Over a month on CPAP, AHI 20.53

[Uff Da]

Here is the Sleepyhead data from last night. Settings were pressure 18 max, 11 min, EPR 3. I added a 5 minute ramp starting at 6.

I still had aerophagia, of course. Since starting CPAP I probably pass more wind in one night than I did before CPAP in a couple of months. But with the EPR, I don't think it was particularly painful nor do I think it woke me like it did at higher pressures without EPR.

It looks like I hit up against the maximum pressure of 18 only briefly a couple of times early in the night, so if this night was typical of what to expect, I don't think a bi-level is necessary to get higher pressures than this machine could provide. But I'd like the opinion of the experts on this panel if you think it is warranted to have a sleep study for a bi-level for other reasons.

My doctor wants me to call within about a week and make an appointment either for such a sleep study if I'm still having "problems," whatever that means, or instead to just make an appointment for an office call in a couple of months. I really don't want another sleep study unless there is evidence I need it. The sleep center is a two hour drive away and the travel and timing is a terrible disruption of not only my sleep and eating schedule, but that of my partner, who'd be the driver. So do those of you with more knowledge of what a bi-level can do think you'd do the study if you were in my shoes?

The initial concern regarding a bi-level is that there were some centrals in my original study, apparently enough that the doctor doing the interpreting thought it should be watched. But how many centrals is necessary before it becomes a problem? I just don't know enough about all this to have much basis for an opinion.

Back to last night's chart. I was awake from about 2:48 until 6:45 or so, so those events in that time period were during wake time. I finally got up, had an early breakfast, then went back to bed and sleep. That always seems to be the time of day I get the best sleep, in spite of all the advice to not eat then go to bed.

[Uff Da]

EPR wasn't as effective at keeping aerophagia at bay last night as the previous night. I started the night with the same settings as Sunday night: pressure 18 max, 11 min, EPR 3 and a 5 minute ramp starting at 6. But I had a lot of events in the first part of the night requiring a high pressure. I also had more mask leakage during this period. When I awoke the second time, around 12:15, it was with some pain with the air swallowing. I then lay awake over an hour trying to expel all the air before I reduced the maximum pressure back to 16, leaving the other settings the same. I was then able to get back to sleep.

Again this morning I had an early breakfast, then went back to bed. Note that in that last "nap" session, I only had one apnea event compared to the many in the earlier sessions. That's happened for the last three days when I ate and went back to bed, twice now with just one event and once with none at all. I also see that I had an unusually large number of events in the first session last night. And last night I did not have a bedtime snack, whereas I usually do. I'll have to pay closer attention to whether or not there seems to be a cause and effect for me, but I'll need to try to keep other variables close to the same. I don't have good enough notes to just go back and look at past results and draw conclusions.

It would be interesting if it turns out that eating before bedtime or in the middle of the night actually gives me fewer events than not doing so when all the advice is to the contrary. My situation is a bit different from the majority, though. I have postprandial hypotension, with a systolic blood pressure that drops 20-30 points and occasionally as much as 50 points after eating. So it makes it a lot easier to get to sleep right after eating. Who knows if there might be additional physiological results from the eating or the BP drop? I'm underweight, so weight gain is not an issue with extra eating. This may prove to be an interesting experiment in the coming months.

[Uff Da]

I'm discouraged. Really discouraged. It seems that everything I've done to get my apnea numbers down gets limited by some other problem which makes it unsustainable.

I was getting some numbers in the "treated" range with my AirFit F10 mask previously. But that was only when I used a cushion under my knees to prevent me from rolling on my side, since side-sleeping created terrible mask leaks. But I have another medical issue which causes pain if I lie in one position too long, so my sleep was often interrupted and I ended up sleeping with the mask no more than a total about four hours most nights, and even that was in two or three sessions.

With the Respironics Wisp nasal mask I got some good numbers several nights, but at the expense of needing to have a chin strap and the mask so tight that my face was contorted, red, and I had marks left on my nose and cheek from the mask. And the chin strap aggravated my jaw pain, making it more difficult to eat. And that was with the cervical collar, too. The collar alone didn't begin the solve the chin drop problem.

More recently I've been using the Quattro FX FFM with a cervical collar. Numbers were up and down, I suspect a lot depending upon how I got the collar adjusted and how I happened to lie that night. At first the Quattro gave me unbearable aerophagia when I tried using it at the higher pressures. With Pugsy's suggestion to add EPR of 3, that helped, but I'm still limited to a pressure of no more than 16, and even that gives me some problems with aerophagia.

Generally, my numbers were better with the Quattro than with the other two masks, though. But Thursday night I just had to take it off and switch back to my AirFit F10. The Quattro tends to vent toward the eyes and I already have dry eye syndrome. I just couldn't tolerate it any more.

It was about 10:15 Thursday night that I switched back from the Quattro to the AirFit. And you can see how bad my events were after that. The machine kept bumping up against the maximum pressure of 16. And that is with EPR of 3. Previous to using EPR, the maximum pressure I could tolerate was 14.

Last night I tightened the AirFit mask more about midnight. That did cut down on leakage after that, but I still ended up with OA after OA after OA in the next couple sessions.

Is there any solution other than trying mask after mask? My AHI in the sleep study was 88, so even these horrible numbers I've been having are an improvement. But the fact that I've had many OAs over a minute in length and one of 102 seconds recently does make me realize this may be a rather serious matter.

[Fetou]

Your max looks to be limiting the machine from where it wants to go. It doesn't seem to ever want to be at your minimum.

[Uff Da]

Your max looks to be limiting the machine from where it wants to go.

Absolutely. And that is precisely why I'm so frustrated. My pressure needs are higher, but setting them any higher causes so much noisy mask leakage that I can't sleep or causes aerophagia so severe that it interferes with sleep. My original prescription was for a maximum pressure of 18, and I suspect that would probably take care of my needs most of the time. But in the first ten days with that pressure, I only got a total of 3.5 to 5.5 hours of sleep with the mask due to the noise. Getting an average of half an hour of sleep a night is not an option. So I had to lower the maximum. And I'm still searching for some way to be able to increase that maximum.

It doesn't seem to ever want to be at your minimum.

That is certainly true in the last two nights. Over a longer time period, 11 had looked about right. But now that I look over the past couple of weeks, I just might consider raising the minimum to 12. It does seem to vary a bit with which mask I'm using.

I have two more masks on order - well, one new mask and a larger size cushion and frame of the AirFit. This could get expensive. Apparently Medicare won't cover another full new mask for another three months. My DME only let me make one exchange.

[palerider]

Your max pressure needs to be 20.

With your EPR set the way it is, your effective pressure is only 13, that's too low to prevent obstructives for you.

You need to get the mask leaks under control.

The quattro doesn't vent towards your eyes, it *leaks* towards your eyes... no mask vents towards the eyes.

Mask liners were what tamed leaks for me, made the FFM comfortable and quiet.

[Fetou]

Your max looks to be limiting the machine from where it wants to go.

Absolutely. And that is precisely why I'm so frustrated. My pressure needs are higher, but setting them any higher causes so much noisy mask leakage that I can't sleep or causes aerophagia so severe that it interferes with sleep. My original prescription was for a maximum pressure of 18, and I suspect that would probably take care of my needs most of the time. But in the first ten days with that pressure, I only got a total of 3.5 to 5.5 hours of sleep with the mask due to the noise. Getting an average of half an hour of sleep a night is not an option. So I had to lower the maximum. And I'm still searching for some way to be able to increase that maximum.

It doesn't seem to ever want to be at your minimum.

That is certainly true in the last two nights. Over a longer time period, 11 had looked about right. But now that I look over the past couple of weeks, I just might consider raising the minimum to 12. It does seem to vary a bit with which mask I'm using.

I have two more masks on order - well, one new mask and a larger size cushion and frame of the AirFit. This could get expensive. Apparently Medicare won't cover another full new mask for another three months. My DME only let me make one exchange.

I think you need to take the pressure increase as an unavoidable thing in this circumstance, and work to get a mask fit and machine that will work for you. If EPR of 3 helped with the aerophagia (which seems to be the limiting factor here), then it would seem to me that a bi-level device would be worth a shot.

[palerider]

then it would seem to me that a bi-level device would be worth a shot.

Maybe... but would still need to get the EPAP high enough to hold the airway open.

Right now, the machine is running like a bilevel on 16/13 max.

[Fetou]

then it would seem to me that a bi-level device would be worth a shot.

Maybe... but would still need to get the EPAP high enough to hold the airway open.

Right now, the machine is running like a bilevel on 16/13 max.

I was thinking something along the lines of 5.0 P/S over 13, with the objective being to allow for higher IPAP tolerance. No guarantee that this would fix the aerophagia of course.

[palerider]

then it would seem to me that a bi-level device would be worth a shot.

Maybe... but would still need to get the EPAP high enough to hold the airway open.

Right now, the machine is running like a bilevel on 16/13 max.

I was thinking something along the lines of 5.0 P/S over 13, with the objective being to allow for higher IPAP tolerance. No guarantee that this would fix the aerophagia of course.

The problem with that is that it wouldn't do any good at all to combat obstructive apneas.

it's EPAP that holds the airway open so that you can inhale. IPAP will help avoid other breathing issues, but if you don't have enough EPAP, and the airway collapses, then .... nothing happens.

You could have an EPAP of 13, and PS of 12... and if that airway closes, you'll never trigger the higher pressure, because you can't inhale.. and even if there was higher pressure, it won't open a closed airway, in some cases, it's like pushing on a 'pull to open' door.

[zoocrewphoto]

Generally, my numbers were better with the Quattro than with the other two masks, though. But Thursday night I just had to take it off and switch back to my AirFit F10. The Quattro tends to vent toward the eyes and I already have dry eye syndrome. I just couldn't tolerate it any more.

When I started, I had trouble with the Quattro FX leaking by my eyes. Somebody here told me that the mask was too high on my nose. Try starting it a little bit lower on your nose, and see if that leak clears up. Also, if you happen to have a smaller head, there is a smaller headgear that can be ordered.

[Uff Da]

When I started, I had trouble with the Quattro FX leaking by my eyes. Somebody here told me that the mask was too high on my nose. Try starting it a little bit lower on your nose, and see if that leak clears up. Also, if you happen to have a smaller head, there is a smaller headgear that can be ordered.

Yes, I'd read instructions to start with it lower on the nose and tried to do that. Have been even more cautious after your post, though. I think part of the problem is that I have so little room for error due to the sizing. My measurements came out right on the edge between small and medium, but my chin tends to drop when I sleep. With my AirFit F10 in a small, my chin often ends up dropping below the mask in my sleep, causing terrible leaks. So I bought the Quattro in a medium. Unfortunately, I also happen to be very thin, so I think I should probably have a small in width and a medium in length. I seem to have to get it set exactly right and practically not move to prevent leaks at the top or at the chin. So the hunt goes on for a better fitting mask.

[zoocrewphoto]

When I started, I had trouble with the Quattro FX leaking by my eyes. Somebody here told me that the mask was too high on my nose. Try starting it a little bit lower on your nose, and see if that leak clears up. Also, if you happen to have a smaller head, there is a smaller headgear that can be ordered.

Yes, I'd read instructions to start with it lower on the nose and tried to do that. Have been even more cautious after your post, though. I think part of the problem is that I have so little room for error due to the sizing. My measurements came out right on the edge between small and medium, but my chin tends to drop when I sleep. With my AirFit F10 in a small, my chin often ends up dropping below the mask in my sleep, causing terrible leaks. So I bought the Quattro in a medium. Unfortunately, I also happen to be very thin, so I think I should probably have a small in width and a medium in length. I seem to have to get it set exactly right and practically not move to prevent leaks at the top or at the chin. So the hunt goes on for a better fitting mask.

You might try the small size along with the cervical collar to help keep your mouth from dropping open. I have a similar issue. If there were an extra small size, I could probably use it. The small seems a bit large for me. Too low, and I get leaks at the bottom. My lip has never come outside the mask, but I can get leaks there. And I had to get smaller headgear to keep it from moving around on my face.

[Uff Da]

You might try the small size along with the cervical collar to help keep your mouth from dropping open.

I'm already using a cervical collar - with both of these masks. And yes, my mouth still drops down below the mask. I have a receding chin, which probably makes that easier to happen than for most people. I tried a chin strap, but that gives me jaw pain, which makes it difficult to eat, which causes me to lose even more weight. And I'm already underweight. Can't seem to win here.

[Uff Da]

I think you need to take the pressure increase as an unavoidable thing in this circumstance, and work to get a mask fit and machine that will work for you. If EPR of 3 helped with the aerophagia (which seems to be the limiting factor here), then it would seem to me that a bi-level device would be worth a shot.

My doctor's office called today and told me the doctor is recommending me for a sleep study for a bi-level machine. The big concern I have is this: isn't my limiting factor of getting a mask that doesn't leak going to be just as limiting or even more so on a bi-level as on my current one? Yes, part of my problem is aerophagia. Even after one or two hours with maximum pressure of 14 (no EPR), I have to lie there releasing air for an hour or two before I can hope to get back to sleep again. But I'm also awakened by the burps, toots and whistles of leaks when the pressure goes over 14 many times.

I've been unsuccessful with three masks so far. I have two more (purchased used) on hand to try. So we'll see within the next week whether or not those are any better. But I sure don't want to end up doing another sleep study and possibly buying a more expensive machine only to find I'm still limited to masks that won't tolerate higher pressures!