I have been using APAP since New Year and still feel sleepy. Need help with settings

[Too Sleepy]

Hello,

Thank you to whoever replies to this. I was diagnosed with an AHI of 11, purely hypopneas- no apneas or RERAs were noted during my in-lab sleep study. I have severe symptoms: drowsiness, sleepiness and general body fatigue. This all started about three years ago and has been progressively getting worse and worse. I started using APAP full-time from the 1st of January, before that I was getting acclimated and couldn't use the mask a full night. However, I progressed to now being able to fall asleep and wake up with the mask secure without any issues. I use P10 nasal pillows which I find comfortable.

Regarding APAP settings, my doctor hasn't helped me at all. I had no titration study done. When I was given my diagnosis near the end of last year the doctor simply said "try out a fixed pressure of 4" without any evidence as to why that would help- it didn't. My reported AHI was too high and I couldn't use the CPAP a full night so I changed it to APAP mode, min 4.6 and max 8. EPR 3, full-time. With these settings I'm able to use the APAP throughout the night.I haven't been able to get an appointment with the sleep department since then (NHS).

I'm still very tired, and although it could be that my body is recovering from sleep debt, I have a feeling that something isn't quite right with my CPAP therapy. And I don't have the knowledge to be able to tell what's wrong. Could any of you please help me? OSCAR screenshots below.

Notes:
- Fall asleep and wake up fine with the P10 Nasal pillows
- I have woken up with a dry mouth for the last three days. All the other times I haven't noticed a dry mouth at all.
- I seem to still be waking up during or after dreams, as I have a vivid recall to my dreams.

Current settings:
- Min 4.6
- Max 8
- EPR 3, full-time

Thanks!

[robysue1]

Too Sleepy,

Welcome to the forum.

I was diagnosed with an AHI of 11, purely hypopneas- no apneas or RERAs were noted during my in-lab sleep study. I have severe symptoms: drowsiness, sleepiness and general body fatigue. This all started about three years ago and has been progressively getting worse and worse.

Severity of symptoms is not always correlated with severity of the undiagnosed sleep apnea. But most people who have severe symptoms find the transition to xPAP therapy a bit easier than those of us who didn't have severe symptoms.

I started using APAP full-time from the 1st of January, before that I was getting acclimated and couldn't use the mask a full night. However, I progressed to now being able to fall asleep and wake up with the mask secure without any issues. I use P10 nasal pillows which I find comfortable.

So you're about 3 weeks into full time therapy.

Regarding APAP settings, my doctor hasn't helped me at all. I had no titration study done. When I was given my diagnosis near the end of last year the doctor simply said "try out a fixed pressure of 4" without any evidence as to why that would help- it didn't. My reported AHI was too high and I couldn't use the CPAP a full night so I changed it to APAP mode, min 4.6 and max 8. EPR 3, full-time. With these settings I'm able to use the APAP throughout the night.I haven't been able to get an appointment with the sleep department since then (NHS).

Far too many new CPAPers (on both sides of the Atlantic) have an experience similar to yours.

Congratulations on making the decision to just take things into your own hands and start making reasonable changes to the settings so that you can get some sleep and benefit from your APAP.

I'm still very tired, and although it could be that my body is recovering from sleep debt, I have a feeling that something isn't quite right with my CPAP therapy. And I don't have the knowledge to be able to tell what's wrong. Could any of you please help me? OSCAR screenshots below.

The data that you have posted looks excellent in terms of efficacy, but given how far you've zoomed in on the detailed data for Jan 17 and Jan 20, it's hard to figure out what the overall night's leaks look like or what the pressure was doing on those nights.

You are still waking up several times a night to turn the machine off and back on: I can pick that up from the Sessions data.

On Jan 17 your total time using the machine was under 6 hours, so you may simply have not gotten enough sleep (with the machine) that night.

In other words, from the Oscar data you've posted, it's hard to pinpoint what your feeling that "something isn't quite right" might be related to.

So let me ask you some questions that don't require you to analyze the data in order to answer:

1) Are you getting to sleep comfortably at the beginning of the night when your pressure is close to 4.6cm? If not, describe what's not comfortable as best you can.

2) How many times do you typically wake up during the night? When you wake up, do you know why you're waking up? In particular, are you waking up uncomfortable for any reason?

3) Are you aware of leaks at any point during the night? Or are you surprised when you look at the data in Oscar and the data says you have leaks?

Notes:
- Fall asleep and wake up fine with the P10 Nasal pillows
- I have woken up with a dry mouth for the last three days. All the other times I haven't noticed a dry mouth at all.
- I seem to still be waking up during or after dreams, as I have a vivid recall to my dreams.

You may be experiencing both sleep rebound and REM rebound: Now that your sleep is not being interrupted by the hypopneas all night, the body may be craving more sleep and spending more time in REM. This should start to resolve in a few more weeks.

The dry mouth may be related to leaks. Even small leaks that you ordinarily would not need to worry about can cause dry mouth problems.

You can try consciously training your tongue to stay touching the top of your mouth right behind your upper front teeth. This is the normal natural resting spot of the tongue, but when it slips down from there in the night, air can enter the oral cavity from the nasal cavity. Typically when too much air builds up in the mouth, you either get a small mouth leak from air leaking through closed lips OR you open your mouth and get a larger leak OR you swallow the air and (potentially) wind up with aerophagia---i.e. enough air in your stomach to cause discomfort.

You can also try using Biotene or other products designed to help fight dry mouth problems. Xylimelts is another product that is often recommended.

Increasing the humidifier setting can also help with dry mouth problems. If you are currently using a heated hose on Auto temp and Auto humidity, you'll need to switch to Manual in order to select a higher humidity setting. Keep in mind, the higher the humidity setting at a given temperature, the more likely you are to have problems with rainout. Sometimes you just have to deal with a compromise between the humidity the nose & mouth wants and the problems caused by rainout. But most people are able to find a sweet spot where there's enough humidity to prevent the dry nose & mouth problems, but not enough to cause problems with rainout.

[Too Sleepy]

Hello robysue1,

Thank you very much for your reply, I really appreciate it.

- Apologies for the zoomed in data, I have attached screenshots of those nights that are zoomed out so you can see the entirety of the night. Do these give a better idea of what's going on?
- Unfortunately, anything to do with humidity and temperature in manual mode causes rainout. Even at the highest tube temperature I experience rainout if I've manually set the humidity. I now have it all set to auto and it's going great. My nose is clear 95% of the time.

1) Yes I am getting to sleep comfortably at night with 4.6cm of pressure. In fact, I've tried to increase the pressure to 4.8cm (my average pressure is 5.3 and I thought it'd be best to get the minimum as close to that as possible) and I can't handle it. It appears that any higher than 4.6cm and I feel like I'm struggling to inhale all that air even with EPR on. In terms of max pressure: previously I set it at 9cm and a few times I woke up during a dream, looked at the CPAP and saw pressure at 9, and concluded that my breathing became more restricted during REM sleep prompting a pressure increase. However, that pressure increase must have woken me up.

2) Before therapy I wouldn't wake up during the night at all. However, the first one to three weeks of therapy there's been times where I would wake up 1-3 times at night. Some of those times I need to pee; that was new to me. I also seem to still have vivid recall of my dreams. However, recently I would say that the wake ups are decreasing. However, I seem to sleeping more. I sleep 6-8 hours, wake up and pee, then sleep another 4-6 hours.

3) I am not aware of any leaks when I sleep. The high leaks in OSCAR surprised me. I have been waking up with dry mouth recently which makes me think that perhaps I am opening my mouth which may explain those leaks. I am going to start mouth-taping from now on and see how that goes. During the day my tongue naturally touches my palate.

[Too Sleepy]

Screenshots here

[Too Sleepy]

Do the leaks seem like a concern?

[zonker]

Do the leaks seem like a concern?

are the leaks waking you up?

[Too Sleepy]

Not that I remember, no. But my concern is micro-arousals. Just like how apnea events wake you up without consciously remembering it.

[ozij]

You can't be getting the necessary therapy with that amount of mouth leaking.
And its quite possilble the leaks are causing arousals you aren't conscious of.

[palerider]

Screenshots here

Well, you see how your pressure line looks like a roller coaster? you're having repeated episodes of breathing problems.

Set your min pressure to 7 and max to 20 and you'll sleep better.

[Too Sleepy]

I took your advice and incrementally increased minimum pressure by 0.2-0.4cm a day and now am at 7cm min and 12max. I still feel terrible. I still feel sleepy. I also corrected the long-duration leaks I had by wearing a chin-strap, that definitely solved the leak issue.


I attached a screenshot here. Why do I still feel so sleepy? Maybe even worse than before.

OSCAR Latest with 7 pressure low leaks.png

[Pugsy]

Do you take any medications of any kind? If so, what? Even OTC?

[Too Sleepy]

No medications at all. Nothing OTC. Is it simply a case of sleep debt and needing more time to recover?

[Miss Emerita]

I'm trying to understand your sleep timing. You start and stop at a variety of times, your total time on the machine per day varies a lot, and the number of sessions you log varies a lot too. Two of the biggest pieces of advice offered by sleep specialists are to go to bed and get up at a regular time and to avoid long naps altogether and even short naps within about 7-8 hours of bed-time. Maybe this is an area in which you might want to make some changes?

[Too Sleepy]

I do need to improve my sleep hygiene, yes. However, it's taken a backseat to first improving sleep quality. Since starting CPAP I sleep more, sometimes 8-12 hours. I have been trying to stick to a more rigid schedule but now there is often days where I sleep 12 hours.

[robysue1]

I do need to improve my sleep hygiene, yes. However, it's taken a backseat to first improving sleep quality.

Sleep hygiene is the key to improving sleep quality after you've got the obstructive events under control. And your data shows that your OSA is extremely well controlled by using the CPAP.

So the remaining problems you are having with sleep quality are probably going to respond better to improving your sleep quality than they will respond to dial winging the CPAP settings hoping to fix a problem that is not there.

Since starting CPAP I sleep more, sometimes 8-12 hours. I have been trying to stick to a more rigid schedule but now there is often days where I sleep 12 hours.

Start by enforcing a reasonable standard wake up time: In other words, get up at the same time every day. It is possible to oversleep, and when we do, that can actually lead to lest restful, less restorative sleep and more problems in the daytime with feeling tired.