It's important to understand that most docs are not particularly interested in dealing with patient's medical problems that lie (mostly) outside their area of expertise---even when those medical problems seem to be causing additional problems with things the doc has prescribed (like CPAP) to treat a condition that is in their area of expertise (like OSA). So it's important (for now) to describe your CPAP adjustment problems in language that the pulmonologist/sleep doc believes falls under his area of expertise. And unfortunately, that doesn't include sinus problems (for now).
But you also write:
Quote:It feels extremely difficult to exhale, and if I do start to fall asleep, I wake up because I'm not exhaling without forcefully blowing.
Call the doc's office back and politely, but firmly state that you have been unable to use the machine at its current settings for more than a few minutes because you cannot exhale comfortably against the 18cm of pressure and that this is preventing you from falling asleep.
I repeat, when talking to this pulmonologist don't bring in all the sinus stuff yet
since he'll just think, "Sinus problems aren't what I do, you need to see an ENT for that." As bad as the sinus stuff is, your first problem with CPAP right now is exhalation against the pressure
and that's a problem that is within the pulmonologist/sleep doctor's supposed area of specialty. So when you are talking with the pulmonologist keep the focus on "I can't exhale against the pressure. What can be done to make it easier for me to exhale against the pressure so that I stand a chance of falling asleep?"
Because there are things
that can be done to help the "can't exhale problem."
Here's a list of things that either the pulmonologist (or you) can do for trying to fix the "I can't exhale" problem that is currently your biggest CPAP adjustment problem:
1) Since you are having real problems exhaling and your pressure setting is so high, it is worth asking the sleep doc whether a bi-level PAP might be in order. A bi-level PAP allows for the inhalation pressure to be set several cm higher than the exhalation pressure, and that in turn typically makes it much easier to exhale fully and comfortably. While many CPAPs have some form of exhalation relief, even if it is set to its maximum setting, that may not provide enough relief for you to exhale comfortably. (Some sleep labs will routinely switch a patient to bi-level during a titration study when the pressure hits 15 cm.)
2) Correctly using the ramp. The ramp allows you to start out at a much lower, nontherapeutic pressure that is comfortable while you are awake. The pressure increases over a fixed amount of time until the desired pressure is reached. The idea is that if the pressure increase is gradual enough, you'll be able to fall asleep before the full blast of 18cm of pressure keys you up or wakes you up. Ideally, the ramp time should be for a bit longer than it takes you to get to sleep. If the starting pressure is too low, however, that can increase discomfort for some people because (ironically) it can feel as though there's not enough air coming through. If the ramp time is very short and the starting pressure is very low, then sometimes the "gradual" increase in pressure doesn't feel so gradual and that can keep you up. So if you want to experiment with the ramp, I'd suggest starting with something like:
Starting ramp pressure = 10cm (or maybe even 8cm if 10cm feels like it's too much)
Ramp time = 30 minutes (if you usually get to sleep in 20-30 minutes without the CPAP).
4) Exhalation relief. If your machine provides exhalation relief, it should be turned on and turned to the max setting. If it doesn't have any exhalation relief, the doc should be willing to prescribe a machine that does. And note: The SenseAwake on the ICON is not really the same as "exhalation" relief---it lowers the pressure when the machine thinks you're awake, which is not the same as lowering the pressure on every exhalation regardless of whether you are awake or asleep.
5) The pulmonologist may be willing to temporarily lower your pressure and raise them a little bit at a time so that you can gradually get used to the prescribed pressure. It may be easier to start out at 10cm of pressure, even though that's not enough to control your apnea. After managing to sleep at 10cm for a week, the pressure could be increased to 12cm for a week. And then to 14 for a week and so on.
6) The pulmonologist may be willing to prescribe an APAP (auto adjusting PAP) with a pressure range of something like 15-20cm. That way you'll only have the pressure really, really high when it's clearly needed.
Once you feel as though you can actually exhale without excessive amounts of effort while using the machine, then it's time to start figuring out what to do about the sinus problems and how they interfere with PAP therapy. For now, you might try using a neti pot or a sinus rinse an hour or so before bedtime to clear out the worst of the congestion.
More suggestions need more information about your equipment: Do you have a heated humidifier? If so, what setting are you using? Do you have a heated hose? If so, what setting are you using?
The funny thing about sinuses is that everybody's are different: Some people's sinuses need the humidifier cranked up to the max. Other people get severely congested if there is any extra humidity at all. Some folks' sinuses love the extra heat provided by a heated hose; others react to the extra heat by becoming extra congested.