I'm a dentist treating myself! CPAP Results... Advice please?

[nee]

Per Miss Emerita's suggestion, I would give a soft cervical collar a try and see if that helps with those clustered OAs.

From what I've read, the soft cervical collar counteracts mandibular retrusion that can result from wearing a full face mask. I'm wearing a nasal pillow in addition to a sleep appliance that keeps my lower jaw held forward, so I'm not sure how much the collar would help. The issue might be that my jaw isn't being held forward enough by my appliance... I'll try adjusting it to hold my jaw even more forward and see how tonight goes.

Since the OP is a Dentist and works in the mouth, I found this article interesting and perhaps relevant.

https://www.dailymail.co.uk/health/arti ... gests.html

Yep! We know that many people benefit from a few different surgeries aimed at reducing the volume of the tongue.

[Pugsy]

We can sleep through some pretty massive mask movement leaks....we can't tell for sure if your leaks are mask movement leaks or mouth opening leaks from just by looking at the leak graph. I suspect probably a little of both is going on.
The machine will still be able to do a decent enough job of sensing and flagging of events up to around 35 L/min leak which is where the larger blocks of leak are seen. I am thinking mask movement a bit for those and the spiky looking large leaks probably mouth opening.
Unless you start seeing a large number of UA or unclassified events or the leaks wake you up I don't know that I would worry a whole lot about the leaks at this stage of things. UAs mean the machine senses something is going on but due to the large leak it can't decide what is going on. I have had it take a week for me to get the tension adjusted on a new mask so it doesn't move around much and I have years of experience with masks and cpap. I don't expect a newbie to cpap to get it done in just a few nights.
The only way to know with 100% certainty if those leaks are mask movement or mouth opening is to make sure the mouth cannot open at all...and you know what that involves...taping. So if you get to a point that you really need to know what is causing those big leaks then maybe tape for one night and see if the leaks reduce or not.

You have some small clustering of OA events especially later on during the night. So possibly REM stage sleep involvement where it's common for OSA to worsen or need more pressure or maybe you were on your back more or maybe a combination of both.

You might want to take the time to learn how to distinguish arousal/awake flagged events from asleep events.
http://freecpapadvice.com/sleepyhead-free-software
Watch all the videos and while it is mainly talking about central/CA apnea flagging...it really pertains to all event categories. The machine doesn't know a thing about sleep status. It just measures air flow and sometimes awake breathing irregular air flow makes the machine think some sort of apnea event is happening when it really isn't.

If the bulk of your flagged events are arousal or awake related false positives then pressure adjustments are unlikely to help.
If you were really asleep when the bulk of those events were flagged then you probably need a little more minimum pressure.
The central apneas/CAs ....more pressure is unlikely going to impact those so for now we just watch them. Even if every single one was the real deal there's not enough of them to really be a problem.

[ragtopcircus]

Fwiw, I tried a custom MAD from a dentist, as well as just about every MAD and TAD on the market. For me tongue advancement was FAR more effective than mandible advancement. The catch is, the tongue is not easy to hold onto. For the suction-based devices, it was easy to curl my tongue and break the seal. Devices with tongue straps were totally useless. My go-to combination was: a Z-Quiet MAD to hold my tongue flat (and advance the jaw as a slight secondary benefit), the Good Morning Snore Solution TAD (suction bulb on the tongue, large/thin/soft flange between my lips and the Z-Quiet/gums), and a WoodyKnows nasal dilator (the version that looks like a tiny pair of snowshoes). It did actually work - when I could keep it in, sleep, and not not throw the whole mess on the floor in my sleep. So, I finally accepted that I need CPAP.

If it was me, I'd be tempted to try raising the minimum to 11. Not that your numbers are bad (they aren't), but you never spend much time at all at 10. Every time you approach it, you start having trouble and you bounce right back up. You may even find that raising the minimum a little reduces the maximum reached (although that is not the goal per se) - it seems to be easier to keep the airway open than to reopen it.

I am not a medical practioner of any sort - I'm an engineer. My expertise is in embedded control and product development. In other words, I'm looking at it from the perspective of what the machine's behavior is telling me; what the algorithm is doing.

[nee]

Thank you pugsy and ragtopcircus for your advice, I'll look more into it.

I just remembered that I didn't mouth tape last night as I did the first night... damn, confounding variable. I wouldn't be surprised if I was getting leaks through my mouth during sleep.

[Pugsy]

I was trying a new mask once and having trouble with big leaks that weren't waking me up so I had no idea where they were coming from.
I knew I was having trouble finding the right tension because the mask frame was a bit large for my head.
I also knew that I have been known to mouth breathe on occasion but normally not for very long or very much but I never taped my mouth because it was more annoying than a little leak was a problem.

Anyway I needed to know for sure if mask moving around was the cause of the leak or if I was mouth breathing massively....so I taped for one night.

The big leaks were still present and the tape was still secure the next morning so I had my answer as to where the leaks were coming from and what was funny....they looked like mouth breathing for about 30 minutes at a time...just like your big chunks.
We used to tell people those big chunks were for sure mouth breathing (and they get told to get a full face mask) but now after my personal experience I don't go down that road.

I tell people to first figure out exactly what the cause and then start looking for a solution based on the cause.

[nee]

Ha, interesting!

Well we'll see if the mouth taping helps with the leaks tonight. I see that on the first night (mouth tape) I had zero leaks, but the second night (no mouth tape) there are those big chunks. The plot thickens...

[ragtopcircus]

I tell people to first figure out exactly what the cause and then start looking for a solution based on the cause.

+1000

Or, my usual way of saying basically the same thing, first figure out what problem you are trying to solve.

[ChicagoGranny]

About "soft" cervical collars, technically, they are foam cervical collars. Some brands come in two densities - soft and firm. (Firm works best for me.)

The collars help maintain the neck/head in the best position for airway patency. They may also help to prevent jaw drop.

The collar yielded dramatic results in my case. My prescribed pressure settings were bilevel 24/18. This pressure need was confirmed by my own experience at home.

With the addition of a cervical collar, APAP settings of min 10 give an AHI usually below 1.0. 95% pressure runs lower than 13.0. The therapy is much more comfortable and effective with the addition of a collar.

[nee]

Third night!

1.11.2020 CPAP.jpg (631.04 KiB) Viewed 5281 times

Changes from the second night:

Increased my minimum pressure to 11 cmH2O. Mouth taped. Brought my lower jaw 1 mm more forward with my oral appliance.

I remember waking up in the morning thinking "holy crap I'm getting absolutely hosed here" and taking the whole thing off before going back to sleep.

Here's a closer look at the clusters of obstructive apneas:

Screen Shot 2020-01-11 at 7.16.02 PM.png (83.41 KiB) Viewed 5281 times

I'm going to purchase a cervical collar and try it tonight.

[ChicagoGranny]

What about sleeping positions? Did you perhaps sleep on your sides or stomach most of the night then roll onto your back around 5:30?

Tip on OSCAR: Click on the Events tab. You will get a list of each event including the time it occurred and the length. Click on any event, and the graph will zoom in to that event.

[palerider]

I'd suggest lowering the EPR by 1.

[nee]

I'd suggest lowering the EPR by 1.

Will do. Curious as to why?

[palerider]

I'd suggest lowering the EPR by 1.

Will do. Curious as to why?

Reducing EPR will have the effect of *raising* your pressure, since EPR is a pressure drop from the set pressure.

The raised pressure *may* help with the centrals you're having, by reducing ventilation a little, and it may help the obstructives, by providing a little more pressure to stent your airway open.

[ragtopcircus]

I'd suggest lowering the EPR by 1.

Will do. Curious as to why?

Reducing EPR will have the effect of *raising* your pressure, since EPR is a pressure drop from the set pressure.

The raised pressure *may* help with the centrals you're having, by reducing ventilation a little, and it may help the obstructives, by providing a little more pressure to stent your airway open.

To elaborate a little on PR's points:
- Over-ventilation can cause excessive CO2 washout from the bloodstream, and CO2 is a breathing trigger. Some people are fairly sensitive to this, leading to treatment-emergent Central Apnea,
- Pressure must be maintained while exhaling to continue stenting the airway open.

On the other hand, some difference between inhalation and exhalation pressure helps reduce breathing effort and flow limitations. It's a balancing act, and everyone is different. I'm most comfortable with a pressure difference of 4.4 and can tolerate a lot more than that, but my wife can't go over 2 without getting centrals.

[nee]

I'd suggest lowering the EPR by 1.

Will do. Curious as to why?

Reducing EPR will have the effect of *raising* your pressure, since EPR is a pressure drop from the set pressure.

The raised pressure *may* help with the centrals you're having, by reducing ventilation a little, and it may help the obstructives, by providing a little more pressure to stent your airway open.

To elaborate a little on PR's points:
- Over-ventilation can cause excessive CO2 washout from the bloodstream, and CO2 is a breathing trigger. Some people are fairly sensitive to this, leading to treatment-emergent Central Apnea,
- Pressure must be maintained while exhaling to continue stenting the airway open.

On the other hand, some difference between inhalation and exhalation pressure helps reduce breathing effort and flow limitations. It's a balancing act, and everyone is different. I'm most comfortable with a pressure difference of 4.4 and can tolerate a lot more than that, but my wife can't go over 2 without getting centrals.

Very interesting, thank you two. I did notice that at an EPR of 3.0 I was getting no resistance to exhalation, so last night I turned it down to 2.0 and I used the cervical collar. I woke up feeling pretty good, didn't note any events where I got woken up by the CPAP going crazy with increased pressure to get me out of obstructive apneas, and I had dreams as well!

Unfortunately, I had forgotten to put the SD card in the machine, so I have no data. Grr... I'll for sure do it tonight.