New to CPAP - Help with pressure settings (ResMed AirSense 10)

[PressurisedPete]

Hello everyone. I was diagnosed with OSA around 3 months ago. I'm 33, normal build and not overweight so it came as quite a shock. However I've struggled with excessive daytime fatigue for years.

I did hospital lab study and it came back with AHI 31. I then did a separate at-home study (set up by a technician) that came back with AHI 10.1 (and also showed my blood oxygen fell to 86%). Both of them flagged hypopneas as the cause.

For some reason my original healthcare provider encouraged me to set a very high pressure (min 14, max 20) and it was causing me a lot of discomfort. I then sought a second opinion with a different provider who thought these settings were crazy and recommended min 4, max 15 and I'm now feeling better most days. But many days I still feel awful and can barely function.

I'm including some screenshots from OSCAR here: https://www.dropbox.com/sh/65eyqi9xi731 ... J2Jha?dl=0

(The one with AHI 3.13 was a day I felt great. The ones with AHI 2.34 and 1.99 I felt terrible all day.)

Gear: ResMed AirSense 10 AutoSet, F&P Eson 2 nasal mask

[Miss Emerita]

Welcome! I know people here will be happy to help, but first could you either attach your Oscar charts as screenshots or use a hosting service like Imgur and provide a link?

[PressurisedPete]

Ah sorry to be unclear. I've included a Dropbox link with screenshots as I wasn't able to upload attachments.

[Jlfinkels]

Ah sorry to be unclear. I've included a Dropbox link with screenshots as I wasn't able to upload attachments.

Keep in mind sleep quality is far more than an AHI number. You can quite easily have a very low AHI but sleep horribly. I’ll leave OSCAR divination to those qualified, but consider your sleep habits or non-habits as they may be contributing to poor sleep quality as well.

[palerider]

. I then sought a second opinion with a different provider who thought these settings were crazy and recommended min 4, max 15

Now, THOSE settings are crazy.

[robysue1]

I did hospital lab study and it came back with AHI 31. I then did a separate at-home study (set up by a technician) that came back with AHI 10.1 (and also showed my blood oxygen fell to 86%). Both of them flagged hypopneas as the cause.

Try to get the summary report with the graphs for both of the studies. It's useful to have them for your own records and comparing them may give you some idea as to why one shows severe OSA and one shows mild-to-moderate OSA.

For some reason my original healthcare provider encouraged me to set a very high pressure (min 14, max 20) and it was causing me a lot of discomfort. I then sought a second opinion with a different provider who thought these settings were crazy and recommended min 4, max 15 and I'm now feeling better most days. But many days I still feel awful and can barely function.

So you haven't had a formal titration study. The providers (doctors? or DMEs?) are using the APAP in lieu of a titration study. That's not uncommon these days.

If you are comfortable breathing at 4cm at the beginning of the night when you are first trying to get to sleep, there's no need to increase the auto range just yet. But your data does indicate that you would probably be better off with a minimum pressure of something like 7 or 8 since your median pressure levels are up around 10cm and your 95% pressure levels are up around 13.25cm.

(The one with AHI 3.13 was a day I felt great.

Here's the data for that good day:
This data is from November 26. It's a pretty decent night overall: Many of those Hs scored around 6:30AM are most likely some so-called sleep-wake-junk (SWJ) where you may have been in a very, very light sleep with some actual wake mixed in that you just don't remember.

Leaks may be a problem. While your leaks stay well below the Resmed definition of "Large Leak", which is 24 L/min, leaks can disrupt sleep by causing you to arouse enough to fiddle with the mask in an attempt to fix the leaks.

You say you are using an F&P Eson 2 nasal mask. Is there a chance you are doing some significant mouth breathing while asleep?

The ones with AHI 2.34 and 1.99 I felt terrible all day.)

Here are the days that you felt terrible all day.

First, this is November 17:


And this is November 23:

There's really not much to distinguish these days from the one where you felt great. The leaks are the same kind of issue on both of these days as they are for the day you felt good---the leak lines just look "flatter" because on these days you did have a few really big, but really short-lived leaks. And so Oscar is using a much larger y-range on the leak graph.

There's an obvious real WAKE in the middle of the night on Nov. 23 where you turned the machine off and back on. And there's a WAKE much earlier in the night on Nov. 17. Some people are pretty sensitive to even one or two prolonged wakes in the middle of the night in terms of how they feel the next day.

There's no real difference in how the pressure increases on the night you felt good the next day and the nights where you didn't. Flow limitations seem to my eyes to be about the same on all three nights. You didn't show the snore graph, but I suspect it looks similar on all three nights.

In other words, there's nothing that immediately screams "Here's why November 26 is so much better than Nov. 17 and Nov. 23."

It could be that your body is finally starting to actually relax and is learning how to sleep well with the mask on your nose. In all seriousness, learning how to sleep well with the mask on your face is a significant part of making this crazy therapy work and for many people that doesn't happen right away.

My guess is that you need to more or less keep doing what you are doing and keep track of how many days each week you feel good and how many days you don't. My guess is that in another few weeks, you might be feeling "good" 5-7 days every week.

But if you aren't, then I'd spend some time thinking about those leaks. They're not big enough to be triggering Mr. Red Frowney Face each and every morning, but they are long enough and persistent enough to ask the question: Could they be triggering some spontaneous arousals? And would eliminating the leaks make you feel better on more days than you do now?

[robysue1]

I'm including some screenshots from OSCAR here: https://www.dropbox.com/sh/65eyqi9xi731 ... J2Jha?dl=0

The attachment "feature" is not functioning because the server is full and Pugsy can't delete the old images that are no longer needed.

Most people upload the images to something like imgur.com and then link from there. To get the image to show up in the post as an image, you need to use the image tag, which looks like a moon/sun over a mountain ridge in the icons at the top of the editing window. You put the url for the image between the two tags.

[PressurisedPete]

Now, THOSE settings are crazy.

Why is that?

Is there a chance you are doing some significant mouth breathing while asleep?

First of all thanks for your detailed analysis. I appreciate it a lot.

I've been taping my mouth every night so I think we can rule out mouth breathing.

So you haven't had a formal titration study.

I forgot to mention that during my first sleep lab they did split study on me. The same doctor first put me on min 9 max 20. Then a few days later she checked the data and bumped me up to min 12 max 20. Then min 13 and finally min 14.

Would it be useful to dig out the results of that sleep lab?

You didn't show the snore graph, but I suspect it looks similar on all three nights.

Yes that's correct. Minimal snoring on all of those nights. Barely anything on the charts.

It could be that your body is finally starting to actually relax and is learning how to sleep well with the mask on your nose. In all seriousness, learning how to sleep well with the mask on your face is a significant part of making this crazy therapy work and for many people that doesn't happen right away.

I do suspect that part of this is psychological. Because this all started 3 years ago with classic insomnia (inability to fall asleep) and I still have a bit of conditioned fear when I go to bed at night (worrying about how bad my sleep will be).

I've since read that insomnia can co-occur with sleep apnea and one possibility is that it's a defence mechanism trying to protect you from a night of breathing issues.

[PressurisedPete]

As an aside, elsewhere someone suggested changing my RedMed's EPR setting to 3 and "full time". As a way of reducing flow limits. Could anyone weigh in on the wisdom of that?

[Jlfinkels]

Now, THOSE settings are crazy.

Why is that?

Not meaning to speak for PaleRider, but as we learn more about how the wee beasties work there is a process of “honing” in on what pressure ranges and other settings work best for each of us. Many sleep doctors prescribe a wide open pressure range figuring the machine will auto-titrate to find the best settings. For many that causes issues like frequent wake-ups, the feeling of air being blown up our noses, aerophagia, and other issues. For some of us wide open settings are fine as we tend to be on the lower end of the pressure spectrum, but for others it leads to problems.

The challenge is finding what works best for you and here is where OSCAR and advice from those knowledgeable becomes so important. With OSCAR those experienced in divination can help you reduce the range to help get better sleep. Without having detailed data the best people can do to help is educated guesses.

As for my non-educated guess without over-analyzing (hopefully those better schooled will chime in as well), you may be better served turning EPR 3 on full-time (to help with flow limits), Set your pressure range to 10-14 (should help with early wake-ups but will take time to get used to as your median is ~10 and 95% is ~13, but this may have to change later), and see how it goes for a few days.

Also, please turn off the calendar and pie chart in your OSCAR graphs as it will allow more data to be shown on the left side.

Good luck!

[Dog Slobber]

Many sleep doctors prescribe a wide open pressure range figuring the machine will auto-titrate to find the best settings.

Not disagreeing that many, including doctors, *think* that auto-titrating will find the best settings. But it is importatnt to point out, they are wrong, *very wrong*.

[robysue1]

It could be that your body is finally starting to actually relax and is learning how to sleep well with the mask on your nose. In all seriousness, learning how to sleep well with the mask on your face is a significant part of making this crazy therapy work and for many people that doesn't happen right away.

I do suspect that part of this is psychological. Because this all started 3 years ago with classic insomnia (inability to fall asleep) and I still have a bit of conditioned fear when I go to bed at night (worrying about how bad my sleep will be).

I've since read that insomnia can co-occur with sleep apnea and one possibility is that it's a defence mechanism trying to protect you from a night of breathing issues.

You are correct: Sometimes insomnia can develop as a defense mechanism in people with untreated OSA.

And worrying about how bad your sleep is going to be when you first go to bed is a really good way to insure that you have a bad night of sleep in terms of how you feel the next morning.

You might want to pick up a copy of Sound Sleep, Sound Mind by Dr. Barry Krakow. The first half of the book is all about insomnia and useful strategies for dealing with it. The second half of the book is a pretty detailed look at the connections between untreated OSA and insomnia as well as a good introduction to how and why xPAP works and how properly treating OSA is a critical part of treating insomnia in patients who develop insomnia that is caused by untreated OSA.

[Miss Emerita]

Now that other and braver souls have clicked on your dropbox link, I have too.

You a lot of flow limitations, which are a primary driver for your pressures. The FLs (or the pressure changes) may or may not be contributing to unrestful sleep. If the FLs originate in your nose, there's not a lot a change in settings can do, but if they are caused by a bit of sagging in the tissues lining your pharynx, then EPR may be of some help. EPR can also help with hypopneas if they are obstructive in nature. (And snores, though you don't seem to have any.)

Like Jlfinkels, I would recommend that you turn on EPR (full-time). You could start with 1, 2, or 3, whichever feels best to you.

And like robysue1, I would also recommend a minimum pressure of 7. This would allow you to have the full benefit of an EPR of 3 even at your minimum pressure, and I suspect you will find it comfortable. Are you using ramp? If you are and like it, keep it; if you are and want to experiment, try turning it off.

As robysue1 notes, your leaks may be contributing to unrefreshing sleep. Or not. Do you have any sense of whether that's true or whether the leaks are mostly from your mask or your mouth?

[palerider]

Now, THOSE settings are crazy.

Why is that?

Because a setting of 4 is correct for very very *very* few people. many people have trouble even breathing at a pressure of 4.
Reducing the max pressure is also foolish except in a few cases.

Based on the screenshots you provided, your pressure should probably be 9-20 Or 12-20 if you're going to use EPR.

[ozij]

Many sleep doctors prescribe a wide open pressure range figuring the machine will auto-titrate to find the best settings.

Not disagreeing that many, including doctors, *think* that auto-titrating will find the best settings. But it is important to point out, they are wrong, *very wrong*.

"Auto-titrate" is one thing - can even be useful.
"Auto-therapy" is different. Human beings can look at the auto-titration, and decide on a good min for auto therapy.

Auto-titrating, from a low level can give info about the minimal pressure needed to prevent most of the destructive obstructive events.
You have to keep in mind that no cpap "blows through" or "blows away" obstructive events. Therapy is meant to achieve good sleep, without oxygen desaturations and with as small a number of obstruction-related arousals as is concomitant with good sleep.

When the APAP's pressure is too low (unless you use the Autoset for Her mode*), you keep dropping to the level where apneas /obstructions occur, your sleep/oxygenation are disrupted. That's why "auto" therapy is different from auto-titration.

"Titration" actually comes from labs (not necessarily sleep labs):

an operation, used in volumetric analysis, in which a measured amount of one solution is added to a known quantity of another solution until the reaction between the two is complete.

My emphasis.
In our case, "complete" means restful sleep, with proper oxygenation implied.

* "Autoset for Her" (a ResMed algorithm) is different from standard "Autoset" in that is sets a bottom limit for the night based on prior events. It's good, if the breath flow and events are interpreted correctly, not so good if they're misinterpreted. Once set, that bottom limit for the night isn't changed.