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Help, one step forward, two steps back
Help, one step forward, two steps back
Hello All:

I am hoping that some of you knowledgeable people can help me get back on track.  First some background.
I started APAP late in December, 2017 following two home sleep studies, one without my oral appliance and one with (I was trying to get approved for a new oral appliance).  AHI without appliance was 47 with appliance 16.  So started my cpap journey.

My first mask was the Swift FX for her - I developed significant nasal, ear and sinus congestion. After trials of other masks including full face (I am very slender - bmi of 19 - with a very narrow chin) I switched to Resmed N20.  I can make this mask work, but need to tape my mouth and splint my nares open using a plastic intra-nasal breathe aid (I have a slightly deviated septum - ENT said that it could be straightened, but I would not have any more nasal capacity.).   I also found that I need to use Flonase daily - usually just before bed to keep my nose as free of congestion as possible + set humidity level at 5 - summer and 7 - winter.  The pressure from the nasal cushion pushes on the plastic splint and causes quite a bit of soreness.
I have trialed a number of full face masks from an on-line supplier and have not been able to make anything really fit my face so until recently stuck with the N20 despite the soreness and inability to control mask leaks as well as I would like.

I have been using Sleepyhead to attempt to improve my therapy.  I have increased pressure from initial prescription of 8 - 14 to the current 11 - 15 with some trial at 16 and 17.  Of great concern for me has been my flow limitation graph.  It has been rather wild looking.  Interesting to me is that I was on a trip overseas (elevations ranging from near sea level to 5000 ft - I live at about 800 ft), and my flow limitation graph was better than I have ever had.  See screenshot.
When we returned I wasn't able to achieve this sort of result. 
I decided to try a nasal pillow mask and chose the P10 as that seemed to be minimalist and less area to seal.
With some initial trial, I have been able to use this mask and get some decent (for me) flow limitation graphs. Although my breath wave shapes look very jagged.

I continued to have variable results and couldn't maintain the better flow limitation graph and in the meantime consulted with a new sleep dentist (he makes his own custom face masks) and began reading more about flow limitations.  The article referenced on your site by Dr. Barry Krakow really sounds like he is talking about me!

I starting experimenting with EPAP as I hadn't been using it.  I first set it to 1.
And then to EPAP of 2.

Expanded view:

And then to 3:  

After reading more regarding flow limitations, I realized that my machine was set to regular apap mode, not the apap for her mode.  So tried the for her mode for 1 night (after a good week of sleep), and it was a disaster.  I felt like I had run a marathon and my chest was so tired (from trying to breathe all night - I think).

Since then, I haven't been able to get back to what was decent sleep for me even by back tracking on my EPAP.  So am not sure where to turn next.  I also can't seem to post more than these 5 images - so apologies.  I will try to follow up with disaster night and last night.
Any help appreciated!
sleepless badger
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RE: Help, one step forward, two steps back
Here are the screen shots that I couldn't get to post to the original message:

Disaster night on apap for her:

And last night - still not good:


I think I have just gotten my body so mixed up, it doesn't know where to turn.  I have been using my original nasal pillow cushion, so was going to use a new one tonight to see if some of the leaking might be the pillows.  I wake up and can feel and hear them leaking especially my right nostril - it seems to be a bit more tilted than the left side.

Thanks again.
Sleepless badger
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RE: Help, one step forward, two steps back
Welcome sleepless badger,

I don't have much advice to give (as I'm newbie), but just wanted to say welcome and to stick with it. One amateur observation though, leak rates seems like it needs to be address in some manner.
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RE: Help, one step forward, two steps back
Hello SteveMac:
Thanks for the welcome.  I know my leak rates aren't good.  I have had some good nights, but despite trying all the adjustments I can think of, I can't get a  consistent fit with any of my masks.  Most nights, the leaks don't wake me up.  However, last night they did and I got the dreaded red frowny face. 
Sleepless badger
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RE: Help, one step forward, two steps back
A BPAP would really help you with the flow limitations!
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RE: Help, one step forward, two steps back
(07-26-2018, 03:59 PM)Walla Walla Wrote: A BPAP would really help you with the flow limitations!

That is what I have been wondering.  However, I need to have my sleep Dr. Write a prescription for it.  I haven't actually been able to see him at all, just the PA and Nurse Practioner.   With my low AHI they wonder what I am complaining about.   I do have an appointment with a different sleep doc, but not until Nov.
Right now, I would just like to get back to where I was before that disastrous trial of the "for her" algorithm.   Don't know how to get there.  What worked before is not working now.  Am hoping the new pillow so help tonight.
Sleepless badger
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RE: Help, one step forward, two steps back
An EPR of 3 should reduce your flow limitations, but you may need to increase your max pressure by 1 as well to compensate for the reduced exhale pressure. Setting the Resmed with an EPR of 3 is like a BiLevel with PS of 3
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RE: Help, one step forward, two steps back
Thank you, jaswilliams.
I will try the bump in pressure.  
I should explain that other than the one week or so where everything seemed to be working reasonably well, I have not felt better!   My AHI has been below 3 from the very beginning.  That is why I was trying to understand and work on flow limitations as I think that may be where much of my issue lies.  Increasing pressures alone don't seem to change the flow graph much.   Plus my tidal volume seems low without some epap.   That hasn't recovered since that disaster of apap for her trial..
Sleepless badger
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RE: Help, one step forward, two steps back
Well - I switched to a new pillow and rigged up a way to hold the pillows more upright (I am using a medium size - but seem to be between medium and large ).  That plus increasing EPR to 2 and bumping up pressure to 12-16 seems to have smoothed things out regarding flow limitations and I am feeling more rested - just not quite there yet but may take time with a number of bad nights behind me!

This screenshot is of the first night - ignore all of the events between 2:15 and 3:30 or so - I was awake most of that time for some reason.  However, the rest of the night was sleep.

The following is last night - flow limitation graph looks good for me and tidal volume has improved - so I am feeling encouraged.  I intend to stay at the EPR of 2 for a week or so to try to get things stabilized and then attempt EPR of 3.  I have found that when I make any changes no matter how small, it takes me awhile to adjust to the change.

Any thoughts??  Suggestions very welcome!
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