Still feel like a zombie with CPAP

I have been using my ResMed 10 series for several weeks now and I still feel very sleepy.

I was diagnosed with UARS, with 50 RERAs per hour. Im young and skinny but apparently my airway is very narrow.

What do you guys think the problem is? Why is APAP not working for me?

There are many potential causes for day time sleepyness. Despite what your doctor probably lead you to believe a CPAP is not the wonder cure that he would like you to think it is. Doctors don't actually know all that much about the physiology of sleep. So therir approach is usually to just throw a CPAP at the problem and see if it helps.

I have been using a CPAP for about 10 years now. It has helped with sleepyness but is not anywhere near a wonder cure for my sleep issues. I can say that I feel better when I use my CPAP than when I don't. I can remind myself of how much the CPAP does help by skipping a night with it.

pablmd wrote:I have been using my ResMed 10 series for several weeks now and I still feel very sleepy.

I was diagnosed with UARS, with 50 RERAs per hour. Im young and skinny but apparently my airway is very narrow.

What do you guys think the problem is? Why is APAP not working for me?

I've heard on many CPAP boards, not only this one - that when new to CPAP it can have the effect of making one more tired and even headaches. I know for me If I had a really bad sinus issue or seasonal allergies while using CPAP, I am tired no matter what. I've been using Cpap since 2013 and I've had sinus issues for 10 years and my sinus problems got worse with Cpap. But I can tell now that I'm less tired compared to what I was like before 2013.

You have your ramp set to the default 45 minutes. This means you are starting at an unrealistic 4.0 cm pressure, and everytime the machine restarts (note the break in therapy in your chart), you lose 45 minute of therapy. You should increase the minimum ramp pressure to 6.0 or more, and limit the ramp time to 5 minutes. Many of us simply turn off the ramp feature. In the case of your chart above, this alone would have given you 80 more minutes of therapy.

Your pressure settings of 9 min and 12 max look pretty good, and I'm surprised to see EPR is off. You might try an EPR of 1.0 for some pressure relief on exhale, and see if your sleep is better. Leaks are significant, and are probably what is keeping you from sleeping well.

Any other medications or conditions that may be affecting your sleep?

pablmd,

Yes, it can take several weeks to a few months before you start feeling better. A few of us take even longer than that: I actually felt significantly worse after starting PAP for six months or more before I very slowly started to feel better. By my one year mark I was finally starting to feel better than I had before starting CPAP.

There are some things that I notice in the data you posted:

There's a 30 minute gap between 6:30 and 7:00 when you weren't using the machine and then there are two somewhat significant clusters of events just before 8:00 and around 8:30. Were you actually asleep at this point? Or were you tossing and turning while trying (unsucessfully) to get back to sleep? And in that case, you only got about 4 1/2 hours of real sleep.

Bedtime on this night is also quite late: The machine was not turned on until 2:30. Before PAP, what did your sleep schedule look like? Bedtime was when? Wake up time was when? How much has that sleep schedule changed since starting CPAP?

It also looks like you might profit from increasing your min pressure up to 10cm since your pressure is almost never below that level except for the Smart Ramp period on your machine. (And does the Smart Ramp ever wake you up once it does start ramping up? I ask because ramping up from 4 to 9 cm in a 10-minute period is a pretty steep increase in pressure and some people are sensitive to such things.)

Finally, you didn't post the Leak graph, but SH indicates that you are spending a small bit of time in Large Leak territory. If your leaks are well under 24 L/min except for the Large Leaks, then leaking is probably not a huge issue for you. But if your leaks are often in the 20-23.9 L/min range (i.e. just under the 24 L/min threshold), then you might need to work on fixing the leaks. With the provided data there's just no way to tell how significant your leak problem actually is.

pablmd wrote:I have been using my ResMed 10 series for several weeks now and I still feel very sleepy.

I was diagnosed with UARS, with 50 RERAs per hour. Im young and skinny but apparently my airway is very narrow.

I think that in bold is the answer to the following questions of yours:

What do you guys think the problem is? Why is APAP not working for me?

Clearly, you therapy is not optimal even for sleep apnea with AHI > 5.0. However, a bigger problem may be your Flow Limitations, I am referring to the last chart on the picture your posted. Those could indicate frequent arousals. You may want to gradually increase your pressure settings.

Unfortunately, once both doctors or folks on this board see your low AHI numbers, they start advising that either you need some time to wait before the therapy make a positive effect or there may something else detrimental to your therapy. Based on my experience (18 RERAs), they are wrong. I could feel terribly sleepy even with 0.0 AHI, but my condition immediately improved once I found the right pressure settings and took control of the leaks and dry mouth.

So, forget what other people say about the necessity to wait before you should feel better or that there is something else affecting your therapy. Take care of your RERAs, and most likely you feel refreshed after one night sleep as soon as that.

I agree with Sleeprider that you could benefit from EPR > 0 (1-3) and that you should turn of Ramp.

Did you by chance get the regular AirSense 10 AutoSet or did you get the AirSense 10 AutoSet for Her model?

tan wrote: Unfortunately, once both doctors or folks on this board see your low AHI numbers, they start advising that either you need some time to wait before the therapy make a positive effect or there may something else detrimental to your therapy. Based on my experience (18 RERAs), they are wrong. I could feel terribly sleepy even with 0.0 AHI, but my condition immediately improved once I found the right pressure settings and took control of the leaks and dry mouth.

So, forget what other people say about the necessity to wait before you should feel better or that there is something else affecting your therapy. Take care of your RERAs, and most likely you feel refreshed after one night sleep as soon as that.

Tan,

Thanks for pointing this out. It is true that the flow limitation graph is somewhat ragged. A small increase in minimum pressure (I had suggested bumping it up to 10cm) may help smooth out that flow limitation curve. And that may indeed be a significant part of the puzzle for fixing pablmd's problems.

Another question/comment: I'm told (but do not know) that the A10 Autoset for Her has an additional auto algorithm that is tweaked somewhat differently than the A10 AutoSet (not for Her) model. I vaguely recall reading something somewhere that ResScan claimed that the "for Her" auto algorithm dealt with flow limitations in a (slightly) different fashion. Can anybody help me out here: If RERAs are a problem, is the A10 "for Her" Auto algorithm supposed to be better at addressing the issue than the regular A10 algorithm?

Note: My question is vague because I'm a PR user but I've had hands on experience with the ResMed S9 AutoSet, which did NOT work very well for me. I have no direct experience with the new A10 algorithms, and I've not read much here about them because I took a six month hiatus from cpaptalk due to things going on in my private life.

Thanks everyone,

I've got the normal 10 series, not the 'for her' version.

I just changed my settings to 10-12 pressure, set EPR to 1 and decreased ramp time.

Ill let you guys know what happens tonight.

Resmed machines dont do RERA reporting (except the A10 for her) so Flow limitation graph is used as a proxy for RERA reporting done by A10 for her or by PRS1 60 series.

Couple of things:
1) You could still have tons of RERAs even with AHI of 0.0 and you will feel unrefreshed in the morning. You should raise your minimum pressure to eliminate/reduce flow limitations. Flow limitation is a precursor to RERAs. So every flow limitation will not be a RERA but on an aggregate basis, they are a good proxy.
2) Other reason for your unrefreshed feeling could be that you are sensitive to pressure changes. Every pressure uptick can cause a EEG microarousal which can knock you out of a deeper sleep stage to a shallower one. This means you are not getting restorative Slow wave sleep. You can try going with a straight pressure instead of variable pressure, in APAP mode. If you make max=min in APAP mode, it works like a cpap but still reports Flow Limitations.

I did both 1) and 2) in sequence. Finally, going to straight pressure did the trick for me. If your pressure need is low enough for you to tolerate, then go with straight pressure for at least 10 days and then report back how you feel.

robysue wrote: Can anybody help me out here: If RERAs are a problem, is the A10 "for Her" Auto algorithm supposed to be better at addressing the issue than the regular A10 algorithm?

I think that RERAs are flagged in the special "for her algorithm" and not in the regular apap setting...and while I don't know if the for Her special algorithm would actually make that much of a a difference here in this situation it is why I asked which model AutoSet this person might have. I don't know if the absence of any RERAs on this report above means that there weren't any or they weren't flagged. I am still trying to figure out what might be something that is flagged only in the the for Her special algorithm.
I also don't know if the "for Her special apap algorithm" would maybe help someone with UARS better but it's another reason for having it available "just in case".
On paper it sounds like the for her special apap mode might be worth trying for UARS since it seems like UARS patients tend to be sort of super sensitive anyway.

How would the OP know which straight pressure to try?

AMK wrote:How would the OP know which straight pressure to try?

In this situation a person will have to rely more on how they feel and not so much on what the software reports show except maybe for watching the flow limitation graphs. With UARS the AHI is often already on the low side so AHI isn't all that good of a marker to watch. In this situation I would go with the 95% pressure as a starting point if I were going to go to cpap mode with a fixed pressure and see how I felt and see what the flow limitations looked like and go from there.
I don't normally use the 95% pressure in most situations as a starting cpap mode pressure but in this situation I would. Seems like from what I have seen with other UARS cpap users they tend to seem to need a little more pressure to feel better than what we would normally go by with just looking at the software reports.

AMK wrote:How would the OP know which straight pressure to try?

If you have been on the APAP for a couple of weeks or more, then in case of Resmeds, take the 95% pressure for the last week and use that as the straight pressure. In case or Respironics, take the 90% pressure (because of the hunt-n-peck algorithm).

Stay on the that pressure for at least one week, then adjust upwards or downwards in 0.5cm increments for 1 week at a time.
Also, make sure you eliminate your Ramp gradually (by reducing ramp time and increasing ramp start pressure).

And EPR/Aflex are your friends. They help to eliminate the Hypopneas and flow limitations once the exhale pressure removes all Obstructives.

All this info is available on the titration document on pubmed or aasmnet websites.

What does a healthy flow limitations graph look like for someone getting good sleep? My graph looks like the one in this thread and I too am exhausted.

I'll try to find that titration document.