User new to changing settings

[mjphyi]

If EPR at 1 was OK for comfort, I would try it turned off or on Ramp only. It should gain you about 1 cm of treatment pressure without increasing maximum pressure. Your latest charts show treatment is still being limited by your maximum pressure setting. I don't see much difference between the May 3 and 4 charts. 

Leaks and flow limitation are totally different. Leaks are loss of air from the mask. Flow limitations are restrictions in flow to and from your lungs.

Thanks. I had always expected to try more pressure at some point, but I believe I will wait on that until I can reliably make the collar work, and tune in the mask straps. But then I'll try more pressure.

Reducing your EPR to zero will not increase your maximum inhale pressure. It will only increase your expiry pressure, which is where apnea normally occurs.

Then I've misunderstood your suggestion. I didn't refer to reducing EPR to zero, as I believe I can probably do that without discomfort, and the only reason not to do that at present is to avoid changing things in the machine while I stabilize mask fit and collar fit.

However, when you said "treatment is still being limited by your maximum pressure" I believed you were advocating a higher max pressure setting, and I was intentionally going to defer that for a few weeks, because I believe it may cause air swallowing (as it did in the past), or mask leaks. Was this indeed what you meant?

I admit that I was hoping (wishful thinking?) that for the longer term, I might be able to keep the Max and Min pressures close, while getting them a little lower, and minimiize leaks.

[Ron AKA]

Then I've misunderstood your suggestion. I didn't refer to reducing EPR to zero, as I believe I can probably do that without discomfort, and the only reason not to do that at present is to avoid changing things in the machine while I stabilize mask fit and collar fit.

However, when you said "treatment is still being limited by your maximum pressure" I believed you were advocating a higher max pressure setting, and I was intentionally going to defer that for a few weeks, because I believe it may cause air swallowing (as it did in the past), or mask leaks. Was this indeed what you meant?

I admit that I was hoping (wishful thinking?) that for the longer term, I might be able to keep the Max and Min pressures close, while getting them a little lower, and minimiize leaks.

I think we were kind of talking past each other a bit. I agree you should make changes in stages. First get the mask and collar stabilized as you suggest. Next I would reduce the EPR to zero if you have not achieved all you want to achieve with the collar. It is not a maximum pressure increase, but it should have the effect of 1 cm more of pressure, and I would expect to see the number of obstructive apnea events come down. The hope would be that your apnea events would be reduced to the point where maximum pressure is not bumping up against your current max pressure setting of 16.6 cm. However, if you get the collar sorted out, reduce EPR to zero, and actual pressure is still bumping up against your max pressure setting, then you are kind of out of options. It then comes down to accepting what you have at that point for AHI, or changing the maximum.

[mjphyi]

So while I was intending to isolate the 4 changes I made one by one, I haven't done so yet. And that is because my index has been rising, culminating in a big jump last night. As 3 changes were machine settings, which have not been changed, and because it feels to me that the collar I have been using is becoming less effective over the sleep period, I am of the opinion that the major contributor in the recent 2 weeks to the therapy effectiveness has been the collar, but now it is not working so well. Would someone care to validate this conclusion from last nights chart, which sent AHI to the 35 range?

The collar seems and feels effective when I first put it on, but by the time I take it off, the foam is way softer, and my jaw seems to have moved back, and is able to lower itself in the direction of moving inside the collar, as the collar either softens, or alters shape. I have a range of inexpensive collars and chin straps coming from Amazon, so they might help.

However I thought I'd ask what the opinion is on hard collars.

[Melman]

I suspect a hard collar would be uncomfortable but have never tried one. I've been using the same OTC soft cervical collar from Amazon for about 10 months. It never softens. I like it because it comes in several heights as well as neck sizes so you can match it to your neck length and size. I do find that proper adjustment is important. If too loose it seems fine at first but will allow my jaw to drop behind it in the course of the night. It doesn't elongate but changes shape from round to oval because it is too loose. Perhaps that's what you are experiencing.

[mjphyi]

I suspect a hard collar would be uncomfortable but have never tried one. I've been using the same OTC soft cervical collar from Amazon for about 10 months. It never softens. I like it because it comes in several heights as well as neck sizes so you can match it to your neck length and size. I do find that proper adjustment is important. If too loose it seems fine at first but will allow my jaw to drop behind it in the course of the night. It doesn't elongate but changes shape from round to oval because it is too loose. Perhaps that's what you are experiencing.

I haven't ruled out finding a better soft one, but i think that means buying several. We'll see what happens.

[Fats Drywaller]

I haven't ruled out finding a better soft one, but i think that means buying several. We'll see what happens.

I don't have one yet, but I've been thinking of buying one. It should be possible to pick the correct size beforehand. For the OTC collar there's a sizing guide on the product page at Amazon.

(Edited to add: Deleted the rest of this, because I realized I'd misunderstood the earlier reply. Sorry, never mind.)

[Sleeprider]

I think a view of a 2-minute segment at about 23:00 hours will show the flow limitations that are driving your pressure.  What we are really looking at is the flow rate chart, but the zoomed in view can show all of the charts just as above.  We can also compare a segment at about 02:45 where your pressure approaches a minimum and flow limitations appear lower.

Your leak rate is acceptable, and I think you may adjust to the soft collar as you become more accustomed to it. This looks like a better result than previous efforts, and hopefully we won't see the OA clusters as you had on May 2.

You didn't give me a date for those zoomed images, so I assumed you were referring to the most recent night, 4th May. If that's wrong, let me know.

I'd also like to be educated on why you consider May 4th as a better result than May 3rd.
Thanks

Sorry, I've been absent from this thread for a bit.  Your images of the flow rate line show classic severe flow limitation.  Now that Ron is not here, let me just say his advise was crap and you need to use the EPR 3 setting full time. This chart shows that as inspiration starts, it is rapidly restricted resulting a decapitated flow rate.   If you're working with a doctor, show him this, and the really bad events you've been having. I think you are a good candidate for bilevel, but it won't hurt to see if the use of EPR helps. Due to flow limitations, your machine will always track the maximum set pressure.  I don't see a need to change that for now. Keep working with a comfortably fitting cervical collar and don't be put-off by some set backs.

[mjphyi]

   

I haven't posted on my own progress for a while, but I have been lurking, and, I hope, learning.
I'll get to some more general updates, but I also wanted to first discuss some aspects of advice that I've often seen given here,
and hypothesize why it may not have worked for me, and elaborate on what did work.

But first the screen shot above.  It's my AHI chart "popped out" from Oscar. It runs from about April 208 to January 2020 with some gaps.
Aside from July 2019 to September 2019 for which I have data from another machine that I have not integrated into this profile, the gaps are due to giving up in disgust at the inconsistency of results. For example, 23rd May 2018, AHI = 1.68, 25th may 2018, AHI = 37.67. Extremely discouraging.

Advice I was given, and which I still see given is that because apneas are appearing in clusters and that indicates positional issues, so I should try using a soft cervical collar. I did, and it did not seem to work for me.

Now that doesn't in the slightest make it bad advice. I am very much in favor of trying things which are simple, inexpensive, and which have the potential to make things very much better. However, because of an improvement that I observed, I believe there is different advice that I rarely see offered, and I wanted to talk about it.

Because, I am a mouth breather. I think I always have been, especially as a kid when I got colds every winter, and seemed to be allergic to almost everything. I'm sitting here now breathing through my nose apparently, only if I use my thumb to block off my nostrils in turn, it seems like my right nostril is 60% blocked, and my left is about 20% blocked. But my upper body is upright now. If I were to lie down, within 2 minutes both of those percentages would rise until I couldn't get enough air to breathe through my nose, and I'd start mouth breathing. For most of my life, sleeping on my side seemed to work better. 

So when I first got a mask, I saw no reason for anything except a full face. The Resmed Mirage Quattro seemed to fit OK. It sort of worked, but it was big in a size Medium). I would estimate its area might be as large as 15 sq inches. Well, at least 12, I can't find it right now. A pressure of 20 cm H2O (more than I usually used) is about 2% of atmospheric pressure, and so there is about 3.5lbs of force pulling the mask off your face at 20cmH2O with a mask area of 12 sq". That's quite a lot. No wonder I sometimes had red lines across my nose.

So I've seen the term "chin tuck" used a lot here and I don't know exactly what it means. I'd assumed it meant that the jaw was hinging open.   Due to trying a few restraints, I don't think that was my problem. I think my problem was that my jaw was translating rearwards, and what that did was to cause leaks around the front of my chin. And I strongly suspect that with a full face mask, you can't get good consistent results if you have leaks.

Anyway, I got a succession of smaller, and more effective, and more comfortable masks, ending up with the Resmed F30 which I used from June 2019 through September 2019. I thought it was the one. But the more I used it, the more it leaked, and tightening it didn't help. I don't think it could, with the amount that my jaw could move rearwards while remaining closed.

So, what happened? Well, sometime in September 2019, when it was early morning, and light, and I'd woken up, but wasn't ready to get up, I managed to notice that I was happily and freely breathing through my nose with my F30, while lying down. Most unusual; what if I could eliminate the chin leaks by using a nasal mask? Luckily before I fell asleep again, I established that this was at a pressure of 12 cm H2O.

So I got one by late September 2019, and you can see the results. I did have to learn how to do it, but the AHI differences are amazing. I think the consistency is better also. But I do still have leaks. Sometimes large leaks (>24L/min). But it doesn't seem to ruin the therapy like those leaks would with a full face. I can often hear the leaks when I'm awake, and they seem to come from the top of the N30i Small Wide mask. I spent 2 nights with my jaw taped shut and as a result, I don't believe the leaks are coming through my mouth. 

I'd like to eliminate the leaks, but I doubt that will happen until I rig up an IR camera and get some results with that. I still can't sleep on my side, as that dislodges the mask and makes leaks, so I sleep on my back, with no pillow, on a waterbed usually.

So that's nearly enough for one post. More to come later including suggestions for the future. I was intrigued myself to review this thread, and see that Sleeprider was suggesting that I might do well on a BiLevel. During my lurking I had wondered that myself, and I'm looking for a used one.

Michael

[mjphyi]

So, where to go from here; I'm replying to my own thread.

Sleeprider is going to come in and make suggestions, probably based on new current data. There's still  quite a lot of that, so I'm going to wait to be told what to post, probably based on the AHI charts I posted above, or maybe it'll be "post some charts where you have Flow Limitations, or CAs, or no OAs". We'll see.

Maybe this thread will fork, but I'll take advice on that. Since the soft collar was no help to me, but the nasal mask was, part of me wants to see if that helps others. But just because it works for me, doesn't mean it would help anyone else.

So, some notes on where I am right now may be educational. I've gone from an S9 Autoset to an Airsense 10 Autoset, and after going to the nasal masks, I've tried some pressure variations, and right now, my AHI range is about 0.6 to 3.0, fairly reliable. The reliability of that made me very happy, but now, I'm thinking about the next phase of bringing the numbers down more.

I'll note that I'm currently about 30 lbs overweight, with the intent of doing something about that, which I know I can do. I'm 3 months out of cataract surgery, and I've taken the advice to take it easy for that long rather to heart; I like being able to see.

Apart from a recent night when my AHI was about 0.5 AND I was about 14 lbs lighter than now, I have NEVER felt like CPAP therapy made me feel more rested in the morning. Nor have I felt bad due to lack of sleep quality. About 10 years ago, I started to take short afternoon naps; I was sad to have to lose that habit when I went back to working for a spell.

Although Its fairly obvious I have apnea, I started on this for MBPS, Morning Blood Pressure Surge. I think CPAP will assist with that process, but either weight loss, or even exercise without weight loss will deal with that.

So the apnea treatment  is an interesting exercise at the moment. I want to understand more how it works, but the biggest beneficiary is the wife who no longer complains that I snore or that I stop breathing.

My limits are that I need a min pressure on 12cmH2O to open up my nasal passages to be a nose breather.
Also I don't want to go above 17, because that's when I start swallowing air, and that wakes me up, and won't let me get back to sleep for at least 2 hours.
There's still enough variation in my nightly results that my experiments with EPR are not conclusive. I tolerate 0,1,2,3.
I have leaks. Leaks with a full face mask appear to me to cause Flow limitations, especially when they start or stop.
Leaks with a nasal mask do not seem to cause FLs, or not nearly to the same degree.
After experimenting with APAP settings, I ended up with the encapsulation of the numbers above, min=12, max=17, EPR=3, APA mode.

That worked well, but no better than a max anywhere between 15 and 17.

So I decided to stop my approximately weekly setting experiments, and now, and for the past several weeks, I've been on CPAP, Pressure=15, EPR=3
and it seems to be working fine. I'm happy with that.

I've tried the N30i masks, the P30i, the N30,
and I'm back to the N30i in a Small Wide size.
P30i in Medium was not comfortable all night,
N30 in Medium did not have a strong enough strap, and would shift and also weaken quickly. It also tends to change it attitude in pitch (to use a pilot term) too much, even if it doesn't slide around my face.
The N30i also has that tendency, to rotate in pitch, but way way less, and it's straps last well.

I've got myself a used Aircurve VAuto that I'm thinking of trying in BiPAP mode in about a month. Until then I'm gong to verify that it produces similar results to what I'm getting now in CPAP mode.  So I'm not in urgent need of suggestions, but I'll start by asking the experts what VAuto settings they would suggest for me when I'm ready, and WHY. And of course I'll need to post some current results, but I'm not sure what are the interesting ones. I'll post a random sample of 3 over the weekend.

Thanks,
Michael

[Sleeprider]

Good to see you resume this thread with a note of success Michael! I have used a nasal pillows mask since 2008, after moving from a comfort gel nasal mask, as I recall, moving from the Resmed Swift II to the Swift LT to the FX as the technology changed and models advanced. I eventually landed on the Airfit P10 and have never used a full face mask. Like you, I have a deviated septum and often resort to mouth-breathing. My younger daughter is a vocal critic of the "breathing noise" I make when I eat and at other times. The nasal pillows mask set me free from that problem and normalized my breathing at night. I still sometimes need to use fluticasone propionate spray to keep a clear nasal airway in allergy season, but I have never been unable to use nasal therapy, even with colds or more severe illness.

The use of nasal pillows allowed me to use my original Resmed M-Series Auto CPAP, by eliminating enough flow limitation that it was comfortable. Of course, at that time i knew nothing of "flow limitation" or why this worked, but I was pretty happy with my AHI in the 2-3 range based on the limited information in Encore software. I bought a used System One BiPAP Auto DS760, and learned about the benefits of pressure support and dropped the AHI down further, and in 2016 I was prescribed my Aircurve 10 Vauto, and with the Sleepyhead, and later OSCAR software, connected the dots between my sense of good therapy and pressure support. I sometime forget how important the nasal pillows are to the building blocks of my therapy success, but since you asked, there it is. BTW, you still have not tried the quietest, lightest and most effective mask on the market, the P10.

It looks like you're ready to build on the success you have enjoyed with the addition of a nasal pillows mask by using bilevel I think the place to start is by setting up the Vauto to work like your Airsense 10, then to make the changes that may transform your comfort, based on the results. I'm ready when you are. You can expect that we will end up with lower overall pressure, and higher pressure support.