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[Treatment] Repeated awakenings on CPAP (every 1-3 hours)
#1
Repeated awakenings on CPAP (every 1-3 hours)
Hi all,

First of all, I wanted to say that I am delighted by the existence of this community and by the extremely helpful Oscar software. 

I would greatly appreciate the community's thoughts on why I am repeatedly waking up during therapy. 

Background:
  • I was diagnosed with OSA in 2016 (AHI 34 in one study and 10 in another, supine AHI 61 in one and 44 in another) and have been using an S9, primarily with Swift FX pillows, since. 
  • The therapy has generally been effective at reducing AHI and tiredness.
  • However, persistent problems with blocked noses interfering with the pillows. I began using a humidifier around 2019, which did not seem to help much. I tried a Mirage Liberty in early 2020 but never managed to sleep using it. I began using Otrivine more and more regularly, before going cold turkey late last year.
Current situation:
  • I now typically wake up every 1-3 hours. In January, the maximum continuous hours of mask use I had was five hours. I had this on five nights. This is extremely disruptive to my sleep.
  • One or other nostril – mainly the right – is blocked almost every night. (I have a deviated septum, which may be one cause). This frequently means that I cannot use the pillows for part of the night – for instance, I would wake up around 6am with a blocked nose and then be able to sleep again only without the mask.
  • My hope was that the main issue was my nose, such that using a full face mask would solve or reduce the problem. I therefore recently acquired an F20 (having read several threads here). It is significantly more comfortable than the Liberty and I am able to sleep with it. However, even now that I have got the leak down, I continue to wake up frequently – in fact more frequently than before, with six chunks of sleep last night between midnight and 6.30am (attached).
  • I cannot see any obvious correlation in the graphs. My tidal volume and respiration rate seem to increase around the time that I awake, but they sometimes increase much more without me waking up. The awakenings are also sometimes correlated with apneas – but not consistently.
  • It’s possible that the cause is environmental. However, I have moulded earplugs to reduce noise. More importantly, the pattern is fairly stable even when I sleep in other places with less/different noise patterns, so this seems unlikely.
  • I’d be very grateful for any thoughts or suggestions you might have.
Attachments:
  • I attach one screenshot from 6 February (F20) and two from 15 and 16 January (Swift FX, showing repeated wakings + stopping therapy mid-night respectively).
Yours,
Pisceo


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#2
RE: Repeated awakenings on CPAP (every 1-3 hours)
For context: a chart with my overall session times over the past month.


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#3
RE: Repeated awakenings on CPAP (every 1-3 hours)
Welcome to the board.  Your flow limits are quite high and flow limits will disrupt sleep and stop you from getting into deep sleep.  We limit these using EPR (exhale pressure relief).

You have your EPR set at 2 but the lowest the pap machine can go is 4.  The EPR is subtracted from the min to get the exhale pressure. So yours min is 5 subtract 2 (epr) from that and you can't go down below 4.  Your EPR is really only 1.

I would set the pressures as follows -
Min 8
EPR 3 full time
Max 11

Try those settings and post again, it will take a few days but I'm sure that you will feel better with these settings.
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
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#4
RE: Repeated awakenings on CPAP (every 1-3 hours)
That's very helpful – shall give it a try. Many thanks.
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#5
RE: Repeated awakenings on CPAP (every 1-3 hours)
Disastrous first night, I'm afraid: the longest I slept was less than an hour (again on FFM). It seems to have flattened out some of the low-level flow limits, but not the peaks. I also seem to have been waking up towards the lower bound (8.0) of the pressure, so I wonder whether it's set too high. Subject to others' thoughts, I'll set it at 6.0.


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#6
RE: Repeated awakenings on CPAP (every 1-3 hours)
It looks like you're using ramp. Have you tried not using it? Or maybe you forgot to turn it off. There should be a setting in the user menu.
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#7
RE: Repeated awakenings on CPAP (every 1-3 hours)
Why do you believe you are waking up? I really DON’T think it is 8 being to high. Min 8 is the inhale pressure and that is low to about normal for an adult. For instance I have to have at least a min 10 or I be feel air starved and remove my mask to get more air.

Do you feel you are not getting ENOUGH air?
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
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#8
RE: Repeated awakenings on CPAP (every 1-3 hours)
Also turn off your Ramp. You are not getting enough therapy because you are in ramp most of the time.
It's not the pressure. try getting a tall glass of water and a straw.
Now for the kid's game, place the straw to near the bottom of the glass and blow bubbles!
I'll bet you had no problems, Assuming the straw was 8 inches deep you just exhaled against the highest pressure your machine can generate, 20cmw.
Your chart, the little bit that is in therapy, is hinting that you need more than 8cmw min.
Many people mistake flow for pressure, they, though related, are completely different.
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#9
RE: Repeated awakenings on CPAP (every 1-3 hours)
As Gideon states... turn off the Ramp.

Look at the graphs. Every time you stop the Cpap and restart it, you are back to ramp pressure which leaves you at less than optimal therapy. This happens several times a night.

Turn off Ramp, set your minimum pressure to 8. (You can adjust from there after a couple nights.)
OpalRose
Apnea Board Administrator
http://www.ApneaBoard.com

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#10
RE: Repeated awakenings on CPAP (every 1-3 hours)
Hi all – many thanks for the input. I had re-enabled the ramp as the shift to an 8 starting point from 5 was uncomfortable, but I take your points. I'll disable it.

At the same time, I do not quite follow how the ramp could be responsible for the key problem here, i.e. the repeated awakenings. That happens at the other end of each mini-session. The only new factors last night were the higher minimum, the higher maximum and the higher EPR, and given that the awakenings happened with the pressure towards the minimum rather than the maximum it seems plausible that it's that minimum which is an issue. Or am I missing some factor? Gideon – what is it about the graphs (including the earlier ones, without the extended ramp) that suggest an 8 minimum may be too low?

Many thanks all again.
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