Last Night Was First Night

[Iancdub88]

Pick some setting(s) that are totally comfortable for you and don't keep changing stuff willy nilly or nightly.

Problem is figuring out what those settings are, haha

[robysue1]

I also had some leaking issues. I am a stomach sleeper by default so I'm sure that doesn't help keep the mask on when I'm trying to get into that position. I did get the pillow with the indentations for the mask but it didn't make much difference so I went back to my normal pillow.

It can take some time to figure out how to sleep in your favorite position with the mask on. But there are people who successfully figure out stomach sleeping while using a mask, even a full face mask. My husband is one of them. In my husband's case, he uses an extra pillow under his stomach to help lift his body up enough to not cause problems with his full face mask.

Another solution for a lot of people is to use what is called the "Falcon" position. It looks like this:

And worst of all, there were more events per hour last night. It seems as though I wake up as soon as I fall asleep at times. I feel like this is a brain thing maybe? Like i'm subconsciously afraid to fall asleep with the mask on? I don't know. I also had some throat tightness this morning.

Yes, it's most likely a "brain thing" where your subconscious is still fighting the whole idea of sleeping with a mask. It happens. But as your body starts to get snippets of higher quality sleep that is not interrupted repeatedly by the apneas, your subconscious mind will let go of its fears and you will start sleeping longer stretches between wakes.

Note also: It is normal to have a few wakes in a good night's sleep. For example, many people wake briefly at the end of each REM cycle. The trick is falling back asleep so quickly that you don't remember the wakes in the morning. (We typically don't remember any wake that is less than about 5 minutes in length when we get up in the morning.)

But for now? Yes, it's going to be a while before your subconscious lets go of its fears completely and you feel like you get a full night of good sleep. How long? That's highly variable, but most people typically start sleeping soundly with the mask in a couple of weeks after starting xPAP therapy.

Anyways, I was able to post last night's results on SleepHQ and would love your help reading them. Thanks a lot!

https://sleephq.com/public/89731e23-af8 ... ac2d0498b2

First thing: Yes, you've got some leaking going on, but your leaks stay well below the 24 L/min "Red Line" set by Resmed as the definition of "Large Leak." So what this means is you need to figure out whether the leaks are part of what's waking you up when you first start to drift off to sleep or not. In general, if the leaks stay below 24 L/min and they are not waking you up, you can just ignore them. But if you are consistently waking up with a feeling that the mask has sprung a leak, then trouble shooting the leaks is worth it---regardless of whether they're "real Large Leaks" or not----just because the leaks seem to be interfering with your ability to get and stay asleep.

So when you wake back up, do you seem to frequently notice leaking around the edge of the mask? Or are you oblivious to the leaks until you look at the data?


Second thing: Yes, your machine is recording too many events. But the question (at this stage) is: How many of those events are real? As in how many of them occurred when you were actually asleep?

As you self report, you were awake for a good bit of the night and you were having some trouble getting into a sound sleep. So many of those events are likely part of so-called "sleep-wake-junk" breathing, or SWJ for short. It certainly looks to me like there are long stretches of SWJ on this night, and if this were my data, I'd be much more worried about not sleeping soundly than the actual AHI. In other words, I'd be trying to figure out what to do to make it easier to get and stay asleep rather than the AHI.

Our wake breathing and our sleep breathing are controlled by different mechanisms and different parts of our nervous system. And wake breathing patterns, including those when you are trying unsuccessfully to get into a real, sound sleep, include a whole lot of raggedness that our machines can score as apneas and hypopneas. Remember that our machines have no way to tell when you are awake and when you are asleep. So if you are awake and you momentarily hold your breath while turning over or while fiddling with the mask, the machine might score an apnea even though you were awake. And these momentary pauses in wake breathing while concentrating are extremely common and we're seldom aware that we're holding our breath for a few seconds. Whether those momentary bits of breath holding wind up being scored as CAs or OAs or some of both depends on how you're holding your breath. If you like to experiment, use the machine for 30 minutes while sitting up wide awake during the day and intentionally alter your breathing patterns and include some intentional long "hold your breath" periods; that can help you sort out whether your machine is more likely to call your wake breath holding a CA or an OA or whether it seems pretty random.

Likewise, wake breathing is usually deeper than sleep breathing, and if there's a stretch of deep wake breathing, the machine might just score a (false) hypopnea or a (false) CA as you are transitioning to sleep.

So for now, I'd recommend concentrating more on teaching your body how to sleep with the mask on rather than the overall number of events. If the AHI remains too high after you are feeling like you are getting a full night of non-interrupted sleep, then there will be plenty of time to troubleshoot the pressure settings at that point.


Third thing: You self report that you think the pressure changes in APAP may be an issue with falling asleep and staying asleep. And there is some evidence in your posted data that is consistent with that feeling. So you might do better in terms of actually sleeping with the machine if you used a fixed pressure for now. And if you're comfortable with trying to get to sleep at 9cm, then set your machine in CPAP mode with a pressure of 9cm and keep EPR set to 3. And then use that setting for three or four nights in a row.

Here's the thing: If you keep making changes in the pressure settings and/or you keep switching from CPAP to APAP and back, you are not giving your body any chance to adjust to all the crazy, new sensory stuff when you're falling asleep. And that can add to the subconscious "fears" of trying to sleep with the mask all night long. So it's important to give any adjustment to the therapeutic settings 3 or 4 days before making another one. That allows your body and mind to figure out what is going on in terms of how the machine feels and how it reacts to your breathing and then start actually trying to sleep soundly with the new settings.

[Iancdub88]

Robysue1, this was all so incredibly helpful and comforting. Thank you so much.

[robysue1]

Anyways, I was able to post last night's results on SleepHQ and would love your help reading them. Thanks a lot!

https://sleephq.com/public/89731e23-af8 ... ac2d0498b2

First, I agree with Pugsy when she says:

This report from last night screams a crappy sleep quality night.
Lots of starts and stops of the machine....screams being awake and with that much arousal/awake breathing then we just have to wonder if you were sound asleep or not when those events got flagged.

I also agree with Pugsy that lowering the EPR is likely to increase your discomfort if you are having trouble exhaling against the pressure.

Next, what I'd like to do is walk you through looking at your data a bit closer by posting some marked up screen shots of what you linked to over at SleepHQ.

Here's the first screenshot I want to discuss:

The "best" sleep breathing you had during this whole night seems to be in that blue box that I've marked on the screenshot. It's only about 20-25 minutes long, and long term what you want is for this kind of breathing pattern to last for most of the night. It indicates that you are sound asleep and the machine is keeping you from having any real obstructive sleep apnea related events.

The stuff in the red boxes looks to me like you were awake. Or possibly (in the first read box), you were bouncing back and forth between wake and a very light sleep without ever transitioning to real sleep. In other words, SWJ breathing that did not happen to be ragged enough to actually get flagged as events. Note also the spike in airflow just before you turn the machine off. That indicates when you woke up. In this case, you didn't fall right back asleep after the arousal happened; instead you woke fully up, turned the machine off and back on, and then you had trouble getting back to sleep. There's nothing particularly "wrong" with waking up and turning the machine off and back on---provided you can get back to sleep quickly. (I often find short wakes in my own data that I don't remember because they lasted less than five minutes from when I woke up enough to turn the machine off and back on and then got back to sleep.)

To help you understand what quality sleep breathing looks like, let's zoom in on the data in that blue box. The zoomed in version looks like this:

When someone is sleeping really well with an xPAP, you see really long stretches of breathing like this with a few bits of "arousal" breathing here and there. (The arousals can be something as simple as turning over in bed or adjusting a sleep position to a normal, brief post-REM wake. If you're feeling fine and you don't remember any periods of tossing and turning, you can safely ignore isolated arousals in terms of "what they mean" about the quality of your sleep.)

Now on this particular night of data, the arousal at roughly 4:21 in the first screenshot leads to what looks like a prolonged wake with a whole bunch of "events" scored, as the next screenshot shows:

After about 40 minutes of struggling to get back to a real sleep, you turn the machine off, change the settings, and then turn the machine back on. None of the events in this stretch are likely real simply because it looks like you never got fully asleep.

After turning the machine back on around 5:08, this is what the zoomed in data looks like:

This time, it looks like you were able to finally transition to real sleep around 5:50AM. As I noted on the screen shot, the CA scored in the orange oval is most likely a normal sleep transitional central that would not be scored on an in-lab sleep test. It's not uncommon and it's considered perfectly normal to have one or two CAs happen as the transition in control of your breathing is changed to the autonomic nervous system as you fall asleep.

The upshot of all this: Until you are actually sleeping more soundly for longer periods of time, don't get too stressed out about the events. For the short term, your number one job is teaching your body and brain---especially the subconscious part of your brain---to accept the mask as a part of your new normal bedtime routine and how to get to a sound sleep with the mask on.

As others have said, part of that process is picking a set of settings and using it for several days instead of making numerous changes to the settings, sometimes in the same night, in the hope of finding a magic setting that "fixes" everything. It takes time for the body and the brain---especially the subconscious part of the brain---to learn how to deal with all the new stuff when starting xPAP. Repeatedly changing the settings doesn't give your body or brain anytime to acclimate to what a particular setting feels like.

For now, I'd suggest that you figure out whether the small leaks are disturbing your sleep even though they are not big enough for Resmed to flag as a Serious Problem with Large Leaks. Pesky leaks that constantly wake you up are a problem with getting to sleep and staying asleep, even if they are not large enough to affect the efficacy of your data.

[vandownbytheriver]

First thing, lets not make so many changes during the night! Set 9cm CPAP, 0 or 1 EPR, and see how you do for a night. Just turn off Ramp, you don't need it, you're not really using it. Stay off your back if you can, I put a pillow behind me to remind me of this. Good luck, let us know etc.

Will lowering the EPR to 1 make it harder or easier to exhale?

Harder. Can you do it? Set Ramp down at 5 for 20min and try.

[Miss Emerita]

One small follow-up to RobySue's posts. Instead of using CPAP mode, try using APAP mode but setting the same value for both minimum and maximum pressure. If I remember correctly, in CPAP mode there will be some data you won't capture.

[robysue1]

One small follow-up to RobySue's posts. Instead of using CPAP mode, try using APAP mode but setting the same value for both minimum and maximum pressure. If I remember correctly, in CPAP mode there will be some data you won't capture.

Miss Emerita,

Thanks for reminding me of that fact.

Yes, in APAP mode, you get information about flow limitations that won't show up in CPAP mode if I recall correctly. RERAs might also be something that is not recorded when the machine is running in straight CPAP mode.

So yes, setting min pressure = max pressure = desired CPAP pressure does give more data than straight CPAP mode, but it gives you the same fixed pressure that CPAP mode provides.

[Iancdub88]

First thing, lets not make so many changes during the night! Set 9cm CPAP, 0 or 1 EPR, and see how you do for a night. Just turn off Ramp, you don't need it, you're not really using it. Stay off your back if you can, I put a pillow behind me to remind me of this. Good luck, let us know etc.

Will lowering the EPR to 1 make it harder or easier to exhale?

Harder. Can you do it? Set Ramp down at 5 for 20min and try.

That was one of the first settings I had to change when I got it. It was too hard to exhale.

[Iancdub88]

One small follow-up to RobySue's posts. Instead of using CPAP mode, try using APAP mode but setting the same value for both minimum and maximum pressure. If I remember correctly, in CPAP mode there will be some data you won't capture.

Miss Emerita,

Thanks for reminding me of that fact.

Yes, in APAP mode, you get information about flow limitations that won't show up in CPAP mode if I recall correctly. RERAs might also be something that is not recorded when the machine is running in straight CPAP mode.

So yes, setting min pressure = max pressure = desired CPAP pressure does give more data than straight CPAP mode, but it gives you the same fixed pressure that CPAP mode provides.

I'm still not sold on if I want a fixed pressure but I will try it for the next few days. Problem is that sometimes 9 feels perfect and sometimes it's too much or too little.

[robysue1]

First thing, lets not make so many changes during the night! Set 9cm CPAP, 0 or 1 EPR, and see how you do for a night. Just turn off Ramp, you don't need it, you're not really using it. Stay off your back if you can, I put a pillow behind me to remind me of this. Good luck, let us know etc.

Will lowering the EPR to 1 make it harder or easier to exhale?

Harder. Can you do it? Set Ramp down at 5 for 20min and try.

That was one of the first settings I had to change when I got it. It was too hard to exhale.

Set EPR where you are most comfortable exhaling against the pressure. I'd suggest setting it to 3 for the full amount of potential exhalation relief, particularly if you decide to try a fixed pressure of 9 cm.

I'm still not sold on if I want a fixed pressure but I will try it for the next few days. Problem is that sometimes 9 feels perfect and sometimes it's too much or too little.

You might want to try a very narrow APAP range. You could set min pressure to 7 or 8 and max pressure to 10 or 11 to allow the machine a bit of variation to adjust to your breathing.

If the problem is that it sometimes feels like 9 too much at the beginning of the night and it sometimes feels like 9 is too little at the beginning of the night, that's a more subtle problem since it involves some inconsistency on how things feel at the beginning of the night and you likely have no idea what it's going to feel like tonight until you put the mask on. My guess is that the more consistent you are with establishing a bedtime ritual and the more consistent you are with teaching your body to just get used to how the pressure feels at the start of the night, the sooner you'll get to a point where you are no longer thinking (or worrying) about how the pressure feels right after you turn the machine on. Rather, you'll be closing your eyes and preparing your body to slip into sleep.

If the problem of the pressure feeling like it's too little happens later in the night after you turn the machine off and back on, then it may be easier to explain: Most of us have no real sense of the pressure if we wake up several hours into the night because our body has gotten use to exhaling against it. If all you need is mental reassurance that the machine is blowing enough air through the mask, the easiest thing to do is to pull the mask slightly away from your nose: You'll immediately feel the air the machine is blowing and letting go of the mask will cause it to settle down back on your face and reseal.

On the other hand, if you wake up feeling like there's too much air being blown in by the machine, that's where using a narrow auto range can help. If you turn the machine off and back on, the pressure is reduced back to min pressure. And sometimes just knowing that the pressure is now 7 or 8 cm instead of 9 or 10 cm is just enough to keep the brain from spiraling into a "worry cycle" about how the pressure is feeling. And keep this in mind: As long as you are actively worrying about your sleep and/or the pressure, you're not sleeping and you're probably managing to keep yourself awake even longer. When I was starting out (some 14 years ago now), I had real problems with significant aerophagia---i.e. swallowing air from the pressure and getting severely bloated. People who have aerophagia can often feel like the pressure is just too much. And that's when being able to simply restart the machine and lower the pressure a bit can really help prevent the worry cycle from getting started.

If you are looking for a place to start with deciding on a set of settings to use for the next 3 or 4 days (minimum), here's what I would suggest:

• Choose APAP mode. It's a bit more flexible than straight CPAP.
• Set min pressure to 7.4 and max pressure to 10.4. This should provide enough pressure at the beginning of the night where you don't feel "air starved", but at the same time, you shouldn't feel like you can't possibly breathe or exhale against the whirlwind of pressure.
• Set EPR = 3. You've said you're not particularly comfortable exhaling against the pressure. So use EPR to give yourself the 3 cm drop in pressure as you exhale. The one downside I see for new users with EPR is that it's easy to start worrying about whether you are "breathing correctly" with the machine. Try not to focus your attention on your breathing. Unless you are super, super sensitive to small changes in sensory stimuli, you should not actively be sensing the pressure change with each of your inhalations/exhalations. But you should feel like exhaling is more natural with EPR turned on.
• Leave the ramp off.
• Leave your hose temperature and humidity settings as they currently are. You haven't been complaining of a wet nose a super dry mouth or feeling too warm or too cold while trying to get to sleep. So chances are the hose temperature and humidity setting is "ok" for now.

Regardless of whether you use my suggested settings or someone else's or pick and choose different pieces of advice from different people, you need to commit to using the same settings for at least 3 or 4 nights, unless you have an absolute, unmitigated disaster. And I don't mean just a difficult night---you are already having those. And I don't mean an AHI that seems too big when you look at the data the next morning.

By unmitigated disaster I mean: A night where you not only feel like you got little or no sleep, but also you felt absolutely horrible during the night when you were tossing and turning for what seemed like an eternity. In my case, aerophagia was usually the cause for an unmitigated disaster: Waking up at 3:00 AM feeling like you swallowed a basketball on the night you decide to increase the minimum (or maximum) pressure setting is an unmitigated disaster.

No matter how bad or fragmented your sleep seems, if you didn't have an unmitigated disaster of a night, resist the urge to change the settings for the full 3 or 4 day period. We don't sleep the same every night and even those of us who have been as xPAP for years have occasional nights where one of Pugsy's aliens pays us a visit and we have an awful night's sleep.

Make some notes each morning about the night with the settings you choose to start with. Were you able to get to sleep ok? How many times do you remember waking up? How long do you think you spent tossing and turning when you woke up? Do you feel rested at all when you have to get up in the morning? Did you wake up with a severely dry mouth---either in the morning or during the night? Do you have any bloating? Did you have any problems with serious rainout during the night? And if you want, you can also track the AHI and leak rate data, but don't start chasing after an AHI = 0.0 if you are not yet sleeping all night long with the machine.

All of that subjective data combined with the objective data from the AutoSet will help you figure out what you might want to change in order to improve your sleep when it's time to consider making a change to the settings: After 3 or 4 nights of data, you will be in a better position of figuring out what one thing to change in an effort to improve your sleep and your therapy. Change that one thing and then stick with the new settings for at least 3 or 4 days while keeping notes before you make another change. It's an iterative process, but eventually you will find settings that your mind and your body can comfortably sleep with.

Typically we recommend changing only one setting at a time: When you change two or more settings at a time and things get worse instead of better, it's hard to figure out which of the changes is most likely the culprit for things getting worse.

[Iancdub88]

Typically we recommend changing only one setting at a time: When you change two or more settings at a time and things get worse instead of better, it's hard to figure out which of the changes is most likely the culprit for things getting worse.

I really appreciate your help. I've been so tired today that I've been feeling really frustrated about the whole thing but this is a huge help.

[robysue1]

Typically we recommend changing only one setting at a time: When you change two or more settings at a time and things get worse instead of better, it's hard to figure out which of the changes is most likely the culprit for things getting worse.

I really appreciate your help. I've been so tired today that I've been feeling really frustrated about the whole thing but this is a huge help.

Given last night's fragmented sleep, I'd be surprised if you didn't feel wiped out today.

And I understand your frustrations about the whole thing. Keep in mind that a large proportion of us "old PAPers" here at cpaptalk.com had our problems ironing out the details of our therapy and more than one of us literally threw the mask against the wall in our bedroom on at least one occasion. We've stuck around to help folks like you who are starting out partly because we know how frustrating it can be and partly because we know how rewarding it is once a person with OSA finally starts sleeping well with the machine and no longer feeling like something the cat dragged in ...

I'm an outlier who had a really hard time adjusting to xPAP therapy. The severe aerophagia set in early and hard. And it triggered a whole lot of severe problems with insomnia. It took me about 6 months, plus a change in machine to a BiLevel to address the severe aerophagia before I could comfortably sleep most of the night. On the other hand, my husband came home from his in-lab titration study feeling better than he had felt in years. And he had absolutely no problems adjusting to it. Boy was I jealous at the time since he started after I'd finally conquered my xPAP problems. To be fair, however, my husband's support was a large part of why I was able to persevere through the early dark days of my own therapy.

Best of luck to you. Keep us posted on how things are going since you are struggling. We'll be happy to give you the support you need to make this crazy therapy work for you.

[Craig H]

It took me a while to become "friends " with my CPAP and the first nights were kind of awful.

One thing I learned was..the CPAP is not controlling my breathing (inhale / exhale cycles) and I did not have to force myself into a new way of breathing.(which I was doing)...to suit the machine!

I was forcing myself into long and regular over deep inhales and regular over exhalations.

When I relaxed into a more normal breathing action ..which were much shorter/shallower...things improved fast.

Something I do that may help is ...when set up , CPAP on, lights out and head hits the pillow...I use a little meditative technique where by I might visualise , rehearse or practice something non stressful in my head.
eg. tying a fishing knot, repairing something, inventing a solution, writing a script or story, visualise guitar chords....currently...debunking flatearth arguments ( ha ha)

I usually drop off inside 3-5 minutes every night.

[Iancdub88]

Something I do that may help is ...when set up , CPAP on, lights out and head hits the pillow...I use a little meditative technique where by I might visualise , rehearse or practice something non stressful in my head.
eg. tying a fishing knot, repairing something, inventing a solution, writing a script or story, visualise guitar chords....currently...debunking flatearth arguments ( ha ha)

I will give this a shot!

Last night was pretty bad. I had an hour straight where I was about to finally reach a full sleep and I would wake up. Then I had a panic attack when the pressure changed. I was afraid to put the mask back on for the rest of the night, I think I'm actually developing a fear of it. I put it back on for the last half hour this morning and it did quell the fear a little bit but I think I'll need to stick to fixed pressure while I get used to it.

I'm really depressed and tired and feeling like giving up on this therapy.

[Iancdub88]

Also, my doctor seemed annoyed that I would mess with the settings. They really just expect the factory defaults to work across the board?