New and need help with settings

[MarthaP]

I'm so grateful to the experienced folks on this board for all I've learned already from reading your advice to others.
I had a home sleep study and was diagnosed with OSA in mid Feb.
I already sleep on my back, with a dental splint and chin strap, in an adjustable bed with the head cranked up to about 45 - 60 degrees (because of bruxism, reflux and a bad left shoulder). I had 29.3 events on the study and was prescribed a ResMed AutoSense 10. They didn't do a titration study, but set the machine on 6 and 12 with a full time epr of 3.

I tried nasal pillows for a few days, but couldn't manage keeping my mouth closed (air blowing out of my mouth), even with a chin strap, so I'm using a ResMed AirFit 30. I've gotten fairly used to having it on my face and have a reasonably low leak rate. The problem is that my events are still high (25 to 30/hr).

When I talked to the DME, he suggested I try setting the max pressure at 20 as a way of titrating myself ("The pressure won't go any higher than it needs to go.") So I did that, and when the pressure went up (I didn't have sleepyhead at that time), it blew the mask off my face. So, I decided on a more gradual approach. I set the max pressure at 15 and fought to keep the mask from leaking all night the first night. The second night I gave up after 2 hours. The third night, I tried sleeping on my left side, with the head of the bed at about 30 degrees. I woke up after 2 hours because of aerophagia. Not just discomfort, which I'd had a few times on previous nights, but really severe pain, belly swollen like a beach ball, cold sweat, and vomiting air. I thought I was dying! I was so scared I turned it off for the rest of the night, and the next night, I turned the pressure back to 6 to 10. I saw my pulmonologist a few days later, who is not interested in the details, but said I could have an in-lab titration study now or try adjusting it myself for another month. I finally have got SleepyHead working on my computer, so I thought maybe you all could help me get through this!

I'm posting the charts from the last couple of nights with the pressures set at min. 7, max 12 - 12.6, epr 3. At this setting, I have some trouble with aerophagia and air blowing into my mouth and waking me up, but I think I'd be able to get used to it and sleep through it. I'm pretty scared of a repeat episode of extreme aerophagia if I have to go up on the pressure. Would reducing the epr help, or does it help to protect me from the aerophagia? How rapidly should I try increasing the pressure to get the apnea under control? I may not even be asking you the right questions, but please tell me what I need to know and what to do next! Thanks so much!

[Pugsy]

Welcome to the forum.

wiki/index.php/Aerophagia

Reducing EPR will effectively raise your pressure a little but probably not enough of an increase to meet your needs in terms of preventing those apnea events and would very likely increase the chance of your having bad aerophagia issues.

You are going to need a lot more pressure than you are using now and very likely will need a different machine (bilevel) where you can have a greater difference between inhale and exhale than EPR can give you. So maybe that in lab titration would be a good thing to have if they do it on a bilevel machine.

In the meantime...keep EPR at 3 and gradually increase your minimum and maximum pressures...like 1 cm each for a week then another 1 cm each (min and max) and see if you can slowly work yourself up to the pressure that will prevent the airway from collapsing and maybe if you are lucky won't be calling the aerophagia monster to come set up shop in your belly.

Your minimum pressure is your most critical setting though.....it does the bulk of the holding of the airway open but when you see it pegged out at the maximum pretty much all night....that maximum needs to be close to your new minimum.

[MarthaP]

Thanks so much for the quick response, and right to the point!
I’ll try the 1 cm/wk ‘at home’ approach unless and until it is successful or clearly doesn’t work for me. And if I have to do the sleep lab titration study, I’ll specifically request a trial on a bilevel machine.
Thanks again!

[Julie]

Hi - you have a lot going on! One thing that occurred to me because of your sleeping position is to wonder if your head tends to fall forward on your chest, cutting your air flow a bit/lot... only you can answer of course, but if you think it's likely, you might want to try a soft/foam cervical collar that'll keep your head up better, help to close your jaw, if not lips, and hopefully give you better results.

[MarthaP]

Thanks, Julie. I’ve tried an “eliminator” cervical pillow, but I don’t really think I do the “chin tuck” thing. I use a buckwheat hull pillow under my neck while I’m sleeping and my head stays up (unless I slide way down in the bed, which doesn’t happen often.). But, as you noted, I have a lot going on. I have had TMJ troubles and have degeneration in both jaw joints. So, while I could sleep on my side things were better. Since my shoulder refused to let me do that any more, I have been using a chin strap to support my jaw while I sleep. Most of those pull your mandible back into the joint, which is painful for me. So I have a homemade one that directs the force straight up, and have now found the PR premium one that can do the same thing. It gets pretty complicated!

[Buffalo77]

I was told not to change the setting and I am very surprised to hear that the OP changed the settings. I won't know how to change my settings but I notice that my CPAP is very weak compared to the settings done while at the sleep lab (done back in 2015). I remember trying to work with strong pressure and trying to follow the rhythm. At home, it is nothing. I want to hear all about the settings and why my CPAP is very weak comparing to the one at sleep lab.

[Julie]

Everyone here changes their settings (after posting Sleepyhead pix according to the 1st "Announcement" main pg here. We can help you with that - get the clinician manual from Apneaboard.com and then come back to this thread. Never try to follow the rhythm - the machine is supposed to adjust to your breathing patterns, not the other way around.

[zonker]

I was told not to change the setting and I am very surprised to hear that the OP changed the settings. I won't know how to change my settings but I notice that my CPAP is very weak compared to the settings done while at the sleep lab (done back in 2015). I remember trying to work with strong pressure and trying to follow the rhythm. At home, it is nothing. I want to hear all about the settings and why my CPAP is very weak comparing to the one at sleep lab.

welcome, bob! please feel free to start your own post and get all the help you need.

here's something to get you going-

viewtopic/t172378/Sticky--Newbies-PLEAS ... STING.html

good luck!

[MarthaP]

I'm back for more advice.

I've been trying to go up gradually on the pressure (1 cm a week, keeping the EPR at 3), hoping I can learn to manage the aerophagia and get the pressure up high enough to control my events. I'm having some success about the aerophagia, I think. It still wakes me up some, but I'm aware of belching sometimes now against the pressure, which I'm pretty sure I couldn't do before. And no more scary episodes. I think being able to belch against the pressure has helped to protect me from the worst of it, and maybe I'm learning to feel when it's getting bad and to wake up and deal with it.

But, I've gone from a max pressure of 12 up to 14 now, with 2 nights at 14. Last night I had the mask and machine on all night (though I was up for a short bit in the middle to revise my mask headgear that was cutting into my ear). My apneas were up to 36! They were 29.3 on my sleep study, and 25 to 30 on the lower pressures.

I have been sleeping with a cervical collar since my last post, instead of the chin strap, to see if that would help. I'm so much better on my side, and I'm thinking the apneas must be positional also because of the way they cluster. But, it doesn't seem to be doing the trick, at least not at my current pressures.

So, my question is whether to continue with the approach of slowly going up on the pressure and be patient, or should I go back to the sleep lab for a titration?

And, on a more general theme, can you tell by looking at the flow rate graph whether you need higher pressure on inspiration or higher pressure on expiration to deal with your obstruction? I'm thinking about whether a bipap machine would potentially be helpful to me. If I need more pressure on inspiration, it might help by letting me have a lower pressure on exhalation, helping me to deal with the aerophagia. But if what I need is a higher pressure on exhalation, I can't see that the bipap would help. So, am I thinking correctly, and can you tell what a person needs by looking at their graphs, or just by trial and error at a titration (or slowly at home)?

I'm attaching my data from last night with the pressure set at 7/14.

Thanks again for your help!!

[Pugsy]

Usually...in general rule of thumb....OAs need more EPAP and hyponeas need more IPAP....

BUT....IPAP also will help with OAs. It's not always a simple either one or the other situation...most often it is a combination of things that we end up with good results. You know the old saying "more than one way to skin a cat"...there's more than one way to achieve desired results with cpap/apap/bilevel.

With your aerophagia issues I seriously doubt you can get things under control without going to bilevel and not have the aerophagia monster set up shop. It's going to be hard enough even with bilevel and the pressures you are apparently going to need.
You need to be seeing your doctor sooner and not later about your issues.

I think that you are going to need to enlist the help of IPAP to help you out with the OAs because EPAP can't do it alone without inviting the aerophagia monster. You need to be able to use a higher difference than you can get with EPR at 3 to stand a chance of keeping the aerophagia monster away.

You need to be making that follow up appointment with your doctor if you don't already have one.
Until then.....you keep increasing the minimum AND maximum to see if you can get to a point where the OAs reduce enough and you are obviously a long way from that with the max at 14 right now.