Settled into CPAP routine, but backsliding on effectiveness

[First World Problems]

First: Thanks to all who have contributed so much amazing information on this forum. What a great resource. I've had so many questions answered just reading the forum I never felt the need to post before today.

Second: Wow, OSCAR is great software.

Now, onto the main show...

I've was diagnosed with severe sleep apnea (API 66) in October 2019 and started CPAP in November 2019 (the backstory is here viewtopic.php?f=1&t=14494&p=1350653#p1350653). Overall I'm very happy with my treatment to date. If I had to characterize my treatment, there are 3 clear phases:

• Adjustment phase (Nov to mid-Dec) -- much better than pre-treatment, but suboptimal results until I adjusted to the treatment and got my mask fitting well.

• Happy phase (mid-Dec to mid-March) -- very happy with the CPAP results. AHI 1-3 on most nights.

• Regression phase (mid-March to now) -- inconsistent CPAP results. Some days ~1 AHI, but many days 5-8 AHI.

Based upon my amateur assessment of OSCAR data (which could be totally incorrect), I notice that my recent apnea events seem to occur in one or more of the following scenarios:

• Apnea events clustered shortly after I go to sleep

• Apnea events clustered shortly before I wake up

• Apnea events clustered around large leak periods ==> This is the one I'm most concerned about.

My goal: Get back to "happy phase" results of 1-3 AHI or better.

Macro question: Can any veterans here provide ideas on how I can achieve my goal based on my descriptions and OSCAR results (see subsequent posts)?

Sub questions:

• Is it common for apnea events to be clustered?

• Are leaks likely an antecedent to an apnea event or the result of increased pressure due to apnea events?

• Would you recommend any machine setting changes based on the results you see

• Should I consider a mask that may be less prone to leaking for side sleepers? If so, any recommendations?

Additional context:

• No machine settings have changed since I started treatment.

• I have not changed my mask model since I started treatment. I do clean the mask with soapy water 2x per week and replace the silicon portion every ~6 weeks.

• If I wake up and my pressure is high (13-15), it is very uncomfortable for me and I have no chance to get back to sleep. If it's in the middle of the night, I'll just turn the CPAP machine off and on to "reset" the pressure.

• Mid-sleep apnea clusters usually seem to accompany large leaks, but large leaks don't always have apnea event clusters

• I tend to be a side sleeper. During the "happy phase" I almost always woke up in the same position in which I went to sleep, but now that rarely happens.

• My DME replenishment order is coming up next month, so if a mask change is required I need to make the decision soon.

• Comfort and effectiveness are my only criteria for a new mask. I have excellent insurance so I'm not worried about the price of a mask.

Thanks in advance for any input you can provide.

Here's an overview of my OSCAR results. Some recent days are very good (AHI < 3), others are poor (AHI > 5)



Here's a good day from this past week with large leaks but minimal apnea events



Here's a bad day (last night) where apnea events align with large leaks



Details on one of the event clusters during the bad day



Cluster of apnea events shortly before I wake from a separate day

[First World Problems]

Okay, I'm obviously not embedding screenshots properly so I'll have to investigate that. In the meantime, here are direct links to the imgur screenshots.

Here's an overview of my OSCAR results. Some recent days are very good (AHI < 3), others are poor (AHI > 5): https://imgur.com/a/IoMGM7M

Here's a good day from this past week with large leaks but minimal apnea events: https://imgur.com/a/BnyyLxZ

Here's a bad day (last night) where apnea events align with large leaks: https://imgur.com/a/1tLw0j3

Details on one of the event clusters during the bad day: https://imgur.com/a/157efvV

Cluster of apnea events shortly before I wake from a separate day: https://imgur.com/a/XulKD0R

[Pugsy]

Go here and watch all the videos.
http://freecpapadvice.com/sleepyhead-free-software
Pay special attention to the last one. While it is mainly talking about central/clear airway apneas you can substitute any event category...we can have false positives in OA and hyponea categories as well.
I suspect a good chunk of those clusters you are having are arousal/awake breathing getting flagged by mistake.
Remember the machine can only measure air flow. It cannot tell when we are asleep or awake. Our awake or semi awake breathing is often very irregular when compared to asleep breathing and the machine can and will flag that irregular breathing as some sort of apnea event. If we aren't asleep though...they don't count.
What might be more important to look at...why aren't we sleeping so great in the first place. So sometimes those flagged events are a symptom of just being awake and not the cause of being awake.

I have some sleep maintenance insomnia issues...wake often during the night....due to pain issues. About 75% of my flagged events are arousal/awake related. I had an AHI of 9 something a couple of weeks ago. 90% of it was arousal related....false positives. It was an unusually bad night for me in terms of back pain and lots of tossing and turning and wake ups.

[Miss Emerita]

Clusters of events are fairly common. Use the resources that Pugsy has provided and check whether yours are "sleep-wake junk." Of course, if you are not really sleeping, or are having repeated arousals, that's a sleep problem in itself. See attachment for an example of the kind of SWJ that I see every night.

Clusters of events during REM sleep are a thing, but the timing of your doesn't look right.

Finally, clusters can indicate a positional problem. Some people are fine on their sides but erupt in events on their backs. And some people, whether on their sides or their backs, will tuck their chins down toward their chests. That can restrict the airway just enough to mess up regular breathing.

It sounds as though you are a side sleeper. Do you ever wake up on your back? If not, maybe chin-tucking is the problem. Try using a soft cervical collar or a "snore collar" to keep your head in a better-aligned position and see what happens.

[First World Problems]

Go here and watch all the videos.
http://freecpapadvice.com/sleepyhead-free-software
Pay special attention to the last one. While it is mainly talking about central/clear airway apneas you can substitute any event category...we can have false positives in OA and hyponea categories as well.
I suspect a good chunk of those clusters you are having are arousal/awake breathing getting flagged by mistake.
Remember the machine can only measure air flow. It cannot tell when we are asleep or awake. Our awake or semi awake breathing is often very irregular when compared to asleep breathing and the machine can and will flag that irregular breathing as some sort of apnea event. If we aren't asleep though...they don't count.
What might be more important to look at...why aren't we sleeping so great in the first place. So sometimes those flagged events are a symptom of just being awake and not the cause of being awake.

I have some sleep maintenance insomnia issues...wake often during the night....due to pain issues. About 75% of my flagged events are arousal/awake related. I had an AHI of 9 something a couple of weeks ago. 90% of it was arousal related....false positives. It was an unusually bad night for me in terms of back pain and lots of tossing and turning and wake ups.

Thanks for the link to the videos. I will definitely watch them.

[First World Problems]

Clusters of events are fairly common. Use the resources that Pugsy has provided and check whether yours are "sleep-wake junk." Of course, if you are not really sleeping, or are having repeated arousals, that's a sleep problem in itself. See attachment for an example of the kind of SWJ that I see every night.

Clusters of events during REM sleep are a thing, but the timing of your doesn't look right.

Finally, clusters can indicate a positional problem. Some people are fine on their sides but erupt in events on their backs. And some people, whether on their sides or their backs, will tuck their chins down toward their chests. That can restrict the airway just enough to mess up regular breathing.

It sounds as though you are a side sleeper. Do you ever wake up on your back? If not, maybe chin-tucking is the problem. Try using a soft cervical collar or a "snore collar" to keep your head in a better-aligned position and see what happens.

Thanks for the insight into the event clusters. I am definitely a side sleeper and never wake up on my back. I'll investigate the cervical collar idea. Can I use a regular pillow with the cervical collar?

[Julie]

Yes as long as you do have the right type and not e.g. the big hard kind you'd wear for whiplash!