felt comfortable during the 3-4 nights I tried) and a couple head straps (better, but annoying when combined with a FFM). I still feel like things haven't changed; still have mask leaks, especially when I turn on my side (my preferred position), still have dry mouth. I'm planning to contact the DME again, to see whether a different mask with the ResMed AirSense 10 is an option; if anyone has mask suggestions, I'd appreciate hearing from you. I'm also considering a cervical brace.

I'm attaching screenshots from a couple recent nights. As you can see, my AHI is usually pretty good, at <5, but my leak data can be all over the place (and, no, I'm not waking up, or aware of it). One of the things that I find so frustrating is how much difficulty I have getting a "consistent" mask fit. I feel as if I can get good results for several nights, and then, without any adjustment of the headgear straps, all of a sudden I'm getting air leaks, mask noise, etc.

Anyway, sorry for "unloading" so much info in one post. Hopefully I at least managed to upload and post the screenshots correctly. As I said (or should have), any input or feedback is welcome.

screenshot-20200412-205342.png

screenshot-20200412-205219.png

screenshot-20200412-205044.png

[zonker]

<r>Hi.<br/>
<br/>
Although I've been using CPAP for many years, I'm still not happy with the functional results: despite taking the maximum daily dose of Armodafinil (generic Nuvigil), I'm still capable of falling asleep by late morning or early afternoon if I'm sitting too long.<br/>
<br/>
My DME, Lincare, replaced my previous cpap about 18 months ago with a ResMed AirSense 10 Autoset; initially they gave me an N10 mask (and never advised that I could try the mask for 30 days and replace it if it didn't work for me). I struggled with it for a while, especially with air leaks and mask noise. I called the DME, followed their suggestions, but continued to struggle, so finally decided to see the DME again, with an additional complaint about my dry mouth. The RT decided that I must be mouth breathing and recommended that I try a FFM, so I replaced the N10 with an F30.<br/>
<br/>
That happened about 6 months ago. During this time, I've also tried mouth taping (never felt comfortable during the 3-4 nights I tried) and a couple head straps (better, but annoying when combined with a FFM). I still feel like things haven't changed; still have mask leaks, especially when I turn on my side (my preferred position), still have dry mouth. I'm planning to contact the DME again, to see whether a different mask with the ResMed AirSense 10 is an option; <B><s></s>if anyone has mask suggestions<e></e></B>, I'd appreciate hearing from you. I'm also considering a cervical brace.<br/>
<br/>
I'm attaching screenshots from a couple recent nights. As you can see, my AHI is usually pretty good, at <5, but my leak data can be all over the place (and, no, I'm not waking up, or aware of it). One of the things that I find so frustrating is how much difficulty I have getting a "consistent" mask fit. I feel as if I can get good results for several nights, and then, without any adjustment of the headgear straps, all of a sudden I'm getting air leaks, mask noise, etc.<br/>
<br/>
Anyway, sorry for "unloading" so much info in one post. Hopefully I at least managed to upload and post the screenshots correctly. As I said (or should have), any input or feedback is welcome.</r>
screenshot-20200412-205342.pngscreenshot-20200412-205219.pngscreenshot-20200412-205044.png

whatever it is you're doing with your text, please stop. it makes it difficult to read.

thank you.

[Pugsy]

whatever it is you're doing with your text, please stop. it makes it difficult to read.

I fixed it for him. If you guys will give me a chance I will fix it when/if I have time.
It has to do with bbc code and the device he is typing on I think.
He probably doesn't even realize it is occurring and how annoying it is.

[zonker]

whatever it is you're doing with your text, please stop. it makes it difficult to read.

I fixed it for him. If you guys will give me a chance I will fix it when/if I have time.
It has to do with bbc code and the device he is typing on I think.
He probably doesn't even realize it is occurring and how annoying it is.

thank you and will do.

now let's get back to what amishboy wants!

[DreamDiver]

Amishboy51

It looks like some great progress on containing leaks from March 31 to April 11. Fantastic!

Notice how on March 31, hypopneas only show up during periods where there are no large leaks. This may be because the machine has a harder time detecting stuff during large leaks. But still, mostly hypopneas.

Even with large leaks mostly under control on April 10, it's still mostly hypopneas and some RERA's. The pressure kept spiking up to 20 because of all the hypops in a typical fashion, looking like Alpine ski slopes.

For much of Aprill 11, your large leaks are mostly under control. For some reason, your pressure wanted to hover way up close to the max, 20cm. It might be interesting to hear what others have to say about that. Also you're breathing deeply from 11:40pm until you get up to pee at 4:30am. Then you get a steady breathing pattern that looks like what for me would be restful sleep from 4:40am to about 6:10am with a pressure that's working, no large leaks and no hypops again until about 6:15. This may be a sleep-position depending thing. Can you remember what position you slept at that point? Then, more heavy respiration.

Since most of what we're seeing is hypopneas, I'm curious what you've set your EPR at. If it's at 3, I wonder if setting it to 2 or even 1 might further reduce your hypopneas. Your 95 percentile for pressure on April 10 and 11 was right up at the top of what the Airsense 10 Autoset can manage. I wonder if you could get all those hypops managed whether that pressure would hover happily at a comfortable 13.3 all night long.

I wonder too if you wouldn't be happier with an Airfit F20. It fits over the nose bridge rather than over the nostrils and may be easier to manage with regards to large leak for some faces.

I hope this helps.

Chris

[Pugsy]

Omit the mask pressure graph and bring the Flow Limitation graph up for viewing...and redo the Sat April 11 detailed report image please.

I think flow limitations are likely the main driving force behind the pressure increases.

Are you having much nasal congestion? Sometimes nasal congestion causes the machine to think a lot of FLs are going on and it will try to kill them with more pressure. Unfortunately more pressure won't kill flow limitations that are caused by nasal congestion.
Need to fix the nasal congestion first.

[Amishboy51]

whatever it is you're doing with your text, please stop. it makes it difficult to read.

I fixed it for him. If you guys will give me a chance I will fix it when/if I have time.
It has to do with bbc code and the device he is typing on I think.
He probably doesn't even realize it is occurring and how annoying it is.

Sorry, Zonker.

You’re right, Pugsy, I had no idea that stuff was there. I used a MacBook Air, but I have no idea why it affected the bbc code. Anyway, thanks for fixing.

[Amishboy51]

Sorry, I reversed the order, but Pugsy, is this what you were asking for?

screenshot-20200413-232928.png

screenshot-20200413-232919.png

screenshot-20200413-232905.png

[Pugsy]

Your flow limitations are a significant part of what is driving the pressure upwards.

[Miss Emerita]

You can use any mask with your machine. In general, the fewer places the mask has to fit your face, the easier the fit, so I wonder whether you might want to try a P10 nasal pillow mask. Maybe you’ll mouth-breathe, maybe you won’t. If you do, you might try a soft cervical collar or an anti-snore collar to help your lower jaw stay up.

Anyhow, it’s a thought. If you try it, get a fit pack with all three sizes.

About the FLs—do you in fact have nasal congestion?

And do you know why the EPR is turned off?

[Amishboy51]

First off, thanks, all, for the input.

Dreamdiver:
So I guess I should be focusing more on the hypops and the pressure; unfortunately, no, I don’t remember my sleeping position at the time. I’ll check out the EPR setting (although Miss Emerita indicated it was turned off).

I looked at the F20 after you suggested it; it seemed like it might still have air leak issues like the F30, since the lower strap seemed the same, but OTOH, the upper strap looked like it’d provide more room around my ears. And you may be right about the fit on the nose bridge vs. under the nostrils; I’ve repeatedly reviewed the fitting instructions from ResMed, but I still wonder if it’s quite as simple as they imply.

============================================

Pugsy:
Thanks, I’d never understood, let alone paid any attention to, flow limitations. So, I checked out the glossary:

“Flow Limitation is a partial obstruction of the airway as detected by a change in the shape of the flow signal.”

I’m still not sure that I know exactly what this means; does it mean disturbance caused by factors other than sleep apnea, like nasal congestion, deviated septum, etc.?

Are you talking about the really elevated pressure spikes on April 11, or the pressures on all 3 nights? And am I correctly inferring that pressure that’s consistently at or near 20 is not good (regardless of AHI, etc.)?

================================================

Miss Emerita:
Thank you, I’ll ask the DME about the P10. I have “some” nasal congestion (e.g., occasionally use Nasacort in a.m.), but I feel able to breathe okay through my nose. And, no, no idea why EPR is turned off; do you suggest I turn it on?

[Amishboy51]

Okay, I managed to get back into Settings, turned EPR on, and set it at 1. Here's last night's OSCAR screenshot:

screenshot-20200415-083954.png

[Pugsy]

Flow limitations can be from 2 areas....in the nose from swollen nasal mucosa and in the airway from airway tissues collapsing a bit.
In the airway they may not end up being hyponeas or OAs but they are the early signs of an impending OA and hyponea. They can disturb sleep. More pressure is the usual remedy for this and it's part of the auto adjusting algorithm for the machine to increase the pressure in an effort to prevent the airway from collapsing
When FLs originate in the nasal mucosa more pressure won't help much. Instead we have to address the swollen nasal mucosa with the usual nasal congestion remedies.

The machine itself doesn't know where the FLs are coming from. It only measures air flow and has no way to know if it's from the nose or the airway so it will still try to prevent FLs with more pressure. Unfortunately if the FLs originate in the nose more pressure doesn't help.

The fact that you kiss 20 cm several times...just means there are times when you need that much, or more, pressure.
From the pattern of increases I suspect REM stage sleep is involved. Those increases correspond to when we normally would be experiencing REM stage sleep. Google "sleep stages" and look at the normal hypnograms and note the pattern for normal REM cycling.
It's common for OSA to worsen in REM and/or cause a need for more pressure. Note the clustering of events when the pressure hits 20 cm...the machine would likely go higher if it could in an effort to prevent those airway collapses but it can't.

This might also be supine sleeping....same thing as with REM...supine sleeping can cause OSA to worsen and need more pressure.

[Amishboy51]

And here is last night, which is the second using EPR. I'm not sure that I'm seeing any significant change in FL or Pressure, with spikes to 20 at midnight and 2:00, and a couple other near-20 spikes. Should I increase EPR to 2 maybe? Something else?

[Pugsy]

How did you sleep last night? How do you feel today?