fatigue with cpap for many years

Hello everyone,

I’ve been using a Resmed Airvurve 10 in ASV mode for about two years. Before I tried Resmed AirSense 10 without succes for two years.

Background

Diagnosed with moderate sleep apnea (baseline AHI around 24 events/hour).
Persistent daytime fatigue for many years despite excellent PAP adherence.
A sleep study under CPAP showed severe sleep fragmentation (about 27 micro-arousals per hour) and reduced deep sleep.
I also have an anxiety/mood disorder and receive treatment for it.

I am often (not everytime) quite sleepy and fatigued in the middle of the morning (around 10:30–11:00 AM), while I usually feel better and more alert in the evening.

My main objective is to:
maximize deep sleep (tracked with Autosleep for Apple Watch),
reduce awakenings and micro-arousals,
improve daytime alertness.

Current ASV settings (the best I tried until now):
EPAP: 9.6 cmH₂O
PS min: 4.2 cmH₂O
PS max: 12.0 cmH₂O
Results from last night
AHI: 1.48/hour
Leaks: almost zero
Deep sleep (AutoSleep): 2h29
Awake/Disturbed: 12 minutes
Total sleep time: 8h28

This was objectively a good night, no wakeup, yet I still felt sleepy around 10:30 AM.

I have attached my OSCAR screenshot from this night for reference.

Questions
Do these settings look close to optimal for reducing sleep fragmentation?
Would lowering PS max slightly (for example to 10 or 11 cmH₂O) potentially improve sleep continuity? I tried but without succes, maybe I had to persevere.
Do you think my persistent mid-morning sleepiness could still be related to sleep fragmentation even when the nightly data look very good?

Any feedback from experienced ASV users would be greatly appreciated.

I see you have user defined events set up, and 2 gets triggered regularly. What are your settings for these? I set these to catch events that are just shy of what would be reported by the machine to catch events that could be causing arousal's but aren't reported. I use 70% 10 Seconds for user 1. I know this should be the same as hypopnea but it catches quite a few events that my Aircurve 10 ASV doesn't report. I set #2 for 20% 8 seconds. It often catches events where I'm not breathing at all but the time is a little short so the machine doesn't flag them. Adding these to the machine reported AHI is more meaningful for me.

On your OSCAR there is a preset view for ASV machines. It will move the mask pressure up in place of the pressure graph. Its more meaningful since it shows more pressure detail. I have complex apnea. The ASV doesn't really tell you if an event is central or obstructive (it reports almost all apenas as unclassified) but if you look at it closely it's usually clear. If you see the machine pulsing the pressure but there is no corresponding flow its obstructive in nature. Getting the EPAP optimized helps me to reduce those events.

Have you tried ASV Auto rather than ASV? You might try using ASV Auto with lower maximum PS, especially if many of your events look to be obstructive. You might try an EPAP range of 9 to 11 for example, with reduced maximum pressure support. Allowing a higher EPAP will help control obstructive events and reduce the need for higher support which may be causing arousals. ASV auto makes the machine behave like an auto CPAP for base pressure, you may need less PS if you can allow for some range on the EPAP. ASV machines can be overly aggressive in my experience. High support pressure wakes me up, I try to minimize it. Some events aren't corrected even with very high pressure support and the support then ends up causing an arousal that the event might not have.

Thanks again for your suggestions.

I tried increasing EPAP to 11 with PS min 3 and PS max 10, and so far it actually seems quite successful. I’m attaching an OSCAR screenshot from last night — AHI was low, leaks almost zero, and I feel somewhat better today.

I also configured User Flag 1 and User Flag 2 in OSCAR like you suggested. Seeing all the UF1 markers is honestly a little worrying, because it makes me wonder how much subtle sleep fragmentation may still be happening even with “good” numbers.

For now I’ll probably keep these settings stable for a few days.

What do you think about the OSCAR graph from this night, especially with the UF1 flags enabled?

Your idea about trying ASV auto mode is interesting too. If the fatigue comes back again in the next few days, I’ll definitely give ASV auto a try.

It would be interesting to see a zoomed in view around 22:50. Also, move up the mask pressure graph so that its next to the flow rate graph. You can click and drag it, or you can double click both to pin them.

Using ASV Auto would allow the EPAP to be lower most of the time which could reduce the maximum pressure when support is high. The mask pressure graph will show more detail on what is happening.

mlmollenkamp wrote: ↑

Fri May 15, 2026 5:16 pm

It would be interesting to see a zoomed in view around 22:50. Also, move up the mask pressure graph so that its next to the flow rate graph. You can click and drag it, or you can double click both to pin them.

Using ASV Auto would allow the EPAP to be lower most of the time which could reduce the maximum pressure when support is high. The mask pressure graph will show more detail on what is happening.

Here is the zoom of yesterday around 22:50

Your situation is obviously different than mine, that's the trouble with only having experience with one person....

I've attached a sample of what I get with user 1, which here is set for 60% for 10 Seconds, so less sensitive than what I had said.

What you can see is I get a UF 1 flag, followed by a couple of pulse changes. Prior to that I was steady breathing (the pink area). I think its pretty obviously an arousal. This is what I look for.

You may need to experiment a little to find a similar setting that calls out this sort of thing. I think I had said 70% 10S, but mine is actually 60% 10 S. I think you may also want to turn on the steady breathing option.

Note also that I use a pulse/oxy ring that integrates with OSCAR. Again its helpful to have the info on the same timeline, the pulse changes that immediately follow the user event probably indicate arousal. The second chart shows a whole night. The pink areas are steady breathing. At the end I slept for a while without the machine but with the ring.

Finding the arousals is of course only half the battle, eliminating them is the goal but not always easy. I have to allow for some events otherwise the machine is aggressive enough that it causes arousals, its a trade off. The settings I got from my titrations (many years ago) eliminated all of my obstructive apneas, but triggered a lot of central apneas and woke me up constantly. Now I usually try to tune for comfort then tweak if it's not effective enough at eliminating events. When I first got the ASV (switching from an auto CPAP) I did the initial settings napping in the afternoon. It helped to not be under pressure to sleep, I just tweaked for comfort. I got pretty close that way.

I hope some of this is useful.

Last night:

* ASV
* EPAP fixed 10
* PS 4–11.6

Results:

* AHI 0.66
* OA 0
* very low leaks
* UF1 (your custom flow limitation flag) only 0.77/h

The first part of the night was difficult because of a heavy restaurant meal (pizza + dessert).
This morning I had some aerophagia, although it may also be related to the meal itself.

What interests me is that breathing looked more stable overall, with fewer flow limitations.

Do you think fixed EPAP 10 could be helping reduce subtle flow limitation / RERA-type sleep fragmentation in my case?

OSCAR screenshot attached.