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[CPAP] ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
#1
‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Hi, as per the title -- I’ve come to realize I need a CPAP (together with my pulmonologist & ENT doctor of course), so I need advice from you pro’s before purchasing my machine.

Questions:
  1. What machine do you recommend based on the data below?
  2. What settings do you recommend? (Note: My first polysomnography shows majority of my events 82% to be precise are of type “Hyp”, don’t know what it means though)

Context & background:


References:
Consolidated in a PDF I can't upload to this post nor link to due to forum rules, given my extensive post, I hope I've proven I'm not a spammer and I'll take the liberty to post it in plain text -- ge.tt/5UCb2s83  [size=x-large][font=apple color emoji]?
  • 2018 (before surgery) Polysomnography* (hospital sleep test):
    AHI: 17  //  avg Saturation: 94%
  • CPAP 1w trial DreamStation Auto CPAP
    See comments below “CPAP (tried for a week)”

  • 2020 (after surgery) Polygraphy** (home sleep test):
    AHI: 15.4  //  RDI: 21.3  //  ODI: 5.1

    Note1: These records are in polish as I live in Poland currently. If some sections are not obvious to interpret, please let me know and I’ll translate the sections that are needed. I’ll realize this is suboptimal as this is a US forum, but to be honest I don’t even know how to translate some of these as I’m not familiar with the terminology.
    Note2: I also have “loads” of medical records such as head scans etc. but prefer to share these on a per-need-basis over PM, nonetheless please flag if it’ll help facilitate the recommendations/discussion.

What I’ve tried so far (to reduce my AHI):
Listed in order
  • Doctor prescribed medication. Antibiotics, steroid sprays, rinsing sinuses, allergy medicine etc.
    Result: Not feeling rested after sleep. (not validated with sleep test, only subjective opinion)
  • CPAP (tried for a week). Used for a week with 5 different masks (started from “nose-pads” to each night increase size ending with a full facial mask at the end of the week), I could not get along with the machine and the fact of wearing a mask at night. I move around alot in my sleep and the mask and hose was “in the way” and disrupted my sleep, and the feeling (and sound) that something was blowing in air into my lungs was uncomfortable and woke me up. I gave up on it and returned the machine as each night I would just pull of the mask and felt it was a relief to be “off the CPAP”. Thinking out loud: Maybe another type of machine would’ve been better for my type of apnea events?
    Result: See above “references”. Reduction in AHI was observed however my subjective opinion was that I did not feel rested after a night’s sleep.

  • Surgery. Drug induced sleep endoscopy (DISE) to determine possible obstructions and then surgery -- straighten deviated septum, cut out non-obstructive-polyp in one maxillary sinus, reduced turbinates, tonsils cut in half, throat soft palate reduction and “stiffening” and reduced uvula-size.
    Result: No reduction in AHI post surgery (confirmed with home sleep test).

  • Professional oral appliance***. I got an MAD. I used two settings on pulling out the jaw and did two sleep tests using these settings for comparison.  
    Result:
    Min. jaw pull-forward position: AHI: 24.4  //  RDI: 34.8  //  ODI: 4.1
    Max. jaw pull-forward position: AHI: 14.2  //  RDI: 21.7  //  ODI: 3.9

    No noticeable reduction in AHI, actually it got worse in the min. position. Sleep test showed snoring went down to neglectable amounts (1h per night previously). It’s worth mentioning that I have overlapping teeth so just wearing the appliance at night just adds pain in teeth and jaw -- it’s not at an acceptable level of "comfortness" at all, so now I’m in discussion of straightening my teeth to redo the oral appliance, but that’ll take a while and given the data it looks like the oral appliance isn’t going to be a viable option to treat the sleep apnea.

Misc things I’ve tried… Tried at various points in the last 3y based on advice found on various forums and websites.
General result for below: Not feeling rested after sleep (not validated with sleep test).
  • Home appliances/remedies. Taping mouth, nostril expanders, essential oils, humidifier, tongue retainer device, chinstrap etc.
  • Diets. Elimination diets, not eating 4h before bed, fasting, low carb diets, vegan/vegetarian diets, no diary diets etc.
    Note: Generally we cook our meals from “scratch” using whole-foods (little processed foods and basically no take-out), and we eat a good amount of vegetables and fruits in all different colors, we drink primarily water, meaning we don’t drink sodas, alcohol, coffee, tea, juices etc.

  • Relaxing. To eliminate “stress” that has been pointed out as a “cause” by doctors and non-doctors, I decided to do two things. I went for a 10d vipassana meditation retreat & I also took 3months of work.

  • Climate/environment change. I’ve been in different climates (US & Europe) for several weeks to eliminate “air pollution” & “air humidity” as a “cause”.

  • Exercising. ....working on it ;-). Currently some weight exercises and some cardio, will start swimming when corona-times gets more sane. I feel better mentally tough.

    Note: I also have an Pulse Oximeter compatible with OSCAR for “simple validation” of remedies at home.


About me & my condition:
  • Sex: Male
  • Weight: 90kg (198lbs)
  • Height: 186cm (6.1 feet)
  • [size=medium]Age: [size=medium]35-40
    Note: I’ve never been obese in my life, in the last 10y I’ve been just [size=x-small]slightly overweight (BMI ~26/27), before that I was below 25 BMI all my young life and active in sports up to age of 20.  

  • Condition history:
    Life reflection:
    I suspect I’ve had some form of sleep apnea all my life as I was always the one to fall asleep when going to the; movies, theater, watching a movie in a dark room, going for a party etc. -- back then we just joked about it (kids you know). Another indication I’ve post-reflected upon is that I've always had “dark circles” under my eyes and always been the “tired”-one among my friends.

    2017 sinus infection:
    3years ago I ended up with a severe sinus infection that resulted in filled sinuses and one ear with fluid. It took about 6months for my ear to get back to “normal”, however reg. the sinuses I was left with a chronic condition with the following symptoms that won’t go away; Post Nasal Drip, feeling congested, sinus pain, face pain, sensitive sinus & nose mucosa.
    After that infection I’ve not woken up rested in the last 3years and I suspect my sleep apnea increased drastically (my gut feeling tells me I went from mild sleep apnea to moderate sleep apnea). I often wake-up with  (or feel during the day) typical sleep apnea symptoms such as; headache, dizziness, lack of ability to concentrate/staying focused during the day, raising heart, decreased libido, brain fog, feel tired all the time, apathy etc. These are symptoms I did not observe before the infection apart from tiredness.
    On top of this, if I have a really bad night's sleep (let's say I additionally have a stuffy nose that is worsening the sleep quality) I can “feel” that my immune system is temporarily degraded and I get various canker sores in my mouth and feel “sick” & drowsy in general.

    I was first diagnosed with moderate obstructive sleep apnea (OSA AHI 17) when doing the above mentioned polysomnography in 2018.

    Note: For the moment I’m close to accepting this as a chronic condition that I’ll have to live with, however I’m now on a quest to improve my quality of life (focus what you are in control over) by treating my sleep apnea so I can sleep better.
    However if you still want to discuss the “sinus condition”, you are welcome to PM me -- I’ve done plenty of things over the past years; steroids, sprays, surgery, tests etc. and I also have plenty of medical records (good data) as a result of that. Of course I would like to be healthy (like anyone else), so If someone has insights/advice (from someone that has gone through something similar or is still going through the same) -- I’m happy to discuss the condition over PM and can share more detailed information there and then.
* SleepDoc Porti
** WatchPat 300
*** TAP-T

Many thanks for your time, I do appreciate it!
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#2
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Hello, Sleepki. I'm sorry to hear about the multiple problems you've been facing. Could you scan and post your most recent sleep study with your personal information blanked out? That would be enormously helpful to everyone who would like to offer you advice about the type of machine that would work best for you and the initial settings that would make sense to try.

If that's not possible, it would be especially helpful to know the breakdown of your AHI into these three kinds of events: obstructive apneas, central apneas, and hypopneas. (Hypopneas are events of 10 seconds or longer involving a reduction of airflow of at least 30% along with a drop in O2 saturation levels. They can be obstructive or central in nature.)
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#3
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Thanks for the reply Dormeo! 

ge.tt/5UCb2s83 is the link to the pdf, but I'll post them as plain images as soon as I hit 4posts on this forum (can't post images before I have 4 posts) 2 more to go... Smile 
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#4
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
You should be able to attach the pdf here without any more posts
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#5
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Still not possible. Sad

Trying again (sorry for the spam -- using this post as a workaround)
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#6
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Thanks, Sleepki. I was able to view the documents using the link. (Great job labeling everything, by the way.)

Your overall AHI in the most recent study was 15.4, including a CA index of .7. There isn't a separate breakout of hypopneas vs. obstructive apneas. Your RDI was 21.3, so you averaged 5.9 RERAs (respiratory-effort-related arousals) per hour. Your percentages of REM and deep sleep were very good, which means that this was a possibly more representative night than people tend to see with even home tests.

Your CA index was negligible, so you don't need a special machine like an ASV. Given the earlier study in which hypopneas predominated, plus the evidence of flow limitations in the CPAP titration, plus the RERAs in the most recent study, I think you would benefit from a machine that can offer bilevel treatment.

Bilevel treatment provides a higher pressure on inhalation and a lower pressure during exhalation. The pressure boost on inhalation can be quite helpful in resolving FLs, hypopneas, and RERAs.

There are two machines I would suggest you consider. One is the ResMed Airsense 10 Autoset, which can offer a pressure difference of 1, 2, or 3 cm H2O. The big market competitor for this machine is the Phillips Respironics Dreamstation, which you tried earlier. The PR machine provides something called Flex, but this is not true bilevel therapy. In addition, many people find that the algorithm for Flex leaves them with the feeling they are being rushed to inhale before they are ready.

The other machine I think you might consider is the ResMed Aircurve VAuto. This offers a larger range of pressure differences than the Autoset, plus some other settings adjustments that you might not need but are there if you want them. PR also make a bilevel machine, but I believe most people here believe the ResMed bilevel is superior.

I don't know how insurance works in Poland, or how open your doctors would be to prescribing a VAuto, but that's what I'd ask for in your place. It does everything the Airsense machine does, plus lots more. But it is about twice as expensive.
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#7
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Awesome, thanks for the reply! I'll call next week to see availability of that "vAuto" machine. Because w/ the dreamstation I had exactly that feeling you mentioned -- it was like suffocating by excessive air coming in. 

Insurance should not be a problem, in PL you get some reduction in price (I think it's 50%), so that'll be less than 1000USD for that machine paid out of pocket, that's a lot of money, but it's peanuts compared to how much I've plowed into my health issues. 

If no more posts I'll sign-up for a trial and post back how it goes. 

Thank you!
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#8
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
Update: I had another sinus surgery in November (opening up the paths to maxillary sinuses and rinsing all sinuses with an hydrodebrider and some antibiotics rinsing on that), didn’t help. After that I realized I have to continue on the CPAP-path. So, I have now also had 18d+ test-run with a ‘ResMed AirCurve 10 VAuto’ at home and daily pulmonologist check-ups along with remote adjustments to the settings on the machine. I’m now ready for the next step, and need some advice on choosing the right machine based on the data. 


Questions:
  1. Machine choice. The clinic recommends AirSense 10 Elite with heated hose and humidifier. Should I go with that machine or do you recommend based on the data below that I should take the more expensive one “VAuto”? 
    Note: For me the difference will be either paying 100USD for the Elite (government subsidized price) or +900USD for the VAuto. Money is not a blocker, but at the same time if I’ll pay for something I’ll never use, then I of course rather not Smile ...on the other hand if I need the more “advanced machine”, then I don’t want to be stuck in a position where I’ve got my hands tied because I lack these "Advanced options". Smile 
  2. Taping mouth. I experienced some leaks during the nights (I guess coming mostly from my mouth). I asked if it’s ok to tape my mouth, but got informed with -- “that’s not something people do, and you could suffocate”. I have used mouth tape with my MAD, and was happy with it. Any experience to share on this? 

Next steps:
Based on responses from experts on this forum I will purchase the right machine and start using it and use OSCAR to upload and analyze my data. 

Note: In the meantime I’ve ordered an INAP (that’s an WINX replacement that creates a vacuum in the mouth to pull the soft palate and tongue base forward -- waiting for it to clear customs), I just got sick and tired of everything after surgery and tilted while looking for options to feel better, so I will try that machine as well, however I have no way of validating the AHI with that machine unless I take another sleep test at home Sad
I also ordered an iqoro (yes I tilted badly Too-funny  ), and decided to start training with that device too (doctors are still trying to rule out GERD and those kinds of things). 


------------------------------------------------------------------------------------------------
Summary of 18d+ ResMed AirCurve 10 VAuto test-run:
  • It was a pain the first nights, but after; the pulmonologist adjusted the pressure, temperature, humidity, changing masks, putting the hose around my pillow -- I kinda felt that at the end of this test-run that “this CPAP-thing is something I can live with if it’ll save my life”. 
  • I still feel like crap even after having good AHI’s with the machine (close to AHI=1), I don’t know if it’s;
    a) a thing of “getting used to the CPAP” and it’ll take a month or so to experience anything,
    b) my REM sleep is interrupted due to hose and mask,
    c) my chronic sinus issues are causing these issues,
    d) I have some other condition (UARS?) that still makes me experience sleep apnea symptoms during the day or
    e) a combination of the aforementioned.

  • I often woke up (or in the middle of the night) with a dry mouth. I would never experience that without the CPAP.
Masks tested:
  • AirFit N20 “Medium”. OK. I get some dryness around the nose, but it’s just “OK” and no zits. 
  • AirFit P10: No-go. Sealed nicely but was too tight on my head and created pain between the nostrils and the upper lip. Got plenty of zits when used for more than 1night. 
  • AirFit N20 “Small”. No-go. Too tight. 
  • Airfit N30. No-go. Created sores on my face. Too tight in general and similar problems to the P10 with zits showing up.

    Reflection on mask choice: 

  • I’ll get an AirFit N20 “Medium” (alternatively AirTouch N20 “Medium” with foam to reduce skin irritation)
  • I’ll get a full face mask (backup) for days when I have a stuffy nose.

    Later down the road I can consider importing a “bleep-mask” to further check if I can reduce leaks. 


Oscar data:
Note: I started w/ different mask experimentation and the last ~10d I was using the N20 medium only. I sampled two detailed ones that I believe are representative, but can extract more if needed. We had some auto pressure in the beginning but despite good AHI numbers it didn’t feel good at all, so the pulmonologist shifted to fixed pressure and reduced it, which felt much better. 

Summary:
   
   
   
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#9
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
PS! Let me know if more charts are needed. 

26th of December, detailed view:

   
   
   

28th of December, detailed view:

   
   
   
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#10
RE: ‘Sleepki’ starting! Need “first-time advice” on machine type & settings (2020-Nov)
The Elite is a static pressure treatment model with full data reporting. The "static", means that you will only be able to set the inhale pressure to a single pressure setting. The next step up is the AirSense 10 Autoset (or the "For Her" model), which allows for a variable pressure treatment range.

The AirCurve VAuto that you mention, is a big step up. It allows for a variable pressure range (like the Autoset), but also allows for a wide range of exhale pressure differences from the inhale pressure. The Elite and Autoset only allow up to a 3 cm pressure difference (in 1 cm steps only) between the inhale/exhale pressures. The VAuto allows steps in .2 cm increments and can go as high as 8 cm in pressure difference. Note: Most users only use a maximum of 5 cm difference in real life.

Do you have any sleep data that you can provide to see if that may help in determining a recommendation?
Edit: You added additional charts since I posted this.

Good luck!
Crimson Nape
Apnea Board Moderator
www.ApneaBoard.com
___________________________________
Useful Links -or- When All Else Fails:
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Attaching Images and Files on Apnea Board
Beginner's Guide to Sleepyhead and OSCAR
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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