Help with Pressure Optimization

[yougotatoyo]

Hello forum members,

I've been reading a lot of the threads in the forums for a long time now. I thought I could learn from other people's experiences but experience has taught me that not everyone's experience/solutions with cpap are the same. I have been struggling with finding optimal therapy for the past year. I am seeking the wealth of knowledge and wisdom from all you great members. Here is were I am with my experience.

I was initially prescribed pressures of
min 6
max 17.6
EPR 3

these min's and max's and EPR have been adjusted many times by my RT. I wasn't feeling any better and they were not listening to my concerns, I decided to take my own therapy into my own hands and started changing my own pressures.

I've tested many pressure settings, as high as the sky. I've attached the screen shot of all my combinations that I have tried and my AHI's are usually low but I have a lot of flow limitations and I just can't figure it out for the life of me.

I am able to sleep throughout the night but when I wake up, I don't feel rested. My brain feels foggy, and I also experience cognitive dysfunction, I'm finding that I am more forgetful. I developed depression and an anxiety disorder because I wasn't getting enough restful sleep. The last year has been my most difficult year of my life.

Please bless me with your help and support, it would be greatly appreciated.

Thank you.

[Pugsy]

Welcome to the forum.

First thing...you have chosen the wrong machine in your equipment profile....you are using the AutoSet....look for it down in the R's on the equipment menu....
ResMed AirSense 10 AutoSet. It got stuck with ResMed in front so it's down in the Rs.

Second thing....do you take any medications of any kind? If so, what?
Any other physical or mental health issues that might impact how you sleep or fee?
Do you wake often during the night? Have trouble falling sleep or staying asleep.
Do you have much nasal congestion happening?

[yougotatoyo]

Pugsy -

Thank you for your prompt response.
I have seen you endlessly help many members who come here seeking help and guidance.
I love your attitude and your approach to these issues. You are always very educational and methodical in your plans.
I can honestly say that I am starstruck that you have commented on my thread.

Back to the thread.

I have updated my equipment, should be good now.

The only medication that I take is Coversyl, blood pressure medication.
No physical health issues.
Had depression and anxiety issues, due to the lack of and restless sleep. But that has been controlled, not medicated.
I don't have trouble falling asleep or staying asleep.
I will occasionally wake up to go to the bathroom. I will momentarily wake up during the night when I roll from one side to the other, but will fall back to sleep fairly quickly.
Only nasal congestion when I've had the flu, which is normal, but normally no congestion.

Thank you so much.

[Pugsy]

I don't know how much of an impact your Coversyl might be having on how you feel during the day but it's a possible factor.
https://chealth.canoe.com/drug/getdrug/coversyl
https://en.wikipedia.org/wiki/Perindopril
these stood out among the potential side effects to me as potentially impacting how you feel or sleep
drowsiness
trouble sleeping
unusual tiredness
along with some other side effects shown.
It may or may not be a factor but it's a possible. I take Losarten for BP...I thought it was rather benign in terms of unwanted side effects and then I discovered one day it isn't so benign after all. Fatigue and drowsiness is a common side effect. Hard to say how much it actually impacts me because I get crappy sleep due to arthritis pain stuff too. Geez...damned if you do and damned if you don't.

The bathroom breaks during the night....are you male and of the age that the prostate can be a factor?

Your AHI is low but your pressure is going all over the place...goes up and stays up for quite a while often.
Most likely it is the flow limitations that are driving the pressures up....after all they are part of what the auto algorithm will try to kill because they are indications that the airway is trying to collapse. It's not collapsing enough to earn a flag but it's trying to so the machine wants to increase the pressure in an effort to kill them.
Sometimes nasal congestion will fool the machine into thinking it needs more pressure...and more pressure won't fix Flow Limitations caused by nasal congestion. You have to fix nasal congestion in the other traditional ways...hence the nasal congestion question. Rule out nasal issues causing the flow limitations.

So while you don't necessarily need more pressure for the AHI side of things ...maybe the FLs are disturbing your sleep quality somewhat and maybe they are a factor in not feeling as good as you want to feel or expect to feel.

Can you look back in your reports for April 30 where you used 14 minimum and 19 maximum for one night and post that detailed report please? I would like to see that report.
Any special reason why you limited that experiment to one night only????
Obviously I am curious as to what the FL graph looked like with that much minimum pressure.

[Julie]

I also imagine the meds are having an effect... and wondering if you've ever come off them even short term while on Apap at an otherwise good pressure setting to see how you felt the next day (actually for a few days to give the Coversyl time to be less effective) and then taken your BP? Cpap is supposed to lower it in most people and you may not realize that it can help you - possibly allowing you to take less of the meds or even go off them.

[yougotatoyo]

Julie -

I have read where APAP can help with lowering BP. I did go off my BP medication for a few months some time last year while on APAP and that didn't go so well. I was having restless sleep which caused me to have anxiety attacks, and without my BP medication, I constantly felt like I was having a heart attack, a couple trips to the hospital after, all blood work and ECGs came back normal. I mentioned to them that I went off my BP meds and the doctors told me never to go off my meds unless consulted with my faimly doctor, I never stopped since. I touched on this topic with my response to Pugsy, maybe I will talk to my family doctor about lowering my dosage back to 4mg again.

[Julie]

Just wondering (again) if the anxiety you feel being off the meds is because you're aware of being off them (temp.) and are afraid of consequences. Have you ever thought about a few sessions (often that's all it takes) with a therapist to learn a little CBT and deal with the anxiety? Please don't think I'm suggesting 'you need a shrink' of course, just a little help (if the above fits).

[Pugsy]

While treating OSA optimally has allowed some people to be able to ditch their BP meds.....doesn't happen to everyone unfortunately.
I guess it all depends on why the blood pressure is elevated and if the sole cause is untreated apnea then obviously it could work out well but for a lot of people there are other causes for the elevated BP and it's like anything else...cpap can't fix a problem that isn't related to sleep apnea no matter how much we might want it to.

I had to start BP meds AFTER I started cpap....obviously my problem isn't related to untreated OSA. Sure which it was.

Always before discontinuing any medication (or changing dosage) especially BP or heart related ....talk to your doctor first.
Some meds have bad side effects just from withdrawal....physical as well as mental.

Now my sister (doesn't have OSA) was having some fatigue issues and she discovered her BP medication had a "fatigue" side effect so she talked it over with her doctor and they changed to a different BP medication and her fatigue issues were greatly improved with the change. So it's possible.....and that makes it worth looking into.

[yougotatoyo]

Pugsy -

Oh, I thought I had already posted a reply to your post but I don't see it in this thread, I guess I'll do it again.

When I started my BP medication last year, I was at 4mg. In October when I had a panic attack and went to the hospital, I was off my BP medication for a couple months (I decided this by myself), the doctor there thought my blood pressure was still too high and prescribed that I should start taking 8mg instead. My family doctor found out and thought that the doctor at the hospital shouldn't have increased the dosage but he went with it anyways, so I've been taking 8mg since. Maybe I need to go back to my family doctor and ask him if I could go back down to 4mg. Now that you've mentioned this, maybe this is one of my issues.

Bathroom breaks are not every night, just seldom. But I am a candidate to get my prostate checked. One more reason to go see my doctor.

Flow limitation has been my struggle for a long time, hence a lot of the pressure changes. I can see the relation between pressure spikes and flow limitations but no OA is flagged, I don't understand why it happens. I can get low AHI numbers for any range from min 6-14, so I never found my sweet spot. I don't have nasal congestion, no deviated septum, maybe I have a chin tuck issue?

I limit my experiments for short periods because I may have felt something was off that day and I instantly resort back to a pressure that I am comfortable with. This strategy has not worked for me obviously, but I am willing to do whatever it takes with help and guidance to get this optimized.

Thank you

[yougotatoyo]

Julie -

The anxiety didn't stem from being off the BP medication. My depression and anxiety were heightened due to restless and lack of sleep. I was struggling to figure out my optimal pressures and I felt like I had no one to help me and guide me through the process because people that I have talked to said that it was fairly easy for them to adapt to CPAP and it changed their lives for the better. I wasn't feeling the same effects and that brought me to a very dark and lonely place. Since then, I have gone to a CBT and I am dealing with it a lot better, without medication. Thank you for your insight into possible external factors that could be my issue.

[Pugsy]

Flow limitations are reduced air flow but they don't always end up being bad enough to earn a flag of some sort.
They can still mess with our sleep though. Anything that can mess with our sleep quality can mess with how we feel.
There's a video somewhere that explains it but I can't seem to locate a link at the moment.
Maybe someone else has the link handy.

All auto adjusting algorithms include snores and flow limitations in what it will respond to with an increase in pressure.
They aren't part of the AHI but they are very much a part of what can be going on with the airway.
Think of them as warning signs that the airway is trying to collapse...maybe not enough to earn a flag (has to be a certain % of reduction lasting at least 10 seconds to earn a flag) but can be enough to impact sleep quality.
They are unwanted for this reason.

[Miss Emerita]

Is this the video?

https://m.youtube.com/watch?v=-gie2dhqP2c

[Pugsy]

Yes, I think that is the video...thank you Miss Emerita.

Let me give maybe another example of how a flow limitation might impact a person.
Apneas and hyponeas have certain criteria that have to be met before a flag is earned...one of the criteria is duration....has to last at least 10 seconds in duration before it can be flagged.
What do you think that a total obstruction that lasts 9 seconds might do to the body? Is it really any different in terms of stress to the body as the 10 second total obstruction???? There can be varying levels of flow reduction from 30 % to 100% but if they don't last at least 10 seconds you don't get a flag.

While these less than 10 second whatever flow reductions might not earn a flag and thus become part of the AHI....the auto algorithm will still sense them and try to kill them and that's what is happening when you see pressure increases and no apneas or hyponeas flagged anywhere around them.
The machine sensed something it didn't like going on with the airway and it increased the pressure in an effort to prevent those whatever flow reductions/limitations from growing up and lasting 10 seconds and earning a flag.

There's a lot more to OSA than just AHI...there's a lot more to feeling those nice low AHI numbers than just getting them.
I wish it was that easy...getting a nice low AHI is relatively easy....feeling those good numbers not so easy though.

[palerider]

Flow limitation has been my struggle for a long time, hence a lot of the pressure changes. I can see the relation between pressure spikes and flow limitations but no OA is flagged, I don't understand why it happens.

I can't remember how clearly it's explained in the video, but flow limitations are more a restriction on the *rate* of the airflow, while hypopneas and OAs are a restriction on the *volume* of the airflow.



You can get a full breath with flow limitations, it's just harder to do it... which results in disrupted sleep.

I like to say that having flow limitations is like breathing through a thin straw... you can still take a full breath, it just takes longer, and you have to work harder to get it... breathe through a straw for a few minutes, and you'll know what I mean.

[yougotatoyo]

Pugsy & Palerider -

Thank you for the explanation on flow limitations.

Based on my chart, what would you recommend as the course of action to reduce these flow limitations?

I am open to suggestions.
Thanks