CPAP not helping?

Hi everyone,

This is my first post here. I was diagnosed with moderate OSA (AHI 15) a few months ago through an at-home sleep test and have had my first CPAP machine (a Philips DreamStation Auto CPAP) for three weeks now. I am an otherwise healthy 26yo male, 140 lbs, 5ft 10in.

My mask is a Philips Amara View full-face mask (I tend to have a stuffy nose at night -- had turbinate reduction surgery 3 years ago, but the problem came back). My machine is setup with an initial pressure of 5 inH2O, ramp turned off, heated humidifier at the highest setting of 5 (I find it to be the most comfortable), and a FLEX/EPR setting of 3 (highest possible).

During these first three weeks, I am still consistently having many sleep apnea events. I still wake up tired and with a headache, and notice no significant change in my energy levels during the day. My AHI wearing the mask has been as high as 10 and as low as 3.5.

While analyzing my data from last night this morning in OSCAR, I see a large cluster of sleep apnea events occurring at around 3 am, with pauses in breathing of 30-60 sec. The machine does not seem to label these apneas consistently, with some of them being labeled as Central Apneas and others as Obstructive Apneas. I've included some graphs below.

The "cluster" of apnea events at 3 am:


The minutes preceding this "cluster:"


The minutes following the occurrence of this "cluster:"


A zoomed-in view of the apnea events:


My current thought is that a position change (maybe from side-sleeping to a supine position) may be triggering these events, but I can't tell for sure. It surprised me that the apneas seem to go on unchanged even when the Auto CPAP increases the pressure from 5 to 10 inH2O. As I mentioned, OSCAR has some of these apneas labeled as OA and others as CA -- I'm not sure if I trust the labeling completely.

Do you have any thoughts on this? Could I be suffering from Central Apnea instead of OSA, contrary to my diagnosis? Because of the whole Covid-19 situation, it's been harder to get a hold of my sleep specialist doctor, so I decided to reach out to this community to see if anyone might have some ideas.

Thank you very much.

Please read the very first post at the top of the page....Newbies Please Read Before Posting

Hi LSAT,

I did read it before posting.

When you read the thread "newbies please read"....did you follow the link in it to this thread?
viewtopic/t158560/How-to-post-images-for-review.html

OSCAR doesn't do the labeling of OA or CA (central).....OSCAR just reports what the machine labels something.
So any label you see comes from the machine and not OSCAR.

The one thing that the machine doesn't know and has no way of knowing is if you are asleep or not.
It will sometimes flag awake breathing irregularities as some sort of apnea event but if we aren't asleep they don't count.
Were you by chance awake during that 3 AM cluster?

Hi Pugsy,

Thanks for the link. I have read through the image instructions but frankly it's a bit of an info overload. I tried to format my graphs as instructed, but apologize if they still aren't right.

I do not recall being awake at 3 am at all.

You are missing some information from your daily detailed report that would help us help you better and faster.
I would rather get too much information than not enough.
All that stuff on the left side...your cropped it out. We need to see it.

Here's how I like to see things for me to best help anyone that is using a Resprionics machine.

The stuff on the left side (minus the calendar and pie chart) are important so that I can see the AHI and breakdown easily along with the settings used. I know people tell us the settings but often what they tell us ends up not being what is being used and it's just easier to verify quickly by looking at the detailed reports.
I like to have one image that includes all the basic details at regular zooming in levels and then if I need something zoomed in on then I will request it.
You zoomed in but not enough to really best evaluate the data you zoomed in on.

Then the graphs on the right side the Events, Flow rate, Pressure and leak graph.

I apologize if your eyes glaze over when trying to read my instructions. I was never very good at putting my thoughts into words and briefly. I do the best I can though. I know it is far from perfect but this is what you get with volunteer stuff....it's not professional because we aren't professionals here. Everyone here is a unpaid volunteer.

If you were asleep when that cluster happened it's likely either you were on your back or maybe happened to be in REM stage sleep both of which it is quite common to worsen OSA and end up needing more pressure to hold the airway open.
I saw clusters like this myself when I first started cpap...and my OSA is documented much worse in REM.
You need a little more minimum pressure to better hold the airway open and prevent the collapse. The current minimum just takes too long to get to where it needs to be to prevent that airway collapse from either supine or REM sleep.

The machine does nothing while any event is happening...it won't try to fix it while it is happening.

Hi Pugsy,

Thanks for your reply. No need to apologize, I appreciate your support. I think I finally got the screen that you were looking for:



I expected that the immediate increase in pressure during an OSA event would open up the airway again. Interesting to hear from your comment that this pressure needs to be applied before the event in order to keep it from happening in the first place. Maybe it's time for a call to my doctor and ask for someone in the office to increase the pressure from 5 to a 7 or so?

I woke up with a terrible headache this morning after having taken the mask off at around 3 am -- whenever I take the mask off, it seems to always happen at around 3. I go to bed at 12 am regularly. Looking forward to having this figured out soon.

Why can't you raise your pressure yourself - like the rest of us have done forever?

It's a common thought that the machine senses an apnea event of some sort and immediately thinks "OMG I need to increase the pressure" and it does it and blows the airway open.
Nothing is further from the truth in terms of what actually happens.
While any apnea event is happening...obstructive or hyponea....the machine sits by and twiddles its little thumbs until the airway opens up naturally. Then the auto adjusting algorithm kicks in and does some evaluation of the current and past status of the airway....and then decides what to do. All this takes time and if you have a cluster of events happen then there's an inherent amount of time spent twiddling the thumbs that slows down the response as well.

Central/clear airway apneas....the machine simply won't respond to at all because the airway is already open and more pressure won't help. Unless someone has a machine designed with a special algorithm to deal with central apneas....centrals get ignored by regular cpap/apap/bilevel machines.

It's a common thought that the machine can respond and go to much higher pressures that might be needed (once the machine goes through its evaluation process and decides more pressure is needed) in the blink of an eye. That it can go from 5 to 10 cm or higher in the blink of an eye. It simply doesn't respond that fast...it can't. It increases a little bit at a time and evaluates as it increases. All this "thinking" can take several minutes to get done and all the while the machine is gradually increasing the pressure the airway can continue to collapse and have apnea events happen.

The whole key to using auto adjusting pressures and having it work optimally is to use it with a minimum pressure that does the bulk of the work preventing the collapse from happening in the first place and then do some increases as needed for special needs...like supine sleeping or REM related worsening of OSA.

They work best when preventing the collapse in the first place and not trying to fix something that gets broken after the break has already happened.
So we need to use a minimum pressure that means the machine can get to what might be needed for those special circumstance in a timely fashion...not take 20 minutes but instead take maybe 5 minutes. We have to give the machine a better head start when using auto adjusting pressure mode.

I have REM dependent OSA meaning my OSA is much worse in REM than in the other stages of sleep. Supine sleeping has never been a big factor for me but REM sure is. It's documented that my OSA is 5 times worse in REM than in non REM and I learned that during REM I might need 6 to 8 cm more pressure than I need in those other sleep stages.
Now I could use a fix pressure that would cover the REM pressure needs but that would mean using around 15 cm all night long just to cover the 20% of the time I am in REM. I could do it but it's not much fun. Instead I prefer to use a lower pressure for 80% of the night and have that lower pressure still be close enough to get to where I need the pressure to be in a timely fashion to deal with REM related pressure needs.

Sometimes all we need to do to give the machine a better head start is a relatively small increase in that minimum pressure.
So I use a little more minimum all night so that I don't have to use a lot more all night. Make sense???

You really only had the one time frame where the machine couldn't do a good enough job....I suspect supine sleeping but it could have been REM or it might have been a combination...on your back and in REM. Doesn't really matter...I think people should sleep in whatever position promotes good sleep if at all possible and since we have no control over REM...just be pre-emptive and cover both with a little more minimum.

I suspect that all you need to clean up your report a little better is a minimum somewhere around 6 to 7 cm...might need a little more but I would start with small increase because often once a better minimum is in place the machine won't have to go as high.
I have seen people see a reduction in the max that is much more significant than the minimum increase.
One case comes to mind where the person was seeing pressures reach 18 cm quite often but with a little 2 cm increase in the minimum the max pressure reached never went above 12 cm.

Prevention is the key....not trying to fix it after it happened. All machines work this way...use a minimum pressure to hold the airway open for most of the time and then increase for the special circumstances that might cause a higher pressure.

@Julie: thanks. I didn't know I could change it myself but found out about the Ramp button + Scroll button trick to get into the Clinical Menu.

@Pugsy: this is very helpful. I was able to increase the Min pressure to 7 and will give it a shot tonight. Will report back with how it goes. Thanks again.

I just gave the higher minimum pressure a try last night, but still getting some apnea clusters. Thankfully the AHI stayed at a 4.27 and I feel OK this morning. I do recall waking up on my back a few times, and made the conscious effort to roll on my side each time. I use a side-sleeping pillow which is quite thin -- when on my back, my head stays flat with the rest of my body (though I've been trying to avoid this position as much as possible for fear it's increasing my apneas). Below are some graphs:

Overview:


Zoomed-in view of an apnea cluster:


Do you think this warrants a further increase in the minimum pressure (7 felt fine), or should I try the current one for a few more nights? Any other suggestion is appreciated.

I suspect some of those OA flags in that cluster are arousal related but the first one is definitely asleep related. It most likely caused the arousal that got you some other OA flags. Some are real and some are a symptom of the arousal from the real OA...if that makes sense to you....so we still want to reduce the real ones a little more.
That along with the other stuff flagged that points to airway obstructions....FLs, RERAs, hyponeas...all point to still needing a little more minimum.

I wouldn't spend a lot of time at this new minimum...maybe one or two nights but based on the other obstructive related stuff...I would go right to 8 cm minimum and see what happens. If all you had was the OA stuff I might spend more time at the 7 minimum but you have other stuff going on as well that points to the airway trying to collapse.

Will try out 8 tonight. Thanks for your input.

The clustering might also be caused by your tucking your chin down toward your chest. If you think that might be going on, then consider wearing a soft cervical collar or a Dr. Dakota-type "snore collar."

One other thought is to get a bed pillow that is thicker where it goes underneath your neck. If you roll onto your back, there's some chance it'll help keep your airway open.

It's impossible to say ahead of time whether either of these ideas would work for you, but you seem to be someone who has a good experimental mind-set, so you might want to give them a try, in addition to adjusting your pressure settings.

My apneas were pretty low until the coronavirus stuff started, then they skyrocketed. I'm wondering if anxiety has anything to do with it. Waiting to see my doctor...

Sent from my SM-G955U using Tapatalk