Getting a machine advice

[dolppl]

Day 2.  Better results I would say from the first night.  No periodic breathing which i find comforting.  Still a lot of CAs, hopefully that is just treatment emergent and will go away with time?

What are your thoughts on the leak rate?  Not sure what 'good' looks like, but I assume that isn't it.  I did wake up quite a few times with a very very dry mouth.  I bumped the humidifier up from 4 to 5 and that may have helped but I am not sure.

Anything else you guys see i should know about i appreciate it.

   

[Sleeprider]

Leaks are okay. Nothng too large or long duration. The main thing is we want you to get comfortable with the therapy. I think in a few days we can try some auto pressure in the 6-9 range, but for now, let's get a good baseline.

[dolppl]

Another night in the books (night #3) and numbers went back up and the CSR is back again.  This time it was towards the beginning of the night and coincidentally (or not) after that event I woke up and felt uncomfortable with the mask on and the pressure and my breathing and 're-ramped' to drop the pressure down to fall back asleep.

I zoomed in on part of the CSR period.  Looking for some feedback.  Hopefully this is just periodic breathing that will go away as i get used to the machine.


       

[dolppl]

Last nights results.  The worst yet.  My diagnostic study had me at an RDI of 22, so getting a 15+ with CPAP is definitely frustrating.

Just power through and hope that i get better when i get used to using CPAP or is it time to make some adjustments?  


The only thing i did change last night was i changed to a different mask.  It was a better mask that i had.  The one i was using seemed cheap and flimsy i changed to a more sturdy one that seemed to leak less as i rolled around when i tried it out. 


   

[Sleeprider]

At some point, you will need to raise the lack of efficacy with your doctor and ask about ASV as an alternative solution. Your doctor will likely advocate giving the CPAP therapy more time, however if he ever suggests trying bilevel (BiPAP) remind him you failed bilevel pressure badly in titration. I'm tempted to ask you to try a fixed pressure at 7.0 and see if that helps reduce events. That is the logical approach in resolving CA, so feel free to give it a try. As this continues, I think ASV may be the best long-term solution.

[dolppl]

Thank you for the advice.  

The questions comes up that I am still in the 'rental' period and have follow ups at 30 days and 60 days to show compliance with the machine i assume.  If i adjust these settings will this cause any issues?

[Sleeprider]

I don't know how accessible your doctor is at this point, but we have many members that self-titrate and change pressures. It does not disqualify you from compliance which is based entirely on use. Your titration showed good results at both 7.0 and 8.0 so we're hardly suggesting anything radical here. If you do better with lower pressure that becomes an important data-point for your therapy. Similarly if t does not improve your results, it is also useful information. I think we both knew going into this that you would not likely achieve efficacy with CPAP or BiPAP. Your titration did not find a pressure that did not have moderate RDI/AHI problems. This trial with CPAP is something most doctors will try and is essentially required by insurance. At some point you will either adapt to CPAP or go to your follow up with the knowledge you need something else. So trying alternative pressures can be done responsibly and just adds certainty that alternate pressures are, or are not effective in reducing events.

[dolppl]

Another thing I probably should have brought up earlier.  I am using the CPAP in conjunction with an oral appliance.  I did this during my in lab sleep study as well.

The reason i am doing this is two fold.  Years ago I had a sleep study done using CPAP without the oral appliance and one done with the oral appliance.  The results were much better when I did the two together.

The other reason is that last time i was on CPAP I would unknowingly take my mask off in the middle of the night and find it running on the floor in the morning.  I figured if that happens now at least i will still have the oral appliance in and will get better sleep than nothing.

Summary:
Baseline AHI (no therapy): ~44
At Home Sleep Study AHI w/Oral Appliance: ~22 (10 years ago it was ~10)
In Lab AHI w/Oral appliance and CPAP ~10 at a pressure of 8 (10 years ago it was ~1.4)

[Sleeprider]

The MAD is another variable. You can try with and without and see if it has any effect. I generally don't like oral devices because for many people they are more painful and harder to get a good mask seal or an increase in mouth leaks. It's up to you, however as I recall, your testing did not point to a lot of hypoxia with events, which is why they were called RERA rather than hypopnea. The oral devicces are usually employed to resolve obstructive apnea and hypopnea. You don't have any of that, so I see no value to including that to your therapy at this time, and omitting the device might reduce your central events and RERA.

[dolppl]

All good information as always.

Follow up question, my background is in statistics and engineering.  The main point in any DOE (which is basically what we are doing right now) is to only change one variable at a time.

What goes first?  Should I stop using the MAD and keep the pressure at 8.  Or keep the MAD in and drop the pressure to 7.  

I would think that advancing my jaw would make less pressure required to open the airway up so I don't think it is a good idea to do both.  My thought is to leave the pressure at 8 for at least a few nights and take out the MAD.

But i will defer to all of you.