Therapy thread - a few weeks into CPAP

[tamaton15]

Been lurking around for a bit beforehand, I'm grateful for all of the helpful advice that I've read on the forum so far. Wanted to get some opinions on how my therapy is currently going, as I've been experiencing a high proportion of clear airway events.

I’ve been APAP’ing for 3 weeks. Current setup:
- Resmed Autoset 11 w/ ClimateLine
- AirFit P10

The main thing I am struggling with is a high proportion of clear airway events / central sleep apneas. Not sure if this is just my body getting used to the machine with treatment-emergent central sleep apnea, or if you all have any suggestions on what to try. I feel marginally better in terms of being able to focus and concentrate from before, but still getting headaches often and needing a nap to get through the day. Would appreciate any suggestions or advice greatly

OSCAR graphs:



Zoomed in on one of the CA events:


Let me know if any additional graphs are needed.

Some background:
Untreated apnea from an at-home sleep study WatchPAT (Lofta) sleep study where I was diagnosed with mild OSA: 6.0 AHI
- Sleeping on right side: 3 AHI. Sleeping on the left side, I had an AHI of 10, but I also only slept for ~30 minutes on my right side during the at-home sleep study.
- Sleeping on back: 9 AHI

Daytime symptoms: couldn’t make it through the day without a nap, brain fog, inability to concentrate. In the last 1.5 years, added a persistent tension headache to the mix

Thanks all for the help!

Usage of CPAP:
- Usually at least four hours a night. Most of the time I end up taking off the mask after a sleep cycle or two (1.5 - 3 hours). I do remember doing this most of the time, and I think what I tell myself is “I’ll put it back on after relaxing a little bit”, but then I fall asleep before remembering to put it back on. Probably a bad habit here that I need to shake.
- Sometimes when I take a nasal spray antihistamine, I’m able to sleep for longer hours with the mask on

Other medical conditions - have bad dust mite allergy, that I have received allergy shots for. While the condition has improved, it doesn’t seem to be at the point where I can abstain from antihistamines altogether. I also take a nasal steroid spray and nasal spray antihistamine daily. The nasal spray antihistamine makes me drowsy.
- Don’t know if I have a deviated septum. I suspect that I might have this issue because the right side of my nose is much more frequently blocked than my left. Will see an ENT in the near future to get this checked out.

Information of what I’ve tried on my Resmed Autoset 11
- Raising the minimum pressure over time from 4 to 6 based on OSCAR data, prescription was originally for 4-20.
- Changed humidity to 80 F degrees and setting of 5. I do have the heated tube and a hose cover to prevent rainout
- Added accessories like a hose clip to prevent some hose dragging. Though I don’t use a hose lift or hang the hose from overhead.
- Gradually practiced getting used to keeping my mouth closed, as I do suffer from large leaks sometimes, and keeping my tongue in a position so that it seals the air from my mouth.

[Pugsy]

What are the odds that you were awake when the bulk of those central apneas were flagged???

About the only thing you can do with your machine to maybe (stress the maybe part) reduce the number of centrals is turn off EPR and that will only help if the centrals are caused by using EPR ....which to be honest I doubt is the cause.
I actually suspect a sizable chunk of those centrals are awake/arousal breathing false positive flagging.
The zoomed in example you gave was zoomed in too much and didn't show the flow rate prior to the flagging well enough to determine sleep status....but I suspect arousal related from the little bit I see.

It hurts nothing to try turning off EPR though and see if it makes any difference.

Several breaks in therapy are seen...means you were awake....so how come the wake ups?

[zonker]

want to thank you for taking the time to read the newbie thread and downloading oscar. this makes it much easier for forum members to offer up advice!

you've already attracted one of our top people in pugsy. so i'll leave you in her capable hands.

just one piece of advice-you might want to maybe use a piece of tape on the mask so that there is a bit of a tug when you pull it off. maybe it'll stop you from removing it completely. or as another forum member suggested, if your hair is long enough, use a bobby pin .

at any rate, welcome to the zoo and good luck!

eta: also one piece of housekeeping-when you get a minute, edit your profile to add your equipment. that way it shows up at the bottom of each post as mine does below.

[Pugsy]

Everyone....just because I replied here doesn't mean that others won't need to reply.
I have been quite ill and I don't know just how much detailed help I can offer anyone.
Some days it's all I can do to ban the new account spammers. I just haven't mentally or physically been up to doing much in depth helping.
Today is an "okay" day....meaning I feel a little bit less like total shit today but I never know how long it will hold.
No energy to do much thinking or typing.

No more novels for a while.

[zonker]

No more novels for a while.

we'll have to look to robysue1 for those, eh?

(ducks/runs)

[Pugsy]

No more novels for a while.

we'll have to look to robysue1 for those, eh?

(ducks/runs)

Yep....I am SO thankful that robysue is here right now. Sure has saved my ass.
She's got a lot more patience than I have right now. I would have long ago told the trolls to go fornicate with themselves.
Anyhow she and I have long laughed about our "novels" and I gladly give her the credit where it is due.....she can do the novels and right now I just can't get the mind kicked into gear to do them myself.

I won't/can't do the novels right now and she is good....really good...and obviously has a lot more patience and energy than I do right now.

We have several very capable helpers here right now what with the usuals and the addition of ozij and robysue.....time for me to let the others shine which I fully intend to do.

[Jlfinkels]

No more novels for a while.

we'll have to look to robysue1 for those, eh?

(ducks/runs)

It had to be said. Always good info though.

[robysue1]

tamaton15,

First, a big welcome to the forum.

I want to second pugsy's question: What are the odds that you were awake when the bulk of those central apneas were flagged???

It's relevant for a couple of reasons: First, "events" that are flagged when we're awake are not real. Second, if you are awake for some substantial periods, that cuts into the quality of your sleep.

The next thing that leaps out of your data and catches my attention is your leak graph. It's true that your leaks mostly stay under the 24 L/min that Resmed uses to define a large leak, and it's even quite likely that Mr. Green Smiley Face showed up in the morning because in eyeballing the data it looks like your leaks were less than 24 L/min for 70% of the night. But the fact remains, there's a lot of leaking going on and there's also some spikiness in the flow graph. The combination says that there's a chance that the leaks are causing you to arouse/wake during the night.

Since you say you are using a AirFit P10 mask, the obvious question with respect to the leaks is: Are you a mouth breather? Or more simply, is your mouth possibly just dropping open even though you continue to breathe through your nose?

Next you write:

Usage of CPAP:
- Usually at least four hours a night. Most of the time I end up taking off the mask after a sleep cycle or two (1.5 - 3 hours). I do remember doing this most of the time, and I think what I tell myself is “I’ll put it back on after relaxing a little bit”, but then I fall asleep before remembering to put it back on. Probably a bad habit here that I need to shake.

Yes, that's a very bad habit that you need to shake. And it's a habit that likely explains why you are still not feeling very well: Even though "compliance" is defined as using the cpap for at least four hours a night, the fact is that genuinely effective therapy means sleeping with the machine all night long, every single night.

As for breaking that bad habit you've developed, I would suggest that when you want to relax a bit without the mask on, force yourself to get out of bed and go to a different room. Read for a while or even just sit quietly. When you start to get sleepy, go back to bed and mask up before going back to sleep.

But it's more than just having the cpap on the entire time you are lying in bed. You have to teach your body how to sleep and how to sleep well with a mask on your nose and the cpap running. That can be hard for some people, but with help you can do it. The thing that you have to do is tackle each of the problems you run into one at a time.

You also write:

- Sometimes when I take a nasal spray antihistamine, I’m able to sleep for longer hours with the mask on

A couple of comments/questions.

First, do you have any ideas on why it seems to be easier to sleep longer hours with the mask on when you use a nasal spray antihistamine?

If you don't use the nasal spray, do you wake up with a badly stuffed nose? And the stuffy nose is what makes it easy for you to say to yourself that it's okay to take the mask off for a bit and that you'll put it back on before you fall back to sleep? If so, then you may need to adjust the humidity level and/or the temperature of your heated hose.

Other medical conditions - have bad dust mite allergy, that I have received allergy shots for. While the condition has improved, it doesn’t seem to be at the point where I can abstain from antihistamines altogether. I also take a nasal steroid spray and nasal spray antihistamine daily. The nasal spray antihistamine makes me drowsy.

Make sure you have a hypoallergenic filter in the machine instead of the standard filter. The hypoallergenic filter will filter out the dust and other allergens from the air being blown into the hose. In the long run, that may help your allergies. But you will need to work out an appropriate humidity/heat combination to keep your particular nose happy. Some noses like a lot of humidity. Other noses don't. You say your humidifier is set to 5, which is kind of in the middle of the humidifier range. And that means you will need to experiment with both increasing the humidity and decreasing the humidity.

[tamaton15]

Thanks all for your time! (Edit: was drafting this while robysue1 was writing their post - will respond to their comments)

What are the odds that you were awake when the bulk of those central apneas were flagged???

About the only thing you can do with your machine to maybe (stress the maybe part) reduce the number of centrals is turn off EPR and that will only help if the centrals are caused by using EPR ....which to be honest I doubt is the cause.
I actually suspect a sizable chunk of those centrals are awake/arousal breathing false positive flagging.
The zoomed in example you gave was zoomed in too much and didn't show the flow rate prior to the flagging well enough to determine sleep status....but I suspect arousal related from the little bit I see.

It hurts nothing to try turning off EPR though and see if it makes any difference.

Several breaks in therapy are seen...means you were awake....so how come the wake ups?

The first stretch I was sleeping for sure. I don't remember for sure on the second and third stretches whether I was awake then or not. Here's a zoomed in part of the first section.



- Sure thing, will experiment with turning EPR off (or maybe keeping it during ramp only to make it more comfortable as I fall asleep, I believe that might be an option)
- Really not sure, to be honest. I sleep with earplugs, but I am also downtown, so occasionally there might be some loud motors. I also will wake up to go to the restroom at least once per night. Lastly, I have a roommate who will sometimes wake me up if they get up in the middle of the night to use the restroom. I think I'm a light sleeper.

-----

Since you say you are using a AirFit P10 mask, the obvious question with respect to the leaks is: Are you a mouth breather? Or more simply, is your mouth possibly just dropping open even though you continue to breathe through your nose?

- Yes, I believe that my mouth is dropping open. Some nights I had much better leak rates though, so I wanted to see if I could avoid taping my mouth or using a chin strap if I could just train my body correctly.

First, do you have any ideas on why it seems to be easier to sleep longer hours with the mask on when you use a nasal spray antihistamine?

If you don't use the nasal spray, do you wake up with a badly stuffed nose? And the stuffy nose is what makes it easy for you to say to yourself that it's okay to take the mask off for a bit and that you'll put it back on before you fall back to sleep? If so, then you may need to adjust the humidity level and/or the temperature of your heated hose.

- My theory is that the nasal spray antihistamine makes me quite drowsy, and also has a better chance of keeping my nose open. Honestly, I think a big part of the "ok to take my mask off" is that I like feeling of my face on the pillow, heh.

Make sure you have a hypoallergenic filter in the machine instead of the standard filter. The hypoallergenic filter will filter out the dust and other allergens from the air being blown into the hose. In the long run, that may help your allergies. But you will need to work out an appropriate humidity/heat combination to keep your particular nose happy. Some noses like a lot of humidity. Other noses don't. You say your humidifier is set to 5, which is kind of in the middle of the humidifier range. And that means you will need to experiment with both increasing the humidity and decreasing the humidity.

- I didn't know that the hypoallergenic filter actually differs from the standard filter. From what I read on the product description, it sounded like the hypoallergenic filter on the Autoset 11 was just for those with polyester allergy. Will order one (right now I'm on a trip so hard for me to get supplies).
- Will give adjusting the temperature / humidity a shot.

In terms of changing settings (temperature, humidity, and EPR were all given as examples), do you have any recommendations on how many of these factors to tweak at one time?

[Jlfinkels]

Been lurking around for a bit beforehand, I'm grateful for all of the helpful advice that I've read on the forum so far. Wanted to get some opinions on how my therapy is currently going, as I've been experiencing a high proportion of clear airway events.
[snip]

I cannot offer advice on your therapy, but can give some as someone who has been using CPAP for about 2.5 years. CPAP is a journey, not a destination. What works tonight may not work tomorrow night. It takes time to adjust to a new way of sleeping, so making too many tweaks works counter to the adjustment period.

Also, don’t chase numbers, chase quality sleep. They are neither mutually exclusive nor mutually congruent, as you can easily have one without the other. CPAP is just one tool to help you get there, but there are many others. Other important things to consider are maintaining good sleep hygiene (room temp, proper lighting, warm or cool to your preference, sounds, etc), not consuming caffeine or alcohol (even chocolate for some) after whatever time your body is still impacted by it at bed time, and learning to relax leading up to bedtime.

Good luck and listen to the smart kids!

[Pugsy]

First rule of experimenting or changing stuff.....keep your variables to a minimum.
Try to make one change only at a time if possible .... if you go making multiple changes at once and something good or bad happens you won't know which change is responsible.

The centrals you zoomed in on look more like post arousal irregularities in breathing getting flagged with maybe the exception of the second one. My eyeballs can't see the time well enough to tell you the time of that flagged event.

The big gulp of air prior to the first flagged event....we don't take big gulps of air like that when we are asleep.
Asleep breathing is very regular and even and rhythmic. You may or may not have been awake or half awake when it was flagged.
It is possible that the first central was nothing more than a turn over in bed and hold your breath while turning.

See these 2 flagged events? No irregular breathing....I was asleep when these got flagged.


And yes....if you need EPR for comfort so you can fall asleep you can sure change it to ramp only and make use of the ramp feature for your EPR experiment.

I doubt EPR is the trigger for your centrals because usually when we see centrals caused by EPR the people have a LOT more centrals than you are having but it hurts nothing to at least do a night without EPR to rule out that as a factor in the centrals.
I think that most likely the centrals are a symptom of poor sleep quality or fragmented sleep.

[robysue1]

In terms of changing settings (temperature, humidity, and EPR were all given as examples), do you have any recommendations on how many of these factors to tweak at one time?

Personally I recommend changing one thing at a time. When you change multiple things at a time and things don't go well, it's hard to tease out the reason why things don't go well. It's also possible for one change (say increasing EPR) might make things better but a second change done at the same time (say increasing the humidity setting) might make things worse. And that most likely leaves you not feeling any better, but also not feeling in any better in a different sort of way.

[tamaton15]

Thanks all. I'll try a modest increase in humidity, changing the setting from 5 to 6. My nose was feeling a bit dry today, so this feels like the right incremental step for comfort instead of adjusting EPR.

I am traveling currently, the last two nights were in a much colder bedroom than I normally sleep in, so I will sleep in another room that is warmer.

The big gulp of air prior to the first flagged event....we don't take big gulps of air like that when we are asleep.
Asleep breathing is very regular and even and rhythmic. You may or may not have been awake or half awake when it was flagged.
It is possible that the first central was nothing more than a turn over in bed and hold your breath while turning.

See these 2 flagged events? No irregular breathing....I was asleep when these got flagged.

So just to confirm, the heuristic is that if the breathing (from the flow rate) is regular, even, and rhythmic beforehand, and there is also no gulp of air (larger change in graph), then it's likely that the flagged OA or CA happening when awake?

[Pugsy]

So just to confirm, the heuristic is that if the breathing (from the flow rate) is regular, even, and rhythmic beforehand, and there is also no gulp of air (larger change in graph), then it's likely that the flagged OA or CA happening when awake?

No....if there is no irregularity prior to the flagging then the event was likely flagged when asleep....my examples above I was asleep.

Now here is an example of asleep breathing and a bunch of awake/arousal breathing after it.
I circled the asleep breathing in red and the rest of it is arousal/awake breathing and any flags that happened when awake simply aren't real asleep events and other than pointing to not being asleep they are meaningless.

[jlsmithseven]

I think my main concern here would be those amount of leaks. Is there a reason for them? I had the P10 once, and I felt it never got a good seal and would slide way too much.