Another newb

[willy737]

FNG here. Really appreciate the forum, the newbie guides and faqs, and all the folks on here helping others. It’s very well put together, yall are awesome! Thanks in advance for helping me, and thank you for helping countless others.

So I’ve done a fair amount of reading and searching on here to educate myself the best I can before posting, but I realize that my knowledge is very limited and wanted to turn to the veterans and get a good start to cpap therapy and to make sure I’m not approaching this improperly. Again, thank you for your expertise and taking the time to read this, I’ll try to keep it concise while providing the necessary info to help get questions answered. Needless to say, let me know if there’s anything I’ve left out. Feel free to just read the TLDRs and skip to the questions and screenshots.


Sleeping background (TLDR - bad sleep for a long time, nothing has helped, probably genetic sleeping issues)

My sleeping issues noticeably began 10 years ago in my late 20s, and have degraded over time. I chalked it up to moderate drinking, and an odd work schedule. Eventually I was able to minimize drinking, to the point of recently quitting all together, and normalize my work schedule. I was still having issues, so I worked on sleep hygiene, tried nutritional supplements, sleeping pills, blood testing, mouthguard, tongue retainer, nasal snore strips, increased exercise, you name it. At one point, my caffeine intake became excessive and was likely contributing to poor sleep, so I quit caffeine to no avail.

My dad had an undiagnosed sleeping disorder, which sounded like moderate to severe OSA. It unfortunately led to depression and got the best of him. My brother self-diagnosed and was successful treating his with a mouthguard. I haven’t had any luck with the all the above approaches, so I began to consider seeing a doc. I’ve hesitated for a while to do so, since any sleep disorder diagnosis would prevent me from working. Previously, a diagnosis would put you out of work for an excessive period of time, so most would ignore any issues and unfortunately treat themselves with alcohol. Thankfully, due to recent noteworthy events, changes have been made to make for a less cumbersome process regarding diagnosis and treatment, so I decided it was time to get the sleep test.


Current state ( TLDR - sleep study showed majority hypopnea events, ENT doc recommended auto pap 4-20, got a dreamstation go)

Sleep test results below. AHI came back at 5.3, with the overwhelming majority being hypopnea events. From what I’ve seen with the apap machine so far, 5.3 is on the low end. I think I hover around 10, but it either way it’s just a number. I absolutely have good days and bad. Bad days I feel like death with morning headaches and hardly any energy throughout the day. Lately, I’ve had way more bad days than good.

ENT doc scoped my airways and found nothing noteworthy, wrote me a prescription for the auto-cpap with pressures 4-20. Since I travel constantly and space is very limited, I decided to go with a travel friendly machine. I did a small amount of research and decided to go with a Dreamstation Go. It was a close tie between that and the airmini, but I really liked how the GO had standard connections right out of the box, and had an sdcard to record data. I have to send data into my doc on occasion, so I wanted that part to be easy. The airsense 10 isn’t all that much bigger, I may switch to it at some point.


Started CPAP (TLDR - considering slowly raising min pressure to reduce hypopneas, reducing a-flex, trying different masks)

Like most others have experienced, it’s a very odd feeling at first. I wanted to drop the min pressure below 4cm, but I’ve gotten used to it now. Now I’m considering raising the minimum pressure to help deal with all the hypopnea events. I’m primarily a nose breathing, side sleeper, with no usual congestion problems, just dry sinuses that I’ll blame on the climate here in Denver, which the humidifier has helped with.

Since my ENT doc prescribed 4-20cm, I don’t want to get too carried away with dial-a-wingin just yet. I’ve only given this thing a week, and I understand it can take months for it to work. However, some slight setting modifications may help suppress the events I’m experiencing, so I’m very open to suggestions. My ENT doc has limited knowledge dialing in paps, and before I start screwing it up, I wanted to get an opinion from the veterans on here. Feel free to tell me to shut up, quit griping, and let the machine sort it out. But if you see something obvious in the screenshots, please kick me in the right direction! I’m getting tired of being tired!

Full disclosure, I did drop the max pressure down to 12. My 90% range is between 7-9cm. More than that starts to disrupt my sleep. I imagine it’s because I’m still not used to the feeling, so over time that can be dialed up (if needed) without disruptions.

At first, the exhale relief was set to A-flex, full 3. However, I’m experimenting with reducing that relief in the hope I can turn it completely off. It’s my understanding that the relief may be useful at first for comfort purposes, but may not be ideal for therapy application.

Initially I was using the Airfit P10 pillows, and although the leak rate and AHI numbers looked good, the mask was uncomfortable. Trying the f30i, which is surprisingly more comfortable, and I have several others to experiment with. At this point, I don’t care what’s on my face, just want to see what works best for the data and how I feel the next day.


Questions

1. Is it too early to increase the minimum pressure to reduce the events? If I can stand it, would working my way up to 6cm possibly be effective at reducing hypopneas?

2. Different masks obviously yield different leak rates. Anything to be concerned about here in
regards to pressure adjustments or anything else? Is it worth sticking to respironics masks
since the machine has settings for them?

3. Anything on these screenshots standout to you? Any recommended adjustments?


Again, thank you!

[Pugsy]

It's not too soon to increase the minimum. You obviously need more.

I actually suggest going back to AFlex at 2 or 3...whichever is more comfortable to you and to really judge the comfort you need to be using more than 5 cm starting minimum. Something like 7 or 8 cm minimum. Sometimes having that difference between inhale and exhale actually helps reduce hyponeas because you can get more IPAP (inhale pressure).
The most anyone can get in terms of a reduction using Flex exhale relief on Respironics machine is 2 cm even at the max of 3 setting.
Plus you only get that if you breathe forcefully because the actual reduction is based on flow rate or strength of breath.

You can keep the max at 12 for now if you wish. If you never reach it then it's really a moot point anyway. The auto response doesn't change between a 12 max or a 20 max. The maximum only really might need to be changed if you hit it often and it wants to go higher but it can't.

[willy737]

Thank you for taking the time to explain that, makes perfect sense. I'll bump it up the minimum pressure and a-flex it to 3 and see how it works out. Will post the data again here in a few weeks with hopefully some improvement. Thanks again!

[willy737]

I bumped the min pressure up to 7cm, and that worked well getting rid of the hypopneas, however I started getting a bunch of centrals. Doing some research on here I decided to reduce the EPR down to 1 from 3, and backed the min pressure down to 6cm..so far so good. Thanks for the guidance on that pugsy! Set the max at 9cm since any higher triggers centrals and wakeups.

So do this look like hypopneas and obstructive apneas? To me they look like centrals. The pressure pulse looks like it gets a response with some inhale and exhale. I understand the machines aren't perfect at flagging everything, and that's fine. Just want to make sure I'm reading these correctly so overtime I can make the appropriate adjustments. Thank you!

[Pugsy]

I can't determine much when I get a zoomed in section without seeing the flow rate just prior to what was zoomed in on.
Plus you have zoomed in a little too much.
I really can't tell central from obstructive by the flow rate anyway.
I can sometimes tell awake from asleep.

[willy737]

Whoops, sorry. How's this? I did roll over a few minutes prior, but I imagine I was back to sleep when these occurred.

So from this data, it's really not possible to tell the centrals from obstructive? I was thinking if there's a variation in the flow rate during the pressure pulse, then it's most likely a central. However..the machine is probably smarter than me at determining this. I would just be surprised if I was getting obstructives now with the cpap, when I wasn't getting them before without it during the sleep study. Thoughts? Again, thanks for your time!

[willy737]

Here's another in case that one wasn't zoomed out enough

[Pugsy]

The machine doesn't know if we are asleep or awake...it only measures air flow and often our normal irregular awake breathing will cause the machine to think the irregular breathing is some sort of apnea event and call it something it isn't because if we are awake or have an arousal...it's not an asleep event. If we aren't asleep then it doesn't count. It's not real and other than making us wonder why we were awake...means nothing.

Your zoomed in section looks more like arousal breathing flagged events to me. I don't think you were sound asleep.
And just because we might not remember being awake doesn't mean we didn't wake up.

All that flow rate from 04:09:30 to the end of the zoomed in section looks like arousal breathing to me. Maybe awake fully or half awake.
You weren't sound asleep.

Here's what a real asleep event looks like. Note the nice rhythmic flow rate/breathing just before and after the flagged event.



What I see on your reports....evidence of crappy sleep quality...lots of probable arousal false positive flags (and they can be any event category). Now as to why the crappy sleep...million dollar question.

Take a look here at the videos and especially the bottom one. I know it talks mainly about central apneas but it can be any category flagged.
When we see arousal or awake breathing just prior to a flagged event we have to think arousal/awake false positive.
http://freecpapadvice.com/sleepyhead-free-software

The machine will respond to false positives because it doesn't know any better.

When sharing the reports...turn off the very short sleep session on the left so we don't have a big blank space causing all the graphs to be scrunched together making it harder to evaluate.
Go to left side and scroll down below the statistics where the sleep sessions are and click on that short session to turn it off and omit it from the big picture and your graphs will be easier to evaluate. You can turn it back on later just by clicking on it again.

[willy737]

My next question was going to be how to turn off the separate sleep sessions, thank you!

Makes perfect sense about the arousal breathing and subsequent flags. I'll check out those videos and keep an eye out for that. I wear a pulse oximeter that shows motion, so maybe that combined with watching for arousal breathing I'll be able to accurately toss out the ones where I'm clearly awake. There's no way to unflag an event to have oscar recalculate your ahi and events, is there? I imagine you'd just have to recalculate manually?

[Miss Emerita]

I think it's great you are taking your treatment into your own hands, and you should most definitely do as Pugsy suggests, but one important element of the big picture is your own careful reflection on how your are feeling. So, how rested are you feeling during the day? About the same as before you started CPAP? Better? Worse?

[Pugsy]

Just click on the short session.
I don't know if you have a box with a check mark in it or if you are seeing a green box.
Clicking on it will either remove the check mark or turn the green to red which turns it off.

[willy737]

I think it's great you are taking your treatment into your own hands, and you should most definitely do as Pugsy suggests, but one important element of the big picture is your own careful reflection on how your are feeling. So, how rested are you feeling during the day? About the same as before you started CPAP? Better? Worse?

I'm feeling about the same. Good days and bad. I've only been on it a little over a week, so I'm sure I need to give it some time. I've heard it's taken some folks upwards of 6 months to improve, so I'll stick with it for however long it takes! I certainly hope I'm not just getting crap sleep quality for whatever reason, like Pugsy said. Kinda kicking myself for doing the home sleep study, instead of pushing to get into a lab. Wondering if the test just flagged a lot of events that may have been related to wakeups, like the cpap does.

I've tried everything under the sun to improve my sleep before going to the cpap, and nothing seemed to work. Keeping my fingers crossed that time and some slight setting changes to the machine is all I need.

[willy737]

Just click on the short session.
I don't know if you have a box with a check mark in it or if you are seeing a green box.
Clicking on it will either remove the check mark or turn the green to red which turns it off.

Got the sort session deselected, thanks! I'm also trying to deselect individually flagged events, like hypops that occurred while I was awake. It'd be nice to be able to do that so your ahi and other stats would recalculate, but I haven't been able to find any guidance on that...if it's possible?

[Pugsy]

No way to remove flagged events except by the short session turning off trick.
Now when you wake up during the night you can reach over and hit the on/off button and create a marker where you can for sure know when you were asleep or awake by the easily seen break in therapy. That will help you manually remove the false positives from manual calculations and if you have a session where you simply have a long time getting back to sleep you can remove it.
Sleep session turning off is the only thing we can do though. I wish there was a way to turn off an individual flag but there just isn't.

What I do is just manually go through the flow rate and count the real asleep events and then divide by number of hours to get the asleep AHI numbers.

[willy737]

Great idea with turning it on and off! I'll try that. That will definitely make manually calculations easier and give me a better idea of what's going on. Thanks for all your help!