[CPAP] AmandaPNW - Therapy Thread

[AmandaPNW]

Hi all,
First time poster, but I’ve been reading for several months. I’m grateful for what I’ve been able to learn so far and I’m hopeful that you all may have some insight for me.

Background: I started using the Sleep HQ O2 ring in January and officially got diagnosed with REM OSA in February following a polysomnogram. My overall AHI is 5.4, but my REM stage AHI is around 15. The underlying cause is airway anatomy. I have done myofunctional therapy and am considering a tongue tie release, but am not a good candidate for treatment by orthodontics, surgery, or MAD. 

I started CPAP with Airsense 11 and P10 mask on April 4. I switched to F40 mask on 4/15 after I realized the P10 would only work for me with a full mouth tape seal. Both masks have been comfortable enough for me to wear all night and leaks have mostly been minimal.

My OSA symptoms are primarily in the second half of the night and are accompanied by heart rate spikes that cause arousals and then insomnia. I used an oximeter without CPAP for 151 nights and my spo2 averages were 13 >3% drops and 89% nadir. I've used CPAP for 20 nights and my averages are 8 >3% drops and 89% nadir, so I am making a little progress. 

My doctor left the pressure range open and scheduled us for a follow up appointment in June. I tried the open range on the first night and had to remove my mask midway through the night due to aerophagia. On 4/5 I began trying small nightly adjustments to optimize my pressure range. I initially set my pressure range at 5-10 (EPR 3). That range helped me adapt but it didn't prevent my spo2 drops.

--As of 4/23 my range was set at 7.6-14 (EPR 2) (screenshot attached). 
--On 4/22 I experimented with dropping to EPR 1 with pressure set at 6.8 - 14, but I reverted back to EPR 2 midway through the night due to arousals and aerophagia (screenshot attached). 
It appears to me that EPR 1 improved the level of responsiveness to my desats. I would love someone more knowledgeable to review my screenshots and share their perspective.

I am not able to import my O2 data into Oscar so I’m also including a chart zoom at 4/23 3:50 am of a pattern of flow limits/spo2 drops where the pressure line never increases (screenshot attached). It appears to me that this is where my symptoms and treatment settings are not aligned, but I'm not sure where to go from here.

I would appreciate your input and advice!

Thanks,
Amanda

   
   
   

[jdougc]

Welcome to the forum,
Can you share a copy of your sleep report with your data redacted?

I bought a device, REMplenish™Myo-Nozzle,  to go on a stainless steel straw to exercise my tongue as I drink.

I also use a SomnoSeal device, very thin and pliable that goes just inside my mouth to minimize mouth leaks. I use mouth tape also, but you might not have to.

Your obstructive events are well controlled, but flow limitations are driving your pressure increases.
EPR is used to treat Flow limitations, set EPR to 3 cm full time. This might increase your CAs
Try a pressure range of 7.4 to 10 cm for a few nights, you may need to raise your minimum if you feel air-starved. 10cm is slightly below your 95%.
This tight window pressure range may  be more comfortable, the larger pressure swings can cause arousals in some people, like me.

After a few more posts, you can share SleepHQ data, showing your O2 data.
Lose the snore chart,

[AmandaPNW]

Hi jdougc, thanks for taking the time reply and share your knowledge. I am up to speed on the REMplenish and have used it daily for about 4 months. Appreciate the rec for the SomnoSeal. I'll try that out.

I did some more reading last night about flow limitations and decide to retry EPR 3 with pressure at 7.8 - 14 (a .2 increase from the last time I used EPR 3 on 4/18). EPR 3 does appear to better treat my flow limits and I think I feel more rested using EPR 3 than I feel with EPR 2 or 1. EPR 3 does correlate with increased time in apnea and CAs. Spo2 drops last night remained in my typical range - 12 > 3% and 90% nadir. 

I'm attaching 4/24 Oscar screenshot and a Sleep HQ screenshot where my spo2 drops can be observed in relation to flow limits and pressure response, at least as an overall pattern. 

Edited to add: I was able attach my redacted PSG as a multi-page PNG image. Let me know if that doesn't work?

Thanks again,
Amanda

   
   
[attachment=78301]

[AmandaPNW]

Following up on posting the PSG report, which was not successful. My redacted PSG report is a multipage PDF. Maybe I should export and upload each page as a separate image file? I'd appreciate guidance on what would work best for sharing that.

[Deborah K.]

I suggest you raise your starting pressure to 8.6, as your new median pressure is higher than that. That will make your pressure range less jumpy as well, and should be more comfortable.

[jdougc]

You might need a few more posts to attach pdfs and links.
The CAs might be as you were falling asleep at first and after the wake up on April 24th . The rest might be treatment emerging.

If you feel air-starved at EPR =3. raise your minimum pressure.

[AmandaPNW]

I appreciate both of you making suggestions. I'm will keep EPR on 3 and gradually raise my minimum pressure each night. Last night I was at 8.2. Looking at Oscar this morning, my flow limits were flat/slightly worse than the previous night and my time in apnea and overall number of CAs increased. I'll keep experimenting with raising the pressure for a few more nights and then check back in. Thanks again.

[jdougc]

Keep track of how feel during the day.

When you said your  flow limits were flat/slightly worse than the previous night, were you zooming in the flow rate chart and looking at the breath shapes?
Could you post a 2-3 minute zoomed in chart or 3 of interesting breathing patterns?

[Deborah K.]

Amanda, I sent you a PM about the REMplenish a few days ago.

[AmandaPNW]

Hi all,

Checking in with an update. I just completed my first 30 days with Airsense 11 for treating my REM OSA (summarized in the first post of this thread).

I've experimented over the last 8 nights with EPR 3 and minimum pressure between 8 and 8.8. Over those 8 nights, median pressure has averaged 8.9. With pressure in this range, my 99.5% Flow Limits have averaged 0.10. (My most common breath shape is rectangular/flat on top.)

However, with the increase in median pressure above 8, I am seeing declining metrics on my oximeter (vs my oximeter readings prior to starting CPAP and when CPAP median pressure was below 8):

--Time Below 90%: average 65 secs vs around 5 secs previously
--# of >3% drops: average 22 instead vs around 10 previously
--Lowest Spo2: average 87 vs around 90 previously

Looking at my Spo2 charts pre-CPAP, I had few breathing disturbances in the first half of the night (spo2 typically remained above 93). This correlates with my PSG diagnosis of REM predominant apnea. After starting CPAP, the charts are now showing more numerous clustered Spo2 drops early in the night. Some are flagged as CAs, but most are not. There are flow limits present in the first half of the night. Occasionally up to 0.30, but more frequently around 0.05 - 0.12. The other data I'm keeping an eye on is Oura ring sleep stages (imperfect, but somewhat useful for rough trends). I typically had few sleep disturbances from 9:30-12:30 and then frequent awakenings from 12:30 on. Since starting CPAP, my average REM sleep has risen by 3 minutes, but my average deep sleep has fallen by 17 minutes.

I continue to not feel rested when I wake up in the morning, no matter how long I'm able to stay asleep. My head and eyes feel heavy and my energy is low.

I understand that treatment emergent CAs can spontaneously resolve as my body adapts, so I'm hopeful that's a potential outcome here? My plan for the coming week is to keep my settings at EPR 3 with pressure range at 8.2-14. I have been prone to change settings nightly and I know I am likely to see clearer patterns of results if I see results for a week before I change.

My theory is that the pressure required to respond to my REM OSAs in the second half of the night is causing new breathing disturbances during my non-REM phases in the first half of the night. Does that seem plausible?

Attaching a link to my SleepHQ report and last night's Oscar and my summary report from the first month.
https://sleephq.com/public/052ee843-073d...6f37a15cb9