[Treatment] advice re sleep quality and mask

[agundla2k]

Hi.  Still using CPAP after failed uvelectomy, repeat tonsillectomy (right tonsil grew back) and in 2017, mandibular maxillary advancement.  The last surgery cut my events to half.  I fear that I cannot find my last sleep study but I want to say that I my AHI was approx 12.  I was fitted for a DreamWear nasal mask (previously I had to have a full-face mask due to mouth breathing).  With that my AHI has averaged 1 or less.  I just downloaded the OSCAR software so if you need more info, please let me know.  As far as sleeping aids, room is super dark, white noise machine, cool, pillow seems to be good and new within the last year.  I have tried a myriad of pharmaceutical things:  ambien (concerned about long term effects), doxyalamine succinate (Unisom)--concerned about long term effects due to first generation anti-histamine, trazadone (tapered off due to weight gain) and now melatonin 10 mg sustained release.  I am getting 30 min exercise 5 days a week.  I still wake about up at least once and stay awake for a hour or more on most nights.  I can think of 1-2 times in the last few months that I feel like I got a good night's sleep.  I thought maybe it was a mask issue so I asked for a refit (which basically consisted of the RT directing me to the Phillips and ResMed websites to search for my own mask and fit it myself in the wake of COVID-19).  I think I did a fairly good job, at least as well as I have had anyone do in person.  I settled on a ResMed AirFit F30 but according to OSCAR, my leak level is much higher.  I have used the AirSense mask test and I am always able to get a good fit in different positions prior to sleeping.  I used it for 7 days and my sleep was worse and my AHI was actually a bit higher on average.  I expected my sleep to be worse for a few days due to adjustment period but I did not expect the AHI to be higher.  I use Autopap and my pressures are between 4 and 4.6 for the range.  I have yet to find a good physician, sleep lab, etc.  I have used 3 different sleep labs and nobody really wants to take the time to show masks and let you try different ones during your titration study.  It is sort of...this is what we have, deal with it.  I cannot go back to a traditional full-face mask as I developed a pressure injury with one of them and now my bridge is super-sensitive.

Thoughts or ideas?

[OpalRose]

Hi agundla2k,
Many folk have trouble finding the right mask fit, so your not alone. I'm sure that you will get some advice on different masks to try. In the meantime, read the Mask Primer. Link below in my signature line.
You can also check some of the suppliers like Supplier #1 for masks. They offer a 30 trial period.

I also have a feeling your pressure settings could be tweaked some. We would need to see some of your data to advise with that. In my signature line below, use the Chart Organization link. This will show you how to set up your daily page in OSCAR and then use the attachment feature to post here.

[Hydrangea]

Just some thoughts, based off of some of my similar experiences:

- Don't discount a full face mask. You could try a hybrid one like Amara View that doesn't touch the bridge of the nose. Oh, I see you're using the F30 - it's the same idea. Also, Dreamwear makes one that is similar, I believe.

- It's possible you're sensitive to the ResMed algorithm, and that's bothering your sleep. If so, try the Soft mode.

- It's possible your mask isn't adequately venting your exhaled air. I have that problem with the Quiet Air elbow that the F30 uses. If you could get hold of an old (not quiet air) elbow from an old F20, you could try that and see if it helps.

Good luck. It sure sounds like you've been through a whole lot!

[agundla2k]

Hello again.  I'm back.  I re-checked my machine's settings and it appears at some point, it was removed from autopap back to regular c-pap.  I changed it back again.  This is my latest screen capture using the Dreamwear nasal mask.  I wasn't sure how many days of data you wanted.         On another note, I have previously tried the Amara mask but I got too many leaks with it after my advancement surgery.  Maybe my issue is just anxiety and not really related to the mask.  What should I be looking at to see if I really am mouth-breathing with my nasal mask?  After sleeping for a week for a full-face mask which forces you to breath through your mouth, I no longer feel as strongly that I was breathing through my mouth.  I compared my AHI and leak rate numbers from the week prior to my full-face mask trial and again for the week after the trial.  Everything (from my untrained eyes) looks better with the nasal mask.

Please let me know what your more experienced eyes see.  I'm still torn about whether the surgery was worth it as the goal was to completely get rid of the need for cpap.

[Crimson Nape]

Your chart looks very good.  The question is, "how do you feel? All the surgeries that I'm aware of only delay the use of a CPAP, at best.

[SarcasticDave94]

If you wish to look at whether mouth breathing is present or not in the data, zoom in to about 2 minutes of the same data chart you posted. Particularly, the black line in the flow rate graph will show individual breaths. There will be info to decipher with that line pattern that can help others see what's going on and advise what is seen. Also what you can do in OSCAR is edit the flow rate chart to have a Zero line going across the entire graph, signifying inhalation above the zero and exhale below that same zero line. I think the zero line is a right click on the flow rate area and then add a zero line.

[Gideon]

The lowest the min pressure should be, with VERY RARE exceptions is 4+ EPR = 4+3 = 7
Set your min pressure to 7 which will let the EPR work, minimize the Flow Limitations that are driving your pressure up, and thus limit your pressure fluctuations and feenl more comfortable.

[agundla2k]

First, because I failed to say it before-THANK YOU!  I am glad that I logged back on to ask for help last week.

This is a zoomed version of the flow rate per @SarcasticDave's request:      

Next response is to @bonjour:  Reset my minimum to 7?  My yearly average need is less than 5.  I have not studied up on this so I am a bit confused about why I would use a pressure higher than my highest average?  And if i reset it, should I titrate it up or just do it all at once?  I'm leaning towards titrating.

To answer how do I feel by Crimson Nape--I rarely feel like I get a good night's sleep.  I'm not sure how much of this is apnea or cpap related compared to age, anxiety over the world in general, etc.  I do feel much better using the nasal mask vs full face.  I'm searching for less leaks---I'm very sensitive to the sound/feel of the mask leaking and that wakes me up more than anything.  The nasal mask fits me so much better...so much so that I will sometimes pull it away just to feel the air to make sure it is is still on (rather than rolling over to look at the machine).  I feel and hear absolutely nothing with it.  In the years that I have used or attempted c-pap, I have tried 6 different masks for extended periods (more during titration studies) and this is by far the best as far as fit.  I just want to make sure that I'm not sacrificing something else to get that quiet fit.   I can no longer use snoring as any sort of indicator.  The surgery did fix that.  My husband said it was eerie to sleep next to me after surgery....he heard nothing!  He still says that.

The surgery was actually recommended when I was 14--I declined not understanding the ramifications at the time as they were not fully explained.  I thought (as did my mom) that it was more of a cosmetic issue (I was born with microtia/atresia-absence of the left ear which also causes some smaller than normal airway, bone structure, etc.).  I am pretty sure (but had no formal diagnosis) that I had airway issues then as I was a heavy snorer even then.  My parents said that I snored as a baby.  My surgeon was not able to advance me as much as he would have liked.  I look completely different from before and I don't think for the better.  I had the options of getting the implants that they use for TMJ as part of treatment but it seemed too drastic to me.  Not sure why I thought that now since it would have been all part of the same surgery.  
Is Soft Mode the ramp up?  If so, I believe that is already engaged on my machine.

[Gideon]

In general a setting of 4 is too low for an adult, and also frequently 5.
Pressure =4, EPR=0 (yours is set at 3)
Pressure =5, EPR = 1
Pressure =6, EPR = 2
Pressure =7, EPR = 3
Pressure =8,8+. EPR=3 (3 is max EPR available)

This simply allows EPR to fully act therapeutically.

Also your 45 minute Ramp is far too long, At your pressures, it should be off.