Minimal Improvement After Years on CPAP, Need Help

[niumplan]

Hello! I’ve been using CPAP since 2021 to treat mild/moderate OSA. I was first diagnosed 14 years ago.

Despite consistently low AHI (<5), I still really struggle with fatigue, brain fog, and other symptoms of poor sleep. I’ve had little success treating these symptoms, so I’m trying to revisit my sleep as a potential root cause

I've seen multiple sleep doctors, but they often dismiss my concerns because my apnea is “controlled.” Still, I feel terrible and want to rule out anything that may have been missed. If anyone can help me interpret my OSCAR screenshot below or suggest what to push for next (e.g. titration, in-lab PSG, etc.), I’d be extremely grateful.

I have included a screenshot from last night.

I’m happy to share any more context or information, but I wanted to keep this post brief. Thank you very much in advance.

Oscar-Screenshot-10-17-2025.png (604.71 KiB) Viewed 13548 times

[Pugsy]

Do you take any medications of any kind for any reason? If so, what?

Do you have any other physical or mental health issues going on?

[niumplan]

The only systemic medications I take are lamotrigine (300mg) and minoxidil (2.5mg). The rest are topical medications. All systemic medications were started within the last year.

I have depression, GAD, and social anxiety. I also have chronic muscle tension/pain.

[Julie]

Pretend you're someone else reading your note(s). What would YOU think and advise given what you see?

[niumplan]

Hi, Julie. Thanks for your suggestion. If I knew what to do, I would have done it already, which is why I've asked for help here.

I have seen several sleep doctors over the years who tell me that my apnea is treated because the AHI is under 5. It kind of ends there, even if I try to follow up. It's hard to know what to push for or who to talk to if I can't get further than this with sleep doctors. My understanding is that sleep disordered breathing is more complex than just AHI (let me know if this is wrong), but I'm not sure who to speak to about those concerns.

[ozij]

My understanding is that sleep disordered breathing is more complex than just AHI (let me know if this is wrong),

You're absolutely right.
Look at how frequently your pressure is going up an down.
Look at the flow limitations.
Look at the leaks.

ResMed machines are quick to respond to flow limitations, but stupid about lowering the pressure when the flow limitations disappear.
You're spending half the night at a pressure of 8.34 or more - and this in a constant up and down mode, never staying for long periods at the necessary higher pressure.

First thing I'd do, is aim to get my minimum pressure to 8.4 -- in the hope that it will prevent many of those flow limitations. Try moving your minimum up. Start doing it gradually - small increments until you get there - and then stick to the higher minimum for at least 5 nights. Go only as fast as you can handle the change, sometimes patience is necessary.
And put your ramp at a minimum of 7.

You're also leaking. Some people can tolerate leaks better that other. If I had those leaks, my sleep would be badly disrupted.
Now - they could be a result of a mask that doesn't fit so well, they could the result of you opening your mouth - whether because of the flow limitations or just so. Once you've gotten used to the higher minimum, lets see what happens with the leaks.

[DreamDolphin]

Disclaimer: This is only an amateur observation. But I've also struggled for a few years with fatigue despite PAP therapy looking good "by the numbers" and I have managed to make significant gains through trial and error and learning.

My first question would be: what else have you tried so far (machine setting configurations, leak control, masks)? Second, is your sleep hygiene already taken care of? By sleep hygiene I mean consistent sleep schedule, optimal physical environment, minimal or no alcohol/drugs before sleep, no screens before sleep, no physical exertion too close to bedtime etc.

That said, if you've got sleep hygiene locked down, there will be no "make this one change to your settings and you've solved the problem". If your sleep professionals are failing you, which sounds like is your case, it will take some ongoing experimentation until you start feeling great and you've finally honed in on what works for you. I too am on my own without quality professional guidance and have gradually self-titrated and learned on my own how to manage leaks and so on.

1. Take some time and learn how to interpret your data in OSCAR. You don't need to become an expert. Start with basics. Recognize what ideal breathing looks like in a flow rate chart. Learn what obstructed breathing looks like (flow limitations versus full apneas etc). Learn how to read some of the other charts which aren't as readily obvious in function as charts like leak rate and pressure: tidal volume, minute ventilation, respiratory rate. Read other sleep data troubleshooting threads in forums. It won't take long before noticing that things start making sense and you'll find yourself identifying meaningful patterns in your own data.

2. Read up on how varying pressures, EPR, and Bi-level configurations impact therapy. You will find a variety of opinions here, some of which are conflicting, but you will walk away with a better understanding than you had before. The idea is that you are self-titrating intelligently rather than blindly trying a bunch of random settings profiles hoping you eventually land on something that works.

3. Make a practice of routinely examining your sleep data. As you make adjustments, you will be able to gauge whether your tests are moving you in the right direction or not.

4. Alongside your examinations, make incremental adjustments to your settings profile. Pay attention to, not only numbers, but how you subjectively feel. Take notes along the way. You WILL see and feel a difference as you go along. Expect setbacks. The journey to optimal therapy isn't a straight line. As long as you're making adjustments intelligently, it can often be three steps forward and one step back. Treat the setbacks where an adjustment makes you feel worse as a data point to learn from. It's just as meaningful to learn what doesn't work as what does.

5. Patience. Lots of patience.

Yes, it's unfortunate that too many sleep professionals are inclined to send patients on their way as long as the numbers "look fine" despite subjectively feeling like crap.

That said, as for this night of data, my point of interest is that period of sleep between 12:50 and 1:30 that looks relatively decent. Is there a pattern here? Is it suggestive of a more ideal pressure configuration? Is it positional (eg, side vs sleeping on your back)? 7-13cm is a fairly wide range. Too wide to know what your optimal pressure range is, in my opinion. I would narrow this down to a range of 2cm as a starting point for experimentation. 6-8 or 7-9 cm etc. Then you can move that 2cm window up and down rather than trying to find an optimal pressure in such a wide range. You may even find that your optimal configuration is somewhere outside your current range. Consider working in EPR adjustments in your experimentation too. But make only one change at a time so you can more easily identify what's working and what isn't as you go along.

[niumplan]

Hello again! I'm back. Thank you for your responses to my post. I'd like to share where I'm at currently.

• I met with an ENT to discuss nasal breathing. More details below.

• I met with Dr. Barry Krakow for coaching. He explained the importance of good nasal breathing.

• I also had an in-lab BiPAP titration on 12/20/2025. More details.

• I got the ResMed AirCurve 10 BiPAP, which I have been using since 12/24/2025; no improvements yet.

BiPAP Titration
I got two hours of sleep, so the data was limited and of dubious quality. Nevertheless, in that time, the settings they settled on were 10.00/8.00 with EPR 2.00. I woke up feeling surprisingly refreshed for two hours of sleep, but it may have been because I was extremely anxious 11:00 PM - 3:00 AM and was still pumped full of adrenaline. The BiPAP treated my apnea well, but...

• There was very little REM sleep due to limited sleep time.

• I had 93 spontaneous arousals, not related to breathing. It's unclear to me if this was over recording time or sleep time. The data in the report was contradictory.

• They observed residual flow limitation that did not resolve with PAP therapy; this was not quantified.

I'm trying to bring my BiPAP settings in line with 10.00/8.00, leaving PS at 3.00 for now. I'm currently at 6.00 min EPAP, 13.60 max IPAP, and 3.00 PS. So far, I don't feel a big change. I'll work on keeping careful notes as I increase min EPAP.

Nasal Breathing
My ENT noted "Septum: bilateral septal deviation in the mid septum, moderate to severe on both sides. The inferior most aspect of the nasal cavity is preserved but the mid nasal cavity is almost completely obstructed on both sides."

I have a cat allergy, so I have started to use azelastine spray, per my ENT. I'm also using Intake breathing strips.

I need to consider a septoplasty in the longer term.

Leaks
I know I should bring down my leaks. I'm hesitant to use mouth tape because my nasal breathing is not good. Wouldn't mouth tape cause problems if I can't breathe through either? I just got a chin strap, so I'll give that shot.

I'm not feeling much improvement. Does anything stand out to anyone else? Things for me to try, pursue, or advocate for? Thank you!

[Nocibur]

I'm not feeling much improvement. Does anything stand out to anyone else?

Yup.

You are (got?) hyperarousal and sleep reactivity (see explanation on Co-Pilot) and there isn't a Magic Button on your xPAP machine for that.

[niumplan]

It's hard to tell if the arousals are relevant. There's some contradictory data in the report.

• 77 total arousals

• 93 spontaneous arousals

• one part of the report states spontaneous arousal index of 34.34 (divided by TST) and the other states 13.58 (divided by TRT)

I'm not sure how there can be more spontaneous arousals than total arousals and why the indexes differ so significantly.

My sleep doctor was nonplussed about the arousals. Perhaps it was from discomfort at the sleep lab or anxiety from not being able to fall asleep for four hours.

I'm not really sure who to go to to get insight into that. He referred me to a sleep neurologist in his practice, so we'll see. I don't feel like I'll be taken seriously. AHI < 5 and all that.

[ozij]

A sleep neurologist sounds like the right kind of professional for spontaneous arousals.
Why should s/he care about a low AHI? It's the spontaneous arousals s/he should care about.