Should I set a higher pressure? Apap + nosepillow.

Andréa · Post by **Andréa** » Fri May 27, 2022 9:15 am

Hi!

When looking at my flow rate and flow limit in Oscar, my analysis is that it could be a good idea upping my ipap a bit to see if that would lower my flow limit. My flow limits are from what I have read a bit high, and as I'm still fatigued with brain fog 1,5 yrs in to pap treatment I figure it's worth tweaking settings to see if it could optimize my treatment.

I also have two more chronic illnesses, ME/Cfs and HMS (why just stop at SA?) - so every tiny percent of better sleep means the world to me.

My sleep tech, a super nice and very supportive person, doesn't think there's any more adjustments to make. But, on the other hand, he hasn't got the time in his tight schedule to study my curves in detail. So, may I use your fine tuned brains?

My AHI normally varies from 2-8, which my sleep tech believes is ok. My own thoughts when looking at my curves in Oscar is that "do I really get good sleep or do I have undetectable micro awakenings due to flow limitations". And that maybe the AHI would not look as good as it does if the software would be more sensitive to possible disturbances.

Hope I've attached according to the "rules" - my brainfog makes it hard to search and read instructions. As you can see, the flow limit peaks after I've fallen asleep while the flow rate looks good when looking at it zoomed out. But when zoomed in, does it really look nice?

All the best
//Andréa

Pugsy · Post by **Pugsy** » Fri May 27, 2022 9:47 am

How about an image of your detail report that isn't zoomed in on?

How come the extremely tight max pressure? Any special reason?
If no special reason by all means, try a much higher max and let the machine try to do a better job killing the FLs.

Are you comfortable changing things yourself?

Your entire report just screams "you need more pressure" for sure more max and maybe more minimum.....
And not just for FL reduction...

Andréa · Post by **Andréa** » Fri May 27, 2022 10:17 am

Miss Emerita · Post by **Miss Emerita** » Fri May 27, 2022 11:22 am

I'm glad you're working with a doctor on your nasal issues. As you know, extended use of decongestant sprays can make swelling of the mucosa worse. Is the ENT aware of your long-term use of decongestant sprays? Have you and your ENT discussed getting you off the sprays before trying to address your congestion with surgery on your turbinates (conchas)?

Your central apneas may represent arousals from sleep: the arousal can cause you to breathe deeply, which washes out some CO2, which lowers your urge to breathe until the CO2 builds back up. Please zoom in on your CAs to see whether that's what's going on with them. I'm attaching an example of what an arousal followed by a CA looks like. After you check on this, let us know what you find. Also, let us know what the breakdown of your AHI was in your sleep test (CAs, OAs, hypopneas).

In following Pugsy's advice, you can always increase your maximum in stages -- maybe by just 1 every night or two -- whatever keeps you comfortable.

The next time you post a chart, do include one that is zoomed out all the way, as Pugsy mentioned. Also, include just some of the graphs:

Events
Flow rate
Pressure
Leaks
Snores
Flow limitations.

CA after arousal.png

Andréa · Post by **Andréa** » Fri May 27, 2022 11:57 am

Thanks for your thoughts!!

I posted a zoomed out chart in the last post, or did I miss something in that one?

Attaching a zoomed in view of my typical CA:s, to brainfogged to try to interpret. What do you think about them?

About my nose. Before I started using decongestant spray I tried everything else, as I really didn't want to get hooked. Tried saline rinsing with nose pot, salt spray, cortisone, kids decongestent spray in micro amounts. Tried increasing the humidity, tried decrease. Nothing worked. My nose clogged at late evening and the only way to get it open was to use the spray I didn't want to. And if I didn't get it opened, I couldn't use my pap and I would become severely ill again, which is the worst and I can't ever risk being so sick again, that I need to be hospitalized.

On top of that I'm on a med that makes the nose clog even more, tried to switch but couldn't use the other med. due to side ex. So it's a mess - to say the least. I've nagged and pointed out to my ENT that I REALLY don't want to wait with surgery to september, as my nose will get even more fu**** up for every day using spray. But there's nothing he can do, I have to wait in line for my turn.

So, I'm sad and worried about my whole situation right now. My latest plan is to only spray in one nostril, so that the other one can recover a bit, and in a couple of weeks change nostril. Don't know if one nostril is enough to breathe through.

Miss Emerita wrote: ↑
Fri May 27, 2022 11:22 am
I'm glad you're working with a doctor on your nasal issues. As you know, extended use of decongestant sprays can make swelling of the mucosa worse. Is the ENT aware of your long-term use of decongestant sprays? Have you and your ENT discussed getting you off the sprays before trying to address your congestion with surgery on your turbinates (conchas)?

Your central apneas may represent arousals from sleep: the arousal can cause you to breathe deeply, which washes out some CO2, which lowers your urge to breathe until the CO2 builds back up. Please zoom in on your CAs to see whether that's what's going on with them. I'm attaching an example of what an arousal followed by a CA looks like. After you check on this, let us know what you find. Also, let us know what the breakdown of your AHI was in your sleep test (CAs, OAs, hypopneas).

In following Pugsy's advice, you can always increase your maximum in stages -- maybe by just 1 every night or two -- whatever keeps you comfortable.

The next time you post a chart, do include one that is zoomed out all the way, as Pugsy mentioned. Also, include just some of the graphs:

Events
Flow rate
Pressure
Leaks
Snores
Flow limitations.

CA after arousal.png

Andréa · Post by **Andréa** » Fri May 27, 2022 12:01 pm

Thanks Pugsy, you're the sweetest!

I can change settings myself.

The tight pressure settings is due to my nose and eyes getting sore from higher pressure (nothing exactly nothing has gone smooth with my SA-tretment, my body is rediculous

), so my tech figured that bc my ahi looked good with the lower settings, this was an ok pressure. But I feel as you say, it really should be higher.

Thing is my nose gets totally clogged and I need to use spray constantly to keep it open, to be able to use nose mask at all. This has of course lead to my nasal conchas growing big, and I'm now waiting for surgery to make them smaller, and hopefully then I'll be able to stop with the awful spray addiction, and also being able to better tolerate higher pressure through my nose.

I can't wear full face mask, then I don't sleep at all. When starting pap I tried tu use full face mask, and ended up at hospital due to extreme sleepdeprivation followed by horrific sleep disturbance symptoms, like parasomnia, halluciations etc. So, nose mask is the only way to treat my SA.

Sorry if my english is a bit off, brainfog and from Sweden.

Did I attach what you were asking for?

Pugsy wrote: ↑
Fri May 27, 2022 9:47 am
How about an image of your detail report that isn't zoomed in on?

How come the extremely tight max pressure? Any special reason?
If no special reason by all means, try a much higher max and let the machine try to do a better job killing the FLs.

Are you comfortable changing things yourself?

Your entire report just screams "you need more pressure" for sure more max and maybe more minimum.....
And not just for FL reduction...

Pugsy · Post by **Pugsy** » Fri May 27, 2022 12:20 pm

Have you played around with different humidity settings to see if more or less moisture helps or hurts the nasal congestion issues?

One nostril that is clear is enough air movement IF it is comfortable for you.
I tend to sometimes wake up with the "nasal cycle" thing where one nostril is totally plugged up and it is the side that is down and when I turn over it clears up.
I don't always have it but when I do I am breathing only through one nostril and I am quite comfortable.
Google "nasal cycle" and you will see what I am talking about.

Start by just changing the maximum pressure to just 10 cm...no need to rush things. Let's see what happens with a change where the machine can maybe go a little higher.

The last image you posted is fine.
We don't really need masked pressure graph as we find that the regular pressure graph is better for general overall viewing.
You can remove the mask pressure graph and in its place just resize your graphs a bit larger especially the events graph.
BUT no need to redo this image.

I tend to lean towards those centrals as being arousal related. If you look at the flow rate/breathing immediately before that first central there is a big gulp of air....and we don't take big gulps of air when we are asleep.

You can watch the videos here if you haven't seen them already as they can help you figure out awake from asleep.
Bear in mind that while they talk mainly about central apneas we can have the same thing happen to OAs and hyponeas.
I call them false positives and I personally have seen false positive in all three event categories.
http://freecpapadvice.com/sleepyhead-free-software
Some of those OAs and hyponeas you see flagged very well could be arousal related and of course they don't really count in the grand scheme of things except to tell us you aren't sleeping soundly which of course is unwanted.

If that activity on the FL graph is mostly from the nasal congestion more pressure isn't going to help reduce the FLs.
The machine might try to kill those FLs with more pressure but when the cause of FL graph activity is nasal related....more pressure doesn't help. You have to instead deal with the congestion in the more traditional measures.

These machines can't tell if we are awake or asleep. They only measure air flow and they can't tell if the air flow reduction it sees in the FLs graph are related to the airway or the nose...it assumes airway and will try to deal with it with more pressure but it won't help. So if you are having much nasal congestion during the night at all then it is very possible that the activity on the FL graph is related to the nasal issues and you will just have to sort of shrug your shoulders and accept that it is nose related and the machine doesn't fix nasal issues. It can only fix airway issues that are a problem starting below the nasal cavity itself.

Now sometimes humidity can cause swollen nasal mucosa....either way....either too much added moisture or too little added moisture can cause the nasal mucosa to swell up and cause congestion, and/or the other not so nice nasal symptoms.
Humidity needs vary widely among individuals. Some people need a lot of added moisture (that would be me) and some people don't need much at all and in fact find that if they get too much added moisture it can cause congestion to be worse.

So if you aren't using a humidifier adding moisture to your air....use it and add some moisture and start out with a middle of the road setting.

If you are already using the humidifier and haven't played around with the settings....try a different setting.
If using a low setting try a higher setting.
If using a higher setting then try a lower setting.
If using a middle of the road setting you can toss a coin but most people will do better with more humidity.
If you take a hot shower and you find that your nose is a bit clearer after a hot steamy shower then you have your answer.

Andréa · Post by **Andréa** » Fri May 27, 2022 12:39 pm

Thanks for input!

I don't believe the flow limitation is due to congested nose as the limitation are most intense the first hours of sleep, when my nose is at it's best bc I've just taken the decongestant spray.

I'll try to raise pressure according to your rec. and adjust humidification.

All the best, and thanks for guidance!

Pugsy wrote: ↑
Fri May 27, 2022 12:20 pm
Have you played around with different humidity settings to see if more or less moisture helps or hurts the nasal congestion issues?

One nostril that is clear is enough air movement IF it is comfortable for you.
I tend to sometimes wake up with the "nasal cycle" thing where one nostril is totally plugged up and it is the side that is down and when I turn over it clears up.
I don't always have it but when I do I am breathing only through one nostril and I am quite comfortable.
Google "nasal cycle" and you will see what I am talking about.

Start by just changing the maximum pressure to just 10 cm...no need to rush things. Let's see what happens with a change where the machine can maybe go a little higher.

The last image you posted is fine.
We don't really need masked pressure graph as we find that the regular pressure graph is better for general overall viewing.
You can remove the mask pressure graph and in its place just resize your graphs a bit larger especially the events graph.
BUT no need to redo this image.

I tend to lean towards those centrals as being arousal related. If you look at the flow rate/breathing immediately before that first central there is a big gulp of air....and we don't take big gulps of air when we are asleep.

You can watch the videos here if you haven't seen them already as they can help you figure out awake from asleep.
Bear in mind that while they talk mainly about central apneas we can have the same thing happen to OAs and hyponeas.
I call them false positives and I personally have seen false positive in all three event categories.
http://freecpapadvice.com/sleepyhead-free-software
Some of those OAs and hyponeas you see flagged very well could be arousal related and of course they don't really count in the grand scheme of things except to tell us you aren't sleeping soundly which of course is unwanted.

If that activity on the FL graph is mostly from the nasal congestion more pressure isn't going to help reduce the FLs.
The machine might try to kill those FLs with more pressure but when the cause of FL graph activity is nasal related....more pressure doesn't help. You have to instead deal with the congestion in the more traditional measures.

These machines can't tell if we are awake or asleep. They only measure air flow and they can't tell if the air flow reduction it sees in the FLs graph are related to the airway or the nose...it assumes airway and will try to deal with it with more pressure but it won't help. So if you are having much nasal congestion during the night at all then it is very possible that the activity on the FL graph is related to the nasal issues and you will just have to sort of shrug your shoulders and accept that it is nose related and the machine doesn't fix nasal issues. It can only fix airway issues that are a problem starting below the nasal cavity itself.

Now sometimes humidity can cause swollen nasal mucosa....either way....either too much added moisture or too little added moisture can cause the nasal mucosa to swell up and cause congestion, and/or the other not so nice nasal symptoms.
Humidity needs vary widely among individuals. Some people need a lot of added moisture (that would be me) and some people don't need much at all and in fact find that if they get too much added moisture it can cause congestion to be worse.

So if you aren't using a humidifier adding moisture to your air....use it and add some moisture and start out with a middle of the road setting.

If you are already using the humidifier and haven't played around with the settings....try a different setting.
If using a low setting try a higher setting.
If using a higher setting then try a lower setting.
If using a middle of the road setting you can toss a coin but most people will do better with more humidity.
If you take a hot shower and you find that your nose is a bit clearer after a hot steamy shower then you have your answer.

Miss Emerita · Post by **Miss Emerita** » Fri May 27, 2022 2:45 pm

Thanks for the totally zoomed-out view. (You can tell if you're zoomed in by seeing the light green area on the Events graph.)

My allergist prescribed Singulair, Azalastine, and Flonase for symptom control. You might nag the ENT about other options you could try.

It's so interesting that your FLs are better during the later part of the night. Is that a consistent pattern?

palerider · Post by **palerider** » Fri May 27, 2022 10:36 pm

Andréa wrote: ↑
Fri May 27, 2022 9:15 am
When looking at my flow rate and flow limit in Oscar, my analysis is that it could be a good idea upping my ipap a bit to see if that would lower my flow limit. My flow limits are from what I have read a bit high, and as I'm still fatigued with brain fog 1,5 yrs in to pap treatment I figure it's worth tweaking settings to see if it could optimize my treatment.

Well, with an abysmal AHI, no wonder you're still tired.

Andréa wrote: ↑
Fri May 27, 2022 9:15 am
My sleep tech, a super nice and very supportive person, doesn't think there's any more adjustments to make.

Super Nice, supportive, incompetent, you've got the trifecta.

Andréa wrote: ↑
Fri May 27, 2022 9:15 am
My AHI normally varies from 2-8,

2 is an upper limit of 'ok' for most people, 8 is "you need a cpap, oh, wait"

Andréa wrote: ↑
Fri May 27, 2022 9:15 am
which my sleep tech believes is ok.

And thus, we're back around to incompetent.

Andréa wrote: ↑
Fri May 27, 2022 9:15 am
My own thoughts when looking at my curves in Oscar is that "do I really get good sleep or do I have undetectable micro awakenings due to flow limitations".

All night, 8+ times an hour.

You've got an auto machine, and the current settings have it chained and manacled so that it can't do *anything* to help you when you need it.

Raise the max pressure, I'd raise it to 20 if it were me, and let the machine actually try and reduce your AHI.

palerider · Post by **palerider** » Fri May 27, 2022 10:38 pm

Andréa wrote: ↑
Fri May 27, 2022 12:01 pm
Sorry if my english is a bit off, brainfog and from Sweden.

Never fear, your English is better than a lot of people that grew up in the USA.

Andréa · Post by **Andréa** » Sat May 28, 2022 4:12 am

So - tonights numbers. I'll raise the pressure even more.

Andréa · Post by **Andréa** » Sat May 28, 2022 4:17 am

Attached tonights chart in a separate post.

My theory about my fluctuation FL is that my deep sleep makes my inside collapse more than when in REM.

I should definitely talk to my dr. about trying som allergy meds! Thanks for support!!

Miss Emerita wrote: ↑
Fri May 27, 2022 2:45 pm
Thanks for the totally zoomed-out view. (You can tell if you're zoomed in by seeing the light green area on the Events graph.)

My allergist prescribed Singulair, Azalastine, and Flonase for symptom control. You might nag the ENT about other options you could try.

It's so interesting that your FLs are better during the later part of the night. Is that a consistent pattern?

Julie · Post by **Julie** » Sat May 28, 2022 5:39 am

Just raise your max pressure - try e.g. 15 (if 20 worries you) and see what happens! There is nothing inherently 'dangerous' about doing it - far less so than leaving it as is.

Stop worrying about your flow rate etc... just see what happens with a high(er) max pressure for even one night.

Andréa · Post by **Andréa** » Sat May 28, 2022 8:08 am

Thanks

And thanks for your input also.

I have such poor and delicate sleep so my sleep tech first goal was to have med sleep at all, which I didn't when the pressure was around 12. That's why I have så low max p. But now, after 1,5 yrs of the tiniest baby steps, I'm able to actually sleep with air blowing into my system. Finally. But I have to raise the pressure slowly, so I don't fu** it up with something my body interprets as a F5 Tornado, and stops sleeping again.

I have been in such a bad state the last yrs before getting:
1. Finally listened to, efter sex yrs of deaf ears, by a young woman dr. (the men dr.s: "SA? Bah, that's for older obese men!!! You're depressed. Here, have som ssri and take a walk when tired!")
2. Examined and put on pap.
3. Assigned a sleep tech that actually was a sleep tech, and not a poor nurse lacking knowledge about pap, doing her best saying: "everything looks good bc your AHI looks fine, don't know why you aren't feeling well, nothing I can help you with though as it can't be related to your pap-tretement".

It's truly scary how I - a very privileged person being a white well educated woman, with a good job, income, family and friends, live in a rich country - could have been so ignored, gaslighted and ridiculed by the health care system. I can't even imagine how hard must be for people without my privileges.

Anyhow, the dr. decided I had a burnout from stress, and that was it. I presented and argued about what was obvious SA-related symtoms (even I as a non medicin-person could see it), but no - burnout and anxiety issues, period. It has been such a Kafkaesk journey, still is in some ways although since I got my SA-diagnosis I'm not longer seen just as a hypochondric mental case looking for somatic answers when I'm actually just "mentally ill". I have also gotten diagnosed with ME/Cfs. But who knows if ME/Cfs would have taken over my life if I'd been properly examined and put on pap seven yrs ago when I got sick. If my bodyly system would have had a chance to rest and recover at night instead of being in constant flight or fight mode, with an activated ans and metabolic system 24/7?

Well well... Now you know, maybe more than you wanted

, why i don't just raise pressure to max.

palerider wrote: ↑
Fri May 27, 2022 10:38 pm

Andréa wrote: ↑
Fri May 27, 2022 12:01 pm
Sorry if my english is a bit off, brainfog and from Sweden.
Never fear, your English is better than a lot of people that grew up in the USA.

Should I set a higher pressure? Apap + nosepillow.

Should I set a higher pressure? Apap + nosepillow.

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Re: Should I set a higher pressure? Apap + nosepillow.

Re: Should I set a higher pressure? Apap + nosepillow.

Re: Should I set a higher pressure? Apap + nosepillow.

Re: Should I set a higher pressure? Apap + nosepillow.

Re: Should I set a higher pressure? Apap + nosepillow.