New to CPAP - Advice needed

[BobH56]

I did a sleep study early this that indicated I had severe OSA, 52 AHI, all obstructives, no CA.
I now have an Airsense 11 auto, pressure 9-16.

With an N30 nasal cushion mask my typical results are an AHI of 5 to 6, typically 3-4 are CAs, 0.5-1.5 are Obstructives.
Leak rate always seems high (25-30) and when tried a chin strap the OSAs increased significantly and the Overall AHI was 8-10.

I bought a full face F30 mask to try and it was quite comfortable, very low leaks (7L) but the results were horrific. AHI was 30 (20 Obstructive, 10 CA).
I'm guessing the straps somehow induced the poor result?? I gather there is something about a full face mask I don't understand but I am not inclined to try it again.
I just am baffled as to why it worked so poorly.

I'm back to the N30 and still hover around 5+ AHI. I have slept 100% on my back while using Autopap and I gather that may be a contributing issue?? Should I try to side sleep?

Attached is a typical result with the N30 from Oscar. I have had the Airsense11 for 1 month now so I am very much still learning.

Any suggestions or insights as to how I may improve things is greatly appreciated.

Bob H.

[Okie bipap]

I would bring the minimum up to 11 or 12. You are spending most of the night there any way.

[BobH56]

Maybe this is common knowledge but ever since I started using the Airsense11 a month ago I have slept on my back 100% of the time as that seemed least
disruptive to the mask/hose. I had been fighting leaks (mouth apparently) and trying reduce the AHI from a range of 5-7. But last night I had an orders in magnitude improvement from a simple change, I tried sleeping on my side. The results were stunningly better. Leak rate was 14L vs 30L, and AHI was 1.1! Such a simple change for a dramatic improvement.

[Pugsy]

What you are reporting with supine sleeping vs side sleeping is actually fairly common.

It's common for supine sleeping to worsen OSA and/or cause a need for a higher pressure when compared to side sleeping.
It's very common to need a much higher pressure when on our backs than we might need when on our sides.

So the lower AHI could simply be from less events happening or it could be from the fact that the pressure could do a better job preventing the events in the first place.
And the lower leak rate is simply because with higher pressures we stand a greater chance for leaks and likely last night the pressures maybe didn't quite as high and thus maybe less chance for increased leaks.

No matter what the cause....happy news for a change.

Now if for some reason you just have to sleep on your back more or again....you can make some adjustments in the minimum pressures that can give you similar results as you got with side sleeping. I know for a fact it isn't always so easy to stay off one's back because I have tried it many times and failed miserably but I try for a different reason. For me there is no real difference in my OSA or pressure needs between supine or side sleeping. I try to stay off my back because when I end up on my back the back screams in pain and wakes me up. I sleep better with much less pain on my side.

If you end up on your back often and you see it in the reports with some ugliness....it can be dealt with so you can get effective/better therapy even when on your back.....should you end up needing to be on your back.

[zonker]

Such a simple change for a dramatic improvement.

it is known but things like this bear repeating. we have a LOT more people who come here to just read rather than post. so what you've done is shared information with one of those readers.

well done, you!

[BobH56]

Thank you both for the replies.

Pugsy, you mentioned some changes in settings could yield better back sleep results. Given my success with side sleeping I will continue with that but it
would be good to have the option for future reference. All of your other assumptions seem to be spot on by the way.

I would have liked to have posted the Oscar screenshots for the above side sleep (AHI 1.2), one of my back sleep (AHI 5.6) , and the one I cannot fathom, horrible results
and experience was my trying a full face F30 mask, an AHI of almost 30, ballooning cheeks, high pressure, unable to nasally exhale. A full face mask seems not an option for
me unless I am missing something? My only guess is the straps somehow induced the excessive apneas, but that is an uneducated guess.

But for now images cannot be posted for the above. (PS:I did my housekeeping of deleting the one image I had previously posted however.)

regards to all.

Bob H.

[Pugsy]

A full face mask seems not an option for
me unless I am missing something? My only guess is the straps somehow induced the excessive apneas, but that is an uneducated guess.

I think that sometimes the lower straps of many full face masks alter the airway position just a little which in turn makes the OSA worsen or more pressure is needed because of that slight difference.
No proof mind you...just my own logic and knowing how the slightest difference in the position of anything can impact the airway. The fix is relatively simple just like it is for supine sleeping....slight increase maybe in the minimum baseline pressure settings.

BUT...you had a lot of other problems with the full face mask besides therapy effectiveness that could present extra challenges when using a full face mask. So I wouldn't be so quick to say "never be able to use a FFM" but instead you might leave the door open for a revisit maybe later when you have become more adjusted and you have a better handle on things in general.

Pugsy, you mentioned some changes in settings could yield better back sleep results. Given my success with side sleeping I will continue with that but it
would be good to have the option for future reference.

I don't know how much more pressure you need when on your back compared to when you are on your side but at some point in the future you might consider a little experimenting with the minimum pressure and see if just a little more minimum enables the machine to get to where it needs to be to fight off the events that happen when you are on your side.
I had to do that myself early on but not because of sleep position ...for me it was REM related worsening of my OSA and significantly more pressure needed only during REM. For me it was just a matter of a couple of cm increase in the minimum and that let the machine get to where it needed to go to deal with REM related stuff.
Again...maybe an experiment you can do later if you wish. No urgent need at this point and heck...you might find you don't end up on your back all that often anyway.
But good to have the option just in case...like maybe for some reason you just can't sleep on your side for a while.
People get broken bones and have surgeries and sometimes we just have to sleep on our backs because side sleeping just isn't going to happen.

[Pugsy]

BTW...the "house cleaning" with attachments...you don't have to be quite so zealous about it.
The idea is to remove old stuff no longer needed and your recent stuff is actually still pertinent.
Now 2 months from now...it won't be needed.
So no need to immediately remove attachments unless you are getting the message that you can't attach anything because the storage is full.

[zonker]

But for now images cannot be posted for the above. (PS:I did my housekeeping of deleting the one image I had previously posted however.)

regards to all.

Bob H.

do you know how to use a picture hosting site, such as imgur.com, and post a link here?

[BobH56]

I have never used IMGUR but just created an account, uploaded the 3 Oscar reports as hidden or private so I hope this works:

https://imgur.com/a/0qLZ2q4


Pugsy offered some suggestions as to increasing baseline pressures for back sleeping or my using a full face mask.
I would have thought that the auto range of the machine would do that and from the Oscar reports the pressure for the full face mask were
high or at the range limit the whole time so not sure how that would help. But I am so new to all this I am open to experimenting and trying things.

Last night I had my second good result (AHI 1.3) from simply switching to side sleeping vs back so that resolves a lot of the issues I seemed to be having.

I am totally amazed the at drastic difference in results from seemingly minor changes, mask, sleeping position, chin strap etc..

Bob

[Pugsy]

When you used the full face mask and needed more pressure the max pressure was limited. You pretty much flat lined at the max of 16 and because the machine couldn't go higher...tons of apnea events didn't get prevented.

It is very possible that in this situation that if your machine COULD have gone higher than 16 that the bulk of those events wouldn't have happened. We have no way to know unless you did another experiment where the only thing changed was the upper limit and let the machine go higher since it obviously wanted to.

Pugsy offered some suggestions as to increasing baseline pressures for back sleeping or my using a full face mask.
I would have thought that the auto range of the machine would do that and from the Oscar reports the pressure for the full face mask were
high or at the range limit the whole time so not sure how that would help.

When increasing the max isn't enough then we increase the minimum pressure.
"Auto adjusting mode" isn't perfect especially when someone needs pressures in the mid to upper teens and the baseline is on the low side of things.
1...the machine can't go from the baseline to much higher pressures in the blink of an eye. It does take a bit of time with the increases
2... and you probably don't know that when you are actually having an apnea event the machine does absolutely nothing. The machine won't even try to blow open the sagging airway tissues because it can't generate enough pressure to move soft tissues that have sagged and blocked the airway.
3...When you have dense clusters like you did on the full face July 8 night with the limit being reached...you get the result you got.....the "fix" for this is to first try increasing where the machine can go.
4...When increasing the max doesn't fix the problem then we increase the minimum to give the machine a better headstart in getting to where it needs to go because if the events start happening in masse the machine will stop doing anything until the events pass since it can't/won't increase the pressure DURING the apnea event. When that happens the machine going up rather slowly anyway simply won't have time to get that pressure up to where it needs to be to prevent the apnea from ever occurring in the first place.

These machines work best by PREVENTING the airway tissues collapse in the first place since they really can't/won't do anything during the event itself. Since the machine can't go from 9 cm to 16 cm in the blink of an eye we give the machine a better headstart with more minimum so that the machine can get to where it needs to be to better PREVENT the collapse...and that's why we tell people to increase the baseline when using auto mode...help the machine get to where it needs to be quickly enough to better hold the airway open and prevent the tissues from collapsing.

It's all about prevention....it isn't about fixing during the collapse.
The baseline pressure stents/holds open the airway so that the tissues don't sag and collapse and the apnea event doesn't materialize.

The machine (in auto mode) uses a combination of several factors to decide if it needs to increase the pressure and how much. Those factors include previous flagged OA/hyponea events...and snores and flow limitations as well. It's a bit complicated and while not horribly time consuming it all doesn't happen in the blink of an eye.

[BobH56]

Pugsy

I truly appreciate your taking the time to review my reports & your insights. This whole CPAP thing seems like one is prescribed a machine and then your left on your
own with no follow up or professional advice.. I doubt I'd get any feedback, at least in a timely manner from the sleep Dr. if I even asked so this place is an tremendous resource.

That said, when I work up the courage to try the full face mask again (F30), I will
change the upper limit from 16 to say 20 (?) and see how that works. If that still isn't it, maybe I'd next adjust the range to yield 12-20 (currently 9-16). Do full face masks in general run higher pressures due to the larger volume?

I have only tried the F30 twice.. the 1st time I had EPR on ramp only and had ballooning cheeks, could not at times exhale through my nose, I had to quit middle of the night it was so unbearable. The report I posted was my second try with it which was actually better. I turned on EPR 3 to see if that would help with the exhalation issues and it did help, but still awful end results.

The reason I had EPR off (its still off for the most part with the N30) was trying to reduce CA events which I'd read may be triggered by EPR.
My sleep study had 0 CAs, yet all of my results had a majority of CAs. However this was when I was back sleeping and yielding an AHI 5.5-7 range with CAs being 3-4.5 of that.

Now that I am at <1.5 AHI side sleeping I don't know if EPR on would have any further benefit. I might experiment but I am just happy that a simple change to side sleeping seems to be working.

[Pugsy]

Do full face masks in general run higher pressures due to the larger volume?

No it doesn't have anything to do with the volume within the mask...X amount of pressure is X amount of pressure no matter what the volume might be.
Instead my own personal thought on the common occurrence of needing more pressure with full face masks has more related to maybe the slight change in the airway position due to the lower straps needed for most full face masks. Sometimes just a tiny bit of difference in the airway position can make it more difficult to stent the airway open and thus needing more pressure to get the job done. Look at your low jaw position with a nasal mask and with the full face mask and I think you will see what I mean.

Now this paranoia about centrals and EPR or really any exhale relief because it's not so much the exhale relief that is the potential cause of the centrals as it is the bilevel pressures that exhale relief end up creating....this paranoia is way over blown and causing undue stress and worry among people.

1...Centrals are NOT the end of the world when we see a few of them. In fact it is normal to have a few centrals happen during the night and it does NOT mean anything bad at all. Like it is normal to have what is called a sleep onset central when we are transitioning from awake status to asleep status. Normal...end of story. The more awakenings we have during the night the greater then chance of having a sleep onset central....remember this point as I will get back to it.
2...The reason that bilevel pressures SOMETIMES can be a cause for central apneas is the way that bilevel pressures work and the fact that for SOME people this bilevel working can cause too much carbon dioxide to get washed out of the blood stream and the carbon dioxide levels simply don't get high enough for the brain to realize it needs to send the "breathe my human" signal to the body. The brain's trigger for "send breathe signal" is actually the carbon dioxide level in the blood stream. When that level doesn't get high enough the brain doesn't tell the body to breathe and a central apnea can occur.
Hold your breath for 10 or 15 seconds...that's essentially a 10 or 15 second central apnea. The airway is open but no air is moving because you aren't making an effort to breathe.

Now this instability in breathing when using bilevel pressures and causing centrals is actually quite rare in the grand scheme of things. It's not very common at all but there's this blown way out of proportion idea that "OMG exhale relief causes centrals so I can't use exhale relief"....yes it can happen but it is very, very rare.
Besides...do you know what the first thing that actually gets tried when someone does exhibit signs of treatment emergent central apnea???? A bilevel machine...yep, that's the first thing tried because sometimes it actually works. If it/Exhale relief really was all that much of a problem why would the first thing to try for central apneas be a machine that does bilevel pressures??

Now in your situation...yes you had a sizable number of centrals flagged but you also had an EXTREME number of OAs flagged and 2 things could have happened.
1....Some of those centrals might simply have been false positives
Watch the videos here to get an idea what I am talking about
http://freecpapadvice.com/sleepyhead-free-software
False positives flagged while you were awake or during an arousal. That number of OAs could very definitely cause arousals or awakenings. These machines can't/don't have any way to know if we are asleep or not. They just measure air flow or breathing and our awake breathing can be very irregular when compared to asleep breathing. The machine can and will flag that irregular breathing as some sort of apnea event. BTW it isn't limited to centrals...I have personally seen false positives in the OA and hyponea category as well. So the central flags could simply be a symptom of poor sleep brought on by the untreated/unprevented OAs/hyponeas and not the cause of the poor sleep.
2...Remember I told you about sleep onset centrals...well when we have a LOT of arousals and then go back to sleep we increase the chances of having more sleep onset centrals as well and those are normal and not a problem unless they are present in numbers enough to cause desats or they continually bounce us out of sleep.

I suspect that your flagged centrals were likely a combination of false positives and sleep onset centrals all brought about from the arousals/awakenings from the truckload of OAs that you had because the machine's pressure couldn't deal with the airway collapsing. I doubt that your centrals were related to using EPR...while not impossible...not really very likely.

EPR or any form of exhale relief is simply a comfort feature. Use it if you like it...don't use it if you don't like it.
I use a bilevel machine that lets me use what is equal to EPR at 4...I just like the way it feels since it mimics my normal breathing. I don't have centrals to speak of beyond maybe an occasional sleep onset central.
It is simply more comfortable for me and to me more comfort equals better sleep.

Now even if someone does find that the bilevel pressure situation does trigger centrals it doesn't always mean someone can't use exhale relief or bilevel pressures. I have a friend who gets about 15 centrals per hour average with exhale relief of 4 cm and essentially zero centrals with just a reduction in the exhale relief to 3 cm. She happens to need starting pressures in excess of 15 so adding in exhale relief is pretty much critical to her therapy. She just can't handle starting at 16 cm without some form of exhale relief.
So even for the rare person that does have a problem with using exhale relief it doesn't necessarily mean that they can't use it at all. Sometimes just reducing the amount of relief will fix the problem.

Everyone really needs to get over this overblown paranoia about centrals...
1...unless there is a truckload of them all night long and every night and we were for sure asleep...they aren't that big of a deal. An occasional central is normal.
2...if someone really does have enough real centrals to be a problem...it's easily dealt with by a different machine
It's fixable.

So for you...use EPR if you like it or don't...it's a comfort setting and it's your comfort that you have to figure out what works for you.
The chances of EPR being a factor in your centrals....slim but even if you are one of the rare ones...it's fixable usually by just reducing the amount of exhale relief...like my friend did.

[BobH56]

Pugsy

Thank you very much for taking the time to write that incredibly detailed response on CAs & EPR. I have been at this for 1 month, (sleep study 3 months ago) and very much am just learning. I simply had read somewhere the notion of EPR & CA having a correlation, tried reducing EPR & had a positive result. I was simply grasping at anything to improve things. I just wish I had seen or had been told my sleep position could have a MAJOR impact on my results earlier. Based on your reply and my recent improved results due to side sleeping I will try EPR this eve at 3 and see what if anything changes. I didn't mind EPR when I did use it, nor do I miss it since my overall experience level is simply too new.

I will also review all of those videos you referred me to (THANK YOU) and it will take some time to digest it all. You have been a tremendous help educating this newcomer to CPAP therapy.

best regards
Bob H.

[Pugsy]

Educate yourself at your own pace. I have been at this stuff for over 13 years now and I still am learning.

Do remember that we don't go making concrete determinations about anything based on one night's worth of data.
We simply don't sleep the same each night and we always expect to see some variations.
Don't panic when you do.

Now I don't know that EPR was the cause of your centrals or not....I do know that it is entirely possible that they could have been from the other reasons I mentioned and also it wouldn't be impossible for you to be one of those rare people.
It could have been that you just slept better the night with the reduced number of centrals.

Bear in mind that when using EPR the baseline pressure does drop during exhale and depending on where your line in the sand is for the pressure not doing a good job holding the airway open that it might drop below that line.
If it does you can either adjust the minimum up a bit to help compensate or reduce the amount of reduction.
Several options and it's not a certainty that you will even need to do anything. So I like to adopt the wait and see policy.