My snoring and flow limitation events and min pressure

[palerider]

No, he clearly mentioned the "pressure spikes" which are the sawtooth patterns on his reports......1.5cm pressure "spikes", "probes", whatever you want to call them.......which you DID.

the spikes are 1.5cm increases in pressure......

If they're NOT bothering him, then FINE.

Uh, no, Den, he wasn't... YOUR quote, AND highlight:

. Numerous "pressure pulses" at over twice the average.

Well, you know how to fix that if you decide to..

and, he even said afterwards:

Well, you know how to fix that if you decide to.

...When I say pressure pulses I don't mean the continuous spikes/probes. According to Sleepyhead they are "Small test probes or puffs of air to help the machine decide if the apnea event is obstructive in nature or clear airway in nature. ...

[RRL]

Well it's been over a week since starting my new mask: PR Nuance nasal pillows. I find this mask much more comfortable and it has not been causing facial or nose irritation which is awesome. Leaks have been OK for the most part (about the same as the prior mask) with a few nights of too muck leakage. I'm still tweaking headgear fit and pressure stuff so I expected some bumps in the road.

My AHI has been consistently higher since starting the new mask. I don't feel any better or worse. Snores and FLs have continued to be relatively low since I increased the minimum pressure from 8 to 10. With the new mask, I tried 9 and 11 minimum pressures and didn't see much change in AHI, snores or FLs - but it was only one night each so I'm not making any conclusions. Last night I decided to reduce it back to 8, my original minimum pressure - snores were noticeably higher in number (no VS snores, though.) This resulted in the machine increasing pressure and briefly maintaining that increase in response to one snoring event, which was preceded by a FL. Only one other time during the past week has my machine increased pressure to respond to an event - the last time was two FL events close together.

My takeaway from all this: VS events continue to be gone since increasing minimum pressure and FLs are consistently lower. AHI is trending upwards. Machine rarely increases pressure in response to events since there are no more VS and significant FLs, which is what triggered them before having increased my minimum. There has not been a significant change in the number of OAs and Hs since starting the new mask and having increased min pressure. My machine has continued to not respond to OAs and Hs - it has only responded (by increasing pressure) to VSs and Fls. So since having increased my pressure, the pressure graph nearly always just shows the characteristic 'saw-tooth' pattern of standard probes/spikes.

I've read about PR machines being more 'conservative' and ResMed machines being more 'aggressive' due to their different algorithms. Palerider has mentioned the word "perverse" in reference to this difference and I would tend to agree. The 'hunt and peck' and constant "Are you OK?' probes also have not ever decided there was an 'improvement' and responded with a sustained pressure increase. I've zoomed in on the breathing and the probes don't seem to be affecting/disrupting me that I can tell, but the concept bothers me. I'm consistently having OAs and Hs throughout the night and my machine does nothing. I've read Robysue's informative post discussing the differences in PR and ResMed machines. I've watched the YouTube video comparing ResMed and PR responses to sleep disordered breathing events (not sure whether this was ResMed 'sponsored' or not.) I've read other threads discussing the machine differences/pros and cons. I know it can be a "Coke of Pepsi", "Chev or Ford" type thing and that both PRS1s and ResMeds are effective for many, but there are but there are obviously very significant differences.

My conclusion is that 1) I don't want to continue having OAs and Hs and have my machine do nothing (I'll have an OA...no response, then another OA 2 minutes later...no response), 2) Based on what I've read and seen, I prefer an 'aggressive' algorithm rather than a 'conservative' one, 3) I'm not feeling any better yet, and this could be in part because of my machine's 'conservative' approach and constant 'probes' and 4) Trying a non-brick ResMed machine seems like a reasonable next step. I spoke to the DME supplier at the hospital where I had my sleep study and they said they supply both PR and ResMed. I asked if there are certain conditions where one brand is supplied over another or if it was a patient preference thing - they endorsed the latter.

I'll see the Dr. later this month. I'll have consistent data of AHI <5 and 100% compliance at >4 hours/night for over 31 consecutive days, so the insurance 'compliance' thing should be satisfied to ensure continued coverage. I want to change to the hospital DME and try a ResMed machine. I'm going to ask my insurance what sequence of steps they recommend I take to make this happen. There will probably be some hassle involved, but at least the hospital DME will have all my sleep study and Rx data in their system already. I'll probably want to try the P10 pillows ASAP too, so I'll have to figure out how to make that happen and have it covered my insurance.

So that's the plan. Thanks for listening. I'm just so sick of seeing all these apneas and have a machine that does nothing!

[palerider]

Palerider has mentioned the word "perverse" in reference to this difference and I would tend to agree. The 'hunt and peck' and constant "Are you OK?' probes also have not ever decided there was an 'improvement' and responded with a sustained pressure increase.

what I was calling perverse is the prs1 poking at you with those probes when everything is nice and smooth, but if you look at enough traces, you'll see when there is uneven breathing, as there might be if a little more pressure was applied, *THE MACHINE DOESN'T EVEN CHECK!!!"

it's the cpap equivalent of the classic nurse waking you up to take your sleeping pill

[RRL]

I should have looked back to see specifically which part of the PRS1 behavior you were talking about. I definitely think the probes poking at the sleeper when everything is nice and smooth is perverse. The nurse bit is a great analogy. I guess the idea is that PRS1 is being 'proactive', but it hasn't made any adjustments for me based on the results of probing, so I would think that after some time of fruitless probing the machine would say, "hmm, I guess I'll stop unless I have a reason to start again." Then I thought perhaps there was some association with the VS2 snores I have throughout the night (anywhere from 9 to 22 events lately)....doesn't seem like it: just found a solid 90 minutes of snore-free, event-free time and the machine was poking at me the whole time?!

Robysue wrote in her comparison post: "Both machines will respond to snoring, flow limitations, and clusters of OAs and Hs by increasing the pressure." From what I've been seeing, my machine has only been responding with increased pressure to most "VS" snoring and the majority of FLs, and the aforementioned are typically flagged as occurring at approximately the same time. Perhaps my machine is not responding to my OAs and Hs because they are not clustered together enough? I've seen some peoples' screenshots and noticed the flagged OAs and/or Hs very close together - my OAs and Hs are not that close together.

Looking back, I have to correct my previous statement that my machine has only responded to VS and FLs. Twice, the machine increased pressure in response to OA/H - when I had two Hs within 2 minutes and another time when I had 3 Hs and 1 OA within 3 minutes. So it seems like my OAs and Hs are usually not 'clustered' together closely enough to trigger a response from my machine. Robysue also said "The S9 algorithm tends to respond to events by rapidly increasing pressure" and "The System One algorithm is slower to respond to events." This is a problem for me. Although a rapidly increased pressure may be disruptive to some, and perhaps would be for me, I'd rather have a machine do something productive, instead of sit there and wait while OAs and Hs continue to occur. For example, a few nights ago I had 3 OAs within about 22 minutes. I realize this is not severe in the grand scheme of things having seen others' screenshots riddled OAs all blended together, but my guess is that the ResMed S9 may have acted on my first OA and provided enough pressure to prevent the next two. Maybe I'm wrong.

Another thing I noticed: I had 4 OAs and 1 H within 64 minutes. During that time, the machine stopped its persistent probing (except for one small probe) and utilized 6 "pressure pulses" which apparently helped the machine 'decide' they were OAs and Hs, yet no other action was taken - apparently because they were not clustered together enough. Wouldn't continuing to probe right after the first identified OA allow the machine to sense if an improvement could me made via increased pressure, like preventing the next OA? Nope. Found another set of 2 Hs. Machine sits there and "pressure pulses" to confirm they are Hs, no more probing, just waiting for subsequent events. Next, I find 2 OAs over half an hour. This time the machine does the pressure pulses AND the pressure probes throughout the timeframe without any increase in pressure to perhaps prevent the next event from happening. Is this some kind of sick coding prank? What am I not understanding? I recognize that both PRS1 and S9 help many people and provide effective therapy, but something just doesn't seem right with this PRS1 algorithm to me. Maybe I'm overreacting. Maybe my PRS1 is actually preventing a lot of events and providing optimal therapy. Maybe the S9 wouldn't prevent events as well. I have no idea. I just want to feel better. Maybe I need to stop looking at the data!

[palerider]

I should have looked back to see specifically which part of the PRS1 behavior you were talking about. I definitely think the probes poking at the sleeper when everything is nice and smooth is perverse.....doesn't seem like it: just found a solid 90 minutes of snore-free, event-free time and the machine was poking at me the whole time?!

indeed

Perhaps my machine is not responding to my OAs and Hs because they are not clustered together enough? I've seen some peoples' screenshots and noticed the flagged OAs and/or Hs very close together - my OAs and Hs are not that close together.

this may shed some light on the 'more aggressive' vs 'less aggressive' ways of doing things:
https://www.youtube.com/watch?v=lzCCgNLya_g

Looking back, I have to correct my previous statement that my machine has only responded to VS and FLs. Twice, the machine increased pressure in response to OA/H - when I had two Hs within 2 minutes and another time when I had 3 Hs and 1 OA within 3 minutes. So it seems like my OAs and Hs are usually not 'clustered' together closely enough to trigger a response from my machine. Robysue also said "The S9 algorithm tends to respond to events by rapidly increasing pressure" and "The System One algorithm is slower to respond to events." This is a problem for me. Although a rapidly increased pressure may be disruptive to some, and perhaps would be for me, I'd rather have a machine do something productive, instead of sit there and wait while OAs and Hs continue to occur.

even the aggressive rapid resmed still takes minutes to increase pressure... only the ASV machines swing into high pressure on the next breath admittedly, it LOOKS rapid on an all night graph.

[RRL]

Thanks for the info!

Edit: I have seen that video - a great example of the concerns I have.

[robysue]

From what I've been seeing, my machine has only been responding with increased pressure to most "VS" snoring and the majority of FLs, and the aforementioned are typically flagged as occurring at approximately the same time. Perhaps my machine is not responding to my OAs and Hs because they are not clustered together enough? I've seen some peoples' screenshots and noticed the flagged OAs and/or Hs very close together - my OAs and Hs are not that close together.

and

Looking back, I have to correct my previous statement that my machine has only responded to VS and FLs. Twice, the machine increased pressure in response to OA/H - when I had two Hs within 2 minutes and another time when I had 3 Hs and 1 OA within 3 minutes. So it seems like my OAs and Hs are usually not 'clustered' together closely enough to trigger a response from my machine.

Yep. If your events are spaced more than 2-3 minutes apart, the machine treats them as isolated events and ignores them. That mimics the AASM rules for manual titration in a PSG by the way.

Robysue also said "The S9 algorithm tends to respond to events by rapidly increasing pressure" and "The System One algorithm is slower to respond to events." This is a problem for me. Although a rapidly increased pressure may be disruptive to some, and perhaps would be for me, I'd rather have a machine do something productive, instead of sit there and wait while OAs and Hs continue to occur. For example, a few nights ago I had 3 OAs within about 22 minutes. I realize this is not severe in the grand scheme of things having seen others' screenshots riddled OAs all blended together, but my guess is that the ResMed S9 may have acted on my first OA and provided enough pressure to prevent the next two. Maybe I'm wrong.

I think you are mistaken here.

Let's look at the math: 3 events in 22 minutes means that the events were spaced at an average of 10-11 minutes apart. (Event 1 occurs at t=0 (start time); event 2 occurs at t=11 minutes after event 1, and event 3 occurs at t=22 minutes after event 1). Those are pretty isolated events and that means that your breathing between them was probably pretty stable, particularly since the machine was not reacting to snoring or FL and increasing the pressure and did not increase the pressure during the one or two pressure pokes that probably occurred during this 22 minute period.

Now what would likely have happened on a Resmed S9? Well first, the Resmed also looks for clusters of events spaced closely together, as in within 2-3 minutes. So if there was no snoring going on and no flow limitations going on, chances are the Resmed would have ignored the event. But even if it did increase the pressure, with a single isolated event with no snoring or flow limitations, the Resmed would have increased the pressure by no more than 1-2cm. And as soon as the breathing was stable (i.e. as soon as the event was "over" and you took a 2-3 good breaths), the Resmed would have started to lower the pressure back down. And it would have taken maybe 5-8 minutes at most to lower the pressure by 1-2 cm. Hence by the time the second event occured, the pressure would likely have been at the same level that it was at when the first event occurred. Same thing for event #3: It's likely that the pressure would have been lowered by 1-2 cm by the time the third event occurred if the pressure had been increased for the second event.

Although a rapidly increased pressure may be disruptive to some, and perhaps would be for me, I'd rather have a machine do something productive, instead of sit there and wait while OAs and Hs continue to occur.

The PR machine did do something during those 22 minutes: It most likely went through two test pressure increases and neither one of them improved the shape of your flow rate curve. In other words, the test pressure increases did not improve the quality of your breathing, and hence the pressure was not raised.

On a Resmed machine during a 22 minute period with three isolated events, if nothing is going on (no snoring, no flow limitations, no events for at least 2-5 minutes or more), the machine really is just sitting there and doing nothing. Or rather if the pressure is at the minimum setting, the machine is just sitting around waiting for an event, or snoring or a flow limitation to develop. If the pressure is above the minimum setting and nothing is going on for at least 2-5 minutes, the machine is actively lowering the pressure back to the minimum pressure setting.

[robysue]

I should have looked back to see specifically which part of the PRS1 behavior you were talking about. I definitely think the probes poking at the sleeper when everything is nice and smooth is perverse. The nurse bit is a great analogy. I guess the idea is that PRS1 is being 'proactive', but it hasn't made any adjustments for me based on the results of probing, so I would think that after some time of fruitless probing the machine would say, "hmm, I guess I'll stop unless I have a reason to start again." Then I thought perhaps there was some association with the VS2 snores I have throughout the night (anywhere from 9 to 22 events lately)....doesn't seem like it: just found a solid 90 minutes of snore-free, event-free time and the machine was poking at me the whole time?!

and

Another thing I noticed: I had 4 OAs and 1 H within 64 minutes. During that time, the machine stopped its persistent probing (except for one small probe) and utilized 6 "pressure pulses" which apparently helped the machine 'decide' they were OAs and Hs, yet no other action was taken - apparently because they were not clustered together enough. Wouldn't continuing to probe right after the first identified OA allow the machine to sense if an improvement could me made via increased pressure, like preventing the next OA? Nope. Found another set of 2 Hs. Machine sits there and "pressure pulses" to confirm they are Hs, no more probing, just waiting for subsequent events. Next, I find 2 OAs over half an hour. This time the machine does the pressure pulses AND the pressure probes throughout the timeframe without any increase in pressure to perhaps prevent the next event from happening. Is this some kind of sick coding prank? What am I not understanding?

I think you have some major misconceptions about both the pressure probing and the pressure pulses and their roles in the PR S1 Auto algorithm going on. You may also have a misconception about what the APAP is actually doing to control your apnea.

Let's start with the most important thing: An APAP is NOT a non-invasive ventilator. The APAP's job is to provide enough additional pressure to make it difficult (but not impossible) for your upper airway to collapse when you are asleep. When you quit breathing due to an apnea, it is NOT the APAP's job to get your breathing started again. Yes, that seems counter intuitive, but APAP is designed to wait for you to wake up enough to open up your airway and start breathing again. Once the event is over, the APAP may choose to increase the pressure by 1-2 cm if certain conditions are met. In order to increase the pressure after the event is over, one or more of the following typically must be present: (1) the event occurred within 2-3 minutes after the previous event---i.e. there's a cluster of two or more very closely spaced events, or (2) there is evidence of flow limitation in the flow rate curve, which can trigger a pressure increase even without an event, or (3) there is snoring present, which can trigger a pressure increase even without an event. If none of these conditions are met, the machine won't increase the pressure after an event.

Next let's talk about the Pressure Pulses: The Pressure Pulses (PP) are not designed to somehow "bust through" an apnea and open up your airway. Busting through an apnea and forcing your airway open would take more pressure than our CPAP/APAP machines can deliver. The Pressure Pulses are designed to allow the machine to figure out whether a potential apnea is a "Clear airway apnea (CA)" or an "Obstructed airway apnea (OA)". The machine sends the PP out and measures the back pressure. If the back pressure does not increase, the extra air presumably went down to your lungs through a clear airway. If the back pressure does increase, the extra air could not get into your lungs, and the apnea is presumed to be an OA. It's important to determine whether apneas are OAs or CAs because increasing pressure in the presence of CAs is a bad idea: Additional pressure does not prevent more CAs from happening and too much pressure can cause more CAs to happen. PPs are also used by the S1 when it is having a tough time tracking your breathing; this most often happens when there is a very large leak.

Finally lets talk about the pressure probes, which are technically one half of the PR Search Algorithm. The test pressure increases are done when the breathing is relatively stable and the idea is to be very proactive. The machine sends out a test 2cm pressure increase every 10 minutes or so and it studies the shape of the flow rate curve intensely during the test pressure increase. If subtle improvements are seen, the machine continues to raise the pressure proactively until no further improvements in the shape of the wave flow are seen. If no improvements are seen, the pressure is lowered back to the original setting. The kinds of "improvements" the machine is looking for represent evidence that the lower pressure was allowing very subtle flow limitations to develop, but these subtle flow limitations were far too small to be scored as an official Flow Limitation, Hypopnea, or OA.

After the pressure has been raised (typically because of events, snoring, or FLs), the PR Search Algorithm also has a test pressure decrease component. Unlike the Resmed machines, the PR S1 does not immediately start decreasing the pressure as soon as the breathing starts to stabilize. Rather, the PR S1 leaves the pressure where it is and then periodically it tests a decrease in pressure. If any subtle deterioration in the flow rate is detected, the pressure is raised back up to the current level. If no deterioration in the flow rate is detected, the machine continues to decrease the pressure until either the minimum pressure setting is reached OR subtle deterioration is detected, in which case the machine increases the pressure back up to the level it was at with no deterioration.

As for that 64 minute period where you had 4 OAs and 1 H scored with a bunch of pressure pulses and test pressure increases, but no actual pressure increase? My guess is that except for the OAs and the H, your breathing probably looked exceptionally good since the machine was doing the test pressure increase probes. The thing to keep in mind is that many isolated OAs and Hs come with NO warning---in other words they don't occur after snoring or flow limitations have been detected. And because there are no warning signs, there's not much that the machine can do to prevent them. And if they're isolated from each other by more than 2 minutes of normal sleep breathing, the PR S1 is not programmed to increase the pressure in response to them. (And neither is an S9 as I recall.)

I recognize that both PRS1 and S9 help many people and provide effective therapy, but something just doesn't seem right with this PRS1 algorithm to me.

It might help you understand what the PR S1 Auto algorithm is trying to do if you had a better idea of what goes on in a manual titration study. I'll try to find the link to the AASM rules for manual titration studies tomorrow night. There's also an old 2009 article that is a benchmark study of the then state-of-the-art auto algorithms from several different companies. Somethings (such as OA vs. CA detection) have changed a lot since 2009, but some of the basic decisions about when to increase/decrease pressure and how much to increase/decrease the pressure are still in place in the algorithms used by today's machines. I'll also try to find my link to that article if you would like to read it.

Maybe I'm overreacting. Maybe my PRS1 is actually preventing a lot of events and providing optimal therapy. Maybe the S9 wouldn't prevent events as well. I have no idea. I just want to feel better. Maybe I need to stop looking at the data!

My best guess is that your PRS1 is doing a good job of preventing most of your events. My guess is that the S9 would also do a good job at preventing most of your events. Your AHI might even be lower the the S9, but that may or may not make you feel any better. And perhaps you also have a bit of Resmed S9 AutoSet envy. A lot of S9 users think no other machine can possibly be as good as the S9 and they're not shy about saying it around here. (And the S9 is a very good machine. But so is the PR S1.)

Looking at your data is a two-edged sword. If you look at it the first thing in the morning and say to yourself, "Oh shit, I had 5 events last night in a 50 minute period and the machine didn't do a damn thing. And I feel lousy and I bet those events are why I feel lousy.", then looking at the data every day may be negatively influencing you. But if you look at the data and the first thing that goes through your mind is "At least the AHI is below 3.0 today so the machine must be doing something right even though I feel lousy", then the data may be helping you to keep going. (For what it's worth, when I was a newbie, I needed to look at the data every day just to reassure myself that the machine was doing it's job even though I was feeling a whole lot worse than I had before starting CPAP.)

I'll end by sharing something that Morbius said more than once in his many guises: CPAP doesn't fix bad sleep. CPAP fixes sleep disordered breathing and nothing else. If there's anything else wrong with your sleep, you can still feel lousy even though CPAP has fixed your sleep disorder breathing.

And now it's time for me to get some sleep.

[RRL]

Thank you, robysue, for the very detailed information! Things definitely make more sense now

[RRL]

Okay, so about 3 weeks of using the Nuance nasal pillows mask which I started using on March 1. I used the Wisp nasal mask for a little over 2 weeks before starting with the Nuance. Some general comments and observations of my daily experience and review of the data and then some stats:

--> I like this nasal pillows mask a lot more than the Wisp nasal mask - it is more comfortable, less intrusive and no nasal or facial irritation anymore
--> I feel the pillows seal better than the Wisp
--> Mask maintains seal in all sleeping positions
--> There is no annoying whirling of air around my nose anymore
--> Breathing feels relatively natural at a range of pressure settings
--> Flow limitations have been notably less frequent, but more common at min pressure of 8
-->"VS" snoring has been absent at min pressures above 8, but have had a few at lowest treatment pressure of 8 and way less at 8 than with the Wisp
--> Machine increases and maintains a higher pressure in response to FLs and VSs which pop up here and there at the min of 8 with the Nuance, but nothing like the Wisp at 8
--> Machine now seems relatively satisfied with a min pressure of 8, whereas with the Wisp it was routinely increasing pressures from 8 and maintaining them around 10-11ish
--> "VS2" snoring has remained about the same
--> OAs seem more common
--> CAs seem more common
--> Leak rate has been significantly lower
--> AHI has been consistently higher
--> I feel maybe 5% better and not worse
------------------> I feel that I have not yet been able to optimize my therapy with the Nuance pillows.

With the Wisp mask during February I was dialed in at an optimized min pressure of 10 for only the last 3 days (which I enjoyed AHIs of less than 0.70 and had no VSs and way fewer FLs.) Most nights with the Wisp were min pressure 8 and one day at min pressure of 9. Nearly 3 weeks with Nuance pillows I tried various min pressures between 8 and 11 with the past week staying at 8. I've only had one night with AHI less than 1 with the Nuance. Therapy efficacy data according to Sleepyhead is as follows:



FEB AHI: 0.94 OI: 0.23 HI: 0.54 CAI: 0.17 FLI: 0.76

MAR AHI: 1.41 OI: 0.44 HI: 0.55 CAI: 0.42 FLI: 0.36

Edited: I'm not getting this data in the format I'd like

So basically it looks like my Obstructive Index has nearly doubled, Clear Airway Index has more than doubled and Flow Limitation Index has been cut in half. AHI is higher. So more OAs, more CAs and less FLs. I noted earlier less "VS" snores at 8 with the Nuance which in combination with fewer FLs seems to explain my machine's 'satisfaction' with the min pressure of 8 compared with the min pressure of 10 being optimal (low FLs and low/no VSs) with the Wisp. This is far from a perfectly arranged comparison, but I find the Obstructive and Clear Airway numbers troubling. Why more OAs? What can be done...maybe it's the mask? It has actually been nice with the minimum at 8 with the pillows as I've experienced much less air leaking through my mouth and haven't had the chipmunk cheek thing, just wish my numbers were trending better or at least the same as with the optimized Wisp.

Since I still get some actionable FLs and VSs at min 8, I'll try 8.5 tonight which I haven't tried yet. Even though A-Flex is a comfort setting, I may try reducing it from 3 to 2 (at some point) for a bit and see what happens. Level 2 has been uncomfortable when I tried it previously, but that was when I had my min pressure at 10; maybe it will be different this time with a min pressure of 8 or 8.5. I have fiddled with the humidity level, decreasing to 1 and increasing to 3 with no noticeable difference in the numbers. 2 feels most comfortable so I'll just keep that the same. I've even considered reducing the min pressure below the Rx'd min for kicks and see what happens, but plan to wait on that until after I see the doctor on Wednesday for my follow-up/compliance visit. I do also plan to try a straight pressure in CPAP mode, but feel like I haven't found a pressure that seems to prevent the majority of apneas. Pressures at 9, 10, and 11 haven't seemed to make much of a difference in the number of OAs compared to min of 8, but I probably need to give each pressure change a week or so to get a better idea of their effectiveness. One thing I do know is the increased pressures obviously do still cause more mouth leaks and chipmunk cheek issues with the Nuance.

With the doctor, I just plan to go with the flow. I don't have any specific questions. If he notices my average pressure has been higher than Rx'd, I'll just explain that I had increased my minimum pressure to combat VSs and FLs and show charts illustrating that it helped with the Wisp. If he then thinks the minimum should be increased from 8 where I'm at now, I'll explain that I am no longer using the Wisp (which was optimal at 10) and reduced the minimum back to 8 which seems to feel and be working fine with the Nuance (except for the stuff I mentioned in this thread, which I do not plan on mentioning during the visit.) I'd rather read posts here and experiment on my own to try and optimize my Tx with the Nuance because frankly, I don't believe he has much to offer.

So, to reference this thread title, my ("VS") snoring and flow limitations are under control. I would like to have fewer VS2 snores, but at least there are not nearly as many VS snores. I don't know what caused the increase in OAs and CAs and I find it frustrating. I won't consider my treatment optimized with the Nuance until I see better numbers. I'm grateful that my numbers are below 2 and that I'm tolerating the treatment pretty well, I just want to find that "sweet spot." Thank you for listening to my rant ....any comments/advice etc. would be appreciated.

[robysue]

RRL,

Using the Nuance you report:

With the Wisp mask during February I was dialed in at an optimized min pressure of 10 for only the last 3 days (which I enjoyed AHIs of less than 0.70 and had no VSs and way fewer FLs.) Most nights with the Wisp were min pressure 8 and one day at min pressure of 9. Nearly 3 weeks with Nuance pillows I tried various min pressures between 8 and 11 with the past week staying at 8. I've only had one night with AHI less than 1 with the Nuance. Therapy efficacy data according to Sleepyhead is as follows:

FEB AHI: 0.94 OI: 0.23 HI: 0.54 CAI: 0.17 FLI: 0.76

MAR AHI: 1.41 OI: 0.44 HI: 0.55 CAI: 0.42 FLI: 0.36

So with the Wisp your long term AHI = 0.94 and with the Nuance it's 1.41. That's a statistically insignificant increase in the AHI and it's NOT worth worrying about, particularly since you also say this about the Nuance:

--> I like this nasal pillows mask a lot more than the Wisp nasal mask - it is more comfortable, less intrusive and no nasal or facial irritation anymore
--> I feel the pillows seal better than the Wisp
--> Mask maintains seal in all sleeping positions
--> There is no annoying whirling of air around my nose anymore
--> Breathing feels relatively natural at a range of pressure settings
...
--> I feel maybe 5% better and not worse

In short, it sounds like you are more comfortable and significantly less annoyed when you wear the Nuance as compared to the Wisp.

And if you are more comfortable, you are much more likely to get deep, restorative sleep rather than just light, less restorative sleep. And if you are sleeping more soundly with the Nuance, that could explain the slight rise in AHI: You may be getting more REM sleep with the Nuance. But the insignificant increase in AHI is much less important than the fact that you are reporting that you are starting to feel better instead of worse. Feeling Even Marginally Better is the real sign that you are getting close to optimizing your therapy.

You also write:

I don't know what caused the increase in OAs and CAs and I find it frustrating. I won't consider my treatment optimized with the Nuance until I see better numbers. I'm grateful that my numbers are below 2 and that I'm tolerating the treatment pretty well, I just want to find that "sweet spot." Thank you for listening to my rant ....any comments/advice etc. would be appreciated.

You may have found your sweet spot, but you're too hung up on trying to get "near perfect" data.

Here's the thing you need to keep in mind: There's no real point in chasing a super low AHI. For most people, the difference in how they feel if the AHI < 1.0 vs. an AHI in the 1.0-2.0 range depends more on the subjective quality of the sleep rather than the AHI. At this point the difference in AHI is statistically insignificant. The same thing applies to all the other efficacy data as well: If the VS snores are not too numerous and the FLI isn't way out of wack, the most important thing is How Do You Feel and not what the actual numbers are.

In other words, there's a lot more to optimizing CPAP therapy than figuring out how to get perfect or near perfect data. The real trick to optimizing CPAP therapy is to find settings that get the AHI's well below 5.0 with the leaks decently control AND allow you to get to sleep quickly and sleep soundly all night long. In short, you are more likely to feel good if you are getting a full night's sleep with plenty of REM and Stage 3 sleep and an AHI = 1.5 than you are if you are getting an AHI = 0.5, but your sleep is fragmented and restless where you may not be getting enough REM or Stage 3 sleep because of comfort issues.

In your case, you report the Nuance is more comfortable and less annoying than the Wisp. That's a significant improvement in the quality of your comfort, which in return should allow you to sleep better all night long, where better means deeper with fewer arousals and awakenings.

And significantly, you report feeling slightly better with the Nuance. And that's an important sign that your body is learning how to sleep well with the CPAP and Nuance mask. Chances are that if you continue to use the Nuance you will continue to make slow, but steady progress towards feeling noticeably better: Most of us do NOT wake up one morning suddenly feeling like we're on top of the world and raring to go. Rather, the improvements in how we feel are subtle, particularly at first, but they steadily grow. And one day you realize that the new "normal" has a lot less sleepiness, a lot less fatigue, and often a lot less low grade pain than the old pre-CPAP "normal" had. You can't point out exactly when the changes happened because they happened over time. For most people it takes a few weeks to a couple of months of sleeping well with the PAP before they notice a measurable amount of improvement.

In other words, it may be time to start focusing on what allows you to sleep well subjectively rather than what reduces the AHI as low as possible.

[RRL]

Thank you for your response, robysue. Your comments make sense and are well taken.

So with the Wisp your long term AHI = 0.94 and with the Nuance it's 1.41. That's a statistically insignificant increase in the AHI and it's NOT worth worrying about

That is reassuring to hear and as you mentioned it is even less significant since I'm more comfortable with the Nuance.

And if you are sleeping more soundly with the Nuance, that could explain the slight rise in AHI: You may be getting more REM sleep with the Nuance. But the insignificant increase in AHI is much less important than the fact that you are reporting that you are starting to feel better instead of worse. Feeling Even Marginally Better is the real sign that you are getting close to optimizing your therapy.

The concept that I may be sleeping more soundly and possibly getting more REM sleep helps me make more sense of the slight rise in AHI. I was seeing the increased AHI and more OAs as a sign that I was not on the right track to optimizing my therapy. The fact that the VS and FL numbers are good also helps me to see that I may be more on the right track than I think.

You may have found your sweet spot, but you're too hung up on trying to get "near perfect" data.

I'm definitely hung up on trying to get near perfect data. Having seen the three days in a row with AHI less than 0.70 with the Wisp was promising, then I started the Nuance with an AHI of 1.8 which threw me for a loop and I've been chasing those <0.70 nights ever since.

There's no real point in chasing a super low AHI. For most people, the difference in how they feel if the AHI < 1.0 vs. an AHI in the 1.0-2.0 range depends more on the subjective quality of the sleep rather than the AHI. At this point the difference in AHI is statistically insignificant. The same thing applies to all the other efficacy data as well: If the VS snores are not too numerous and the FLI isn't way out of wack, the most important thing is How Do You Feel and not what the actual numbers are....
....The real trick to optimizing CPAP therapy is to find settings that get the AHI's well below 5.0 with the leaks decently control AND allow you to get to sleep quickly and sleep soundly all night long. In short, you are more likely to feel good if you are getting a full night's sleep with plenty of REM and Stage 3 sleep and an AHI = 1.5 than you are if you are getting an AHI = 0.5, but your sleep is fragmented and restless where you may not be getting enough REM or Stage 3 sleep because of comfort issues.

I think it makes sense for me to pay more attention to how I feel and less attention to the actual numbers. While experimenting with the Nuance and pressures, I've realized that my sleep tends to be interrupted with pressures of 10 or higher due to mouth leaks. This would cause fragmented sleep and likely affect the quality of sleep and in turn, how I feel. So since I've found I can tolerate lower pressures with the Nuance, this has meant less leaks and less waking up with air flowing out of my mouth which in turn allows for better quality sleep. So at this point I'm working my min setting up from 8 to a level where I continue to have low VS and FL events but also minimal mouth leaks and optimized comfort.

And significantly, you report feeling slightly better with the Nuance. And that's an important sign that your body is learning how to sleep well with the CPAP and Nuance mask. Chances are that if you continue to use the Nuance you will continue to make slow, but steady progress towards feeling noticeably better

This brings me back to the need to have patience and reminds me to allow myself to time to continue to adapt to CPAP and the mask change. I think it's definitely a "slow and steady wins the race" situation for me. Thanks again for your insightful response!