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[CPAP] When to consider switch from CPAP to Oral Appliance
#1
When to consider switch from CPAP to Oral Appliance
Yes, I know that CPAP is considered the "gold standard" and oral appliance "only if patient doesn't tolerate CPAP well."  In a nutshell, I'm trying to figure out if I'm in the latter category.

History.  I'd been a loud snorer, but very sound sleeper for years, disturbing only my wife.  Following a sudden and otherwise unexplained jump in my blood pressure a year ago, my MD started sleuthing for possible causes and the snoring was a red flag.  Screening, followed by lab test confirmed AHI of 34.  I should mention that I wear a mouth guard to protect against teeth grinding; have done so for 5+ years, and that does not disrupt my sleep pattern.

Treatment and Tribulation.  I was prescribed Philips Dream Machine with heated tube/humidifier, variable pressure set 4-16.  I began with F&P Simplus mask under the assumption (I really wasn't sure) that I was a mouth breather.  I am a side sleeper, and the Simplus mask got dislodged quite a bit.  After considerable struggle and experimentation, I switched to nasal types and found that I did not have mouth leakage (Yay! I thought....).  But the various masks I tried continued to dislodge during my sleep.  And so while my AHI was reliably in the 4-6 range, I was still NOT getting what I considered a decent night's sleep; had great difficulty falling asleep (never a problem in my prior 60 years), and found myself needing to stay in bed 8-9 hours, where I previously (to CPAP) had been fine with 7-8 hours.

I have switched to ResMed P10 mask and .... AHI drops to 3-4.5, mask stays solid on my face, rarely dislodges, leakage stats great,and the mask is quieter than any of the others I had tried.  Everything's perfect .... except I still have great difficulty falling asleep, wake up frequently during the night, and need to stay in bed longer to feel rested.

I should also mention I've been practicing good sleep hygiene - no late screen time, practice meditation & Taoist longevity breathing....and otherwise don't have a lot of stress in my life.

In short, I've tried just about everything I can think of, and still not getting a good night's sleep compared to what I "enjoyed" with an AHI of 34.


Questions.  I'm a newbie here, and delighted to find the wealth of practical advice.  Wish I had found this Forum months ago.   For now, I am wondering:
  1. Any advice of other things I can/should be trying with the CPAP?
  2. Have other folks confronted this "ready to try oral appliance?" question?  How do you know it's time?
Thanks
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#2
RE: When to consider switch from CPAP to Oral Appliance
Download the free Sleepyhead program http://www.apneaboard.com/forums/Thread-...stallation This is going to tell you a lot more about your problems and will let us more effectively help you. Contrary to your assertion you have tried just about everything, you just now arrived on Apnea Board where we can change your results dramatically. You are under the misconception that your auto-CPAP can treat your problems using a pressure range of 4-16. Particularly with the Philips, nothing could be further from the truth. I think your move to the Airfit P10 mask was a move in the right direction. Now get Sleepyhead and follow the links in my signature on organizing the charts and posting as an attachment, and we can solve the rest of the problem. Hopefully we can save you the pain and ineffectiveness of an oral appliance, and let you know the real reason your AHI is still so high and you feel unrested.
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#3
RE: When to consider switch from CPAP to Oral Appliance
Thank you Sleeprider.   I have attached screenshot showing last night's results, plus the overview statistics from start of therapy last June.  Note that I started with the P10 on Jan 10. 

                
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#4
RE: When to consider switch from CPAP to Oral Appliance
Based on you daily graph I think you should increase your minimum pressure to 7 and probably upto 8 lasted but start with a minimum value of 7 you can still use ramp if that helps you get to sleep. But a higher minimum will reduce the number of hypopnoea an obstructive apnoea
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#5
RE: When to consider switch from CPAP to Oral Appliance
Thanks, the graphs help a lot. Your events are biased to hypopnea and obstructive apnea. From the pressure summary we know that your median pressure is 7.8 and your 95% and maximum are 10 cm. For some reason, your machine is not using any of it's range above 10. Based on what we're seeing here, my first suggestion is to increase the minimum pressure to 8.0. I'm sure you won't have any problems tolerating that, and a higher minimum pressure will avoid the lag in increasing pressure to address events, and avoid the machine dropping back to ineffective levels. It is easily seen that most events occur below that pressure.

8.0 cm is a common therapy pressure, and I think it is a good minimum for you. Your machine may rise above 10 from time to time if you give it this head start, and your history shows you often reach 13 to 15 cm. Your history also shows that your AHI and flow limitation were improved with a minimum pressure of 6.0, before you reduced minimum pressure last August. That is not a coincidence. You should be aware that the Philips Auto CPAP is relatively slow to respond to flow limitation and pre-apnea events as compared to the Resmed Autoset. Many people have high hypopnea with Philips as a result of using a minimum pressure that is too low. This will mostly clear up once you optimize the minimum pressure.
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#6
RE: When to consider switch from CPAP to Oral Appliance
Thanks, Jaswilliams.  I will give it a try.

Just trying to learn here -- what are you seeing in the daily graph that makes you think the minimum is too low?
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#7
RE: When to consider switch from CPAP to Oral Appliance
Thanks Sleeprider.  Your post also answers my follow-up question to Jaswilliam.

... I really wish I had found this Forum earlier.  You have explained things so much more clearly in a few short posts than I have gotten out of multiple sessions with multiple DME therapists, LPNs, and MDs.  I'm actually looking forward to going to sleep tonight.
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#8
RE: When to consider switch from CPAP to Oral Appliance
Never.
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#9
RE: When to consider switch from CPAP to Oral Appliance
I use a full face mask, with ResMed oral appliance, and Bi-Level machine. I have a recessed jaw, and my mask now fits better while wearing an oral appliance, and I have less obstructions. If you can't get optimal results from CPAP, may want to ask your doctor to first try a BI-Level/BiPAP machine first. Then consider oral appliance in combination with your machine. The machine itself, was not enough for me to lower my events.
ResMed AirCurve 10 vAuto
Pressure EPAP min 4.4, IPAP 8.4, IPAP Max 18, PS 4.

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#10
RE: When to consider switch from CPAP to Oral Appliance
A few months ago I thought I was ready and my sleep Doctor ordered an overnight sleep study to see if a dental appliance would help me. Ends up Not. It increased my AHI to double of what I was initially untreated.

And last month I asked if I could switch to a ResMed instead Of Philips Respironics. So another overnight sleep study. Showed I slept better with the ResMed. So I received a new ResMed. And Ido Sleep better and Easier with my new device.
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