Using CPAP for Over a Year and Still Experiencing Symptoms; Please Help!

[hyphicti]

Hello,

I am a 29 year old man. I have been using my ResMed AirSense 10 AutoSet CPAP since July 2021. My sleep doctor has said my CPAP data looks great and that my sleep apnea is under control. However, I still feel extremely groggy in the morning and continue to experience symptoms of sleep apnea. I haven't had a transformative experience with CPAP therapy, unfortunately. It feels that little has changed. I asked for an in lab sleep study to check for any remaining issues, but my insurance denied it. I figured I'd ask here to see if there's anything illuminating in my CPAP data. I have included three days of OSCAR data below. Please let me know if you'd like any additional data.

Data

   
   
   

History

I was first diagnosed with severe sleep apnea at 18 with an AHI over 99. I believe I had sleep apnea far before being diagnosed. It took a while to get diagnosed because I was a thin teenager, despite having many classic symptoms.

I tried CPAP therapy in 2013 and failed it.

I had a tonsillectomy and adenoidectomy in January of 2014, because my tonsils were extremely large and obstructing my breathing at night. I was diagnosed with a deviated septum too, but I have not had that surgically corrected.

I was off CPAP therapy after the surgery. A follow up sleep study showed resolution of the apnea. However, my symptoms persisted.

I worked with a sleep doctor on the sleep issues after the surgery. I tried modafinil, which was of no help. Eventually, my doctor told me he couldn't help me anymore, so I gave up.

A few years ago, I tried again. I had an at-home sleep study that showed moderate sleep apnea. My AHI was 8, but my doctor observed that the apneas were clustered together. During the clusters, the AHI was more like 16. They were mainly hypopneas. There were a few central apneas. Please let me know if I should attach that report or any previous in-lab sleep studies I have had.

I have been on CPAP therapy since that time.

Family History

My mother has chronic, severe insomnia. I wonder if it's a circadian disorder, but she refuses to be evaluated for sleep apnea or other disorders. My father and brother appear to have regular sleep.

Symptoms

My primary symptoms include:

• sleep inertia upon waking that lasts for hours unless I take a stimulant (Concerta) or caffeine, which result in marginal improvement
  
• fatigue
  
• difficulty concentrating
  
• headaches
  
• lack of energy
  
• depression
  
• anxiety
  

Experiences with CPAP Therapy

It took a while to adjust, but I now use the CPAP every night. I have a AirSense 10 AutoSet. I use the Philips Nuance Pro Nasal Pillow CPAP mask.

Sometimes, I have trouble breathing with it when falling asleep. Occasionally, my nose will become clogged during the night, which makes it really hard to breath.

I do not believe I breath through my mouth. Sometimes my mouth feels dry, but I haven't noticed it with much regularity. I assume my leak rate would be higher if I was constantly mouth breathing.

Other Treatment History

I was on modafinil for a few years - maybe 2014 - 2017 or so. I don't recall it helping very much.

I was on Trazodone 25mg - 50mg for years. I recently did CBTi therapy, which improved my sleep schedule and helped me come off Trazodone.

Now I only take Concerta 18mg daily as an off-label treatment for depression, fatigue, and cognitive issues. I have been taking it for around 6 months. It helps a little with the fatigue, but I also believe it causes headaches. I'm not particularly impressed.

Conclusion

I know many of my symptoms overlap with depression and anxiety, but I just have this feeling that something about my sleep is still not right. I'm hoping that someone with experience looking at OSCAR data can tell me if there's anything noteworthy in the data and whether it's worth the effort of pushing my doctor to appeal the insurance decision for a sleep study.

Thank you so much!

[staceyburke]

Your AHI is good but your flow limits are very high. Flow limits are apnea just like OA s as nd H events but they are smaller and are NOT counted in your AHI.

YOUR min is set to low at 5. The absolute lowest any pap machine can go is 4. EPR is used to help flow limits and yours is set to 3 full time which is the highest it can go.

But EPR is exhale pressure relief which means it lowers the min on exhale. However, you can’t go below 4, the absolute lowest of your machine. (Min 5 minus Epr 3 is still 4).

Change your min to 7 that will allow you to subtract the EPR 3 to make the exhale pressure 4. That will help lower your flow limits.

[hyphicti]

Thank you for your reply!

I set my minimum pressure to 7 last night. I feel pretty rough this morning - as if I slept four hours or something. Is it normal to feel worse at first? I woke up a few more times than is normal.

What should I be looking out for to be sure I'm improving the flow limits? I read the "Optimizing therapy" Wiki page under the "Flow Limitation Statistics Interpretation" section, and it seems like the majority of my 95% flow limit numbers are in the "marginal" to "good" range, so I'm a little confused. What in my data clued you in to high flow limits?

[staceyburke]

The chart marked flow limits shows all your flow limits. Your chart had it filled the entire night. They are not large individual events but they are continual all night. Smaller and the lest possible is of course best. 

Again they are not included in the AHI but some people are bothered by them and stop people from getting deep sleep or even wakes them up.  You said you were waking up at night so I suggested the flow limits could be the problem because your AHI is good.

[hyphicti]

Thank you.

I took your advice and increased the pressure to 7.

I also change my ramp time from auto to 25 minutes, but it seems like that made me spend more time in ramp-up, because auto was doing a better job detecting when I fell asleep. I will go back to auto.

I attached some screenshots of last night, including a zoomed in shot.. Does this look better to you? I still see many spikes. I feel a little better, but not definitively enough to claim success.

Please let me know what you think!

   
   

[staceyburke]

You do not need any ramp, with EPR at 3 the iechale is as low as you can go. I would try a min 8 and see how CV that feels.