[CPAP] Penn Dickery - Therapy Assistance

[Penn Dickery]

Hi all,

After experiencing most of the classic SDB symptoms for a few years, which have progressed recently to debilitating fatigue, constant headaches and manifest cognitive dysfunction, I (28M) finally got in for an in-lab sleep study, where they found a cluster of hypopneas (~15) during my brief time in REM sleep. To my disappointment, they didn't record RERAs, at least as far as I can tell. The technician who composed the report merely noted "flow limitation" without elaboration. 

For the record, I've recently been evaluated by a couple oral surgeons who both adamantly agreed I was a classic candidate for MMA surgery. I also have a fairly severe pectus excavatum (a big old dent in my chest) that's compressing my heart (based on CT imaging), and which I've been advised to have surgically corrected in the near future. Since I'm skinny, don't smoke, and live a relatively healthy lifestyle, I suspect these two issues (my small jaws and chest deformity) taken together are sufficient to explain my breathing problems in sleep and waking, and I have my fingers crossed that surgery can address my fatigue. But that's down the line, and there are no guarantees in life, so I'm trying to work with what I have right now, because I'm starting to get pretty desperate.

Anyway, although my AHI (~2) was technically too low to meet the diagnostic criteria for apnea, my pulmonologist agreed I have REM-specific apnea if not UARS, and gave me a prescription for a Resmed 11 set to APAP 4-16cm with EPR 3. Based on the advice I've seen on this forum and elsewhere, after a few days I went ahead and raised the minimum pressure to 8. Maskwise, I'm using an Airfit P10 nasal pillow. 

I've been trying my best to use the machine consistently and acclimate to it over the past few weeks, but to my dismay I feel as crappy as before I started using it. I also seem to be experiencing some level aerophagia with it, since I'm waking up with abdominal bloating/pain that goes away after some time on the porcelain throne. Of course, my doctor pointed out that my AHI is <1, so, despite the lack of improvement of my symptoms, he assured me my treatment is going great. 

I've been looking at my OSCAR data over the past couple days, and when I zoomed into the flow rate waveforms I noticed I'm having a large number of what appear to be flow limitations the machine isn't registering as such. However, I'm quite a noob at this, so I was hoping someone who actually knows what they're doing would be kind enough to lend an eye to my data and help me get some relief from CPAP therapy. 

I've attached the full report here, as well as a more zoomed in screenshot (screenshot 3) which captures a few of those suspect flow rate waveforms I mentioned above. To my eye, it looks like I'm prone to having trouble both inhaling and exhaling, since in addition to a lot of weirdly irregular breaths (which could have something to do with my respiratory musculature not working right due to my chest deformity), I'm seeing a number of waveforms that flatten out for 10-15 seconds before resuming their previous pattern. 

Thanks everyone.

[Deborah K.]

Your flow limits are terrific.  Don't give them another thought.  I suggest that you lower your start pressure to 6 because of your chest issues. I think the 8 you have set is causing your aerophagia.  6 is lower than we generally suggest, but it might be necessary in your case.  Try it tonight.  If you still have the aerophagia, drop it to 5.

Many people find the adjustment to pap therapy a bit difficult.  Don't let it discourage you.

Best wishes for achieving great therapy and comfort!

[Sleeprider]

AHI is of course excellent, and your 95% flow limit is showing as 0.00, so with EPR 3 you are already getting as much benefit in that area s your Autoset can give. Higher pressure seems like an unlikely solution and would make aerophagia worse. You might see some improvement with the higher pressure support and timing functions on the Aircurve Vauto, but it's unlikely your doctor is going to go there. You can always try as it is a better device and can improve comfort. Anyway, I don't see a way to affect the occasional flow limits with the current CPAP. I'd like to help, but am at a bit of a loss of what to try different from your current setup which looks pretty optimal.

[Deborah K.]

Penn, are you going to lower your upper pressure limit to 5 or 6 TONIGHT? You really should.

[Penn Dickery]

Hi Sleeprider, thanks for looking at my data. I'll keep trying with a lower pressure as Deborah suggested, and I'll keep an eye out for a VAuto. I agree my doctor is very unlikely to try to get one for me. My theory is I'm experiencing microawakenings from brief flow limitations that wouldn't bother most people that much. I could be totally wrong. I suppose I'll find out one way or another if and when I go in for surgery. In any case it's only been a few weeks, so it's possible I could see some improvements as I get more used to the machine.

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Penn, are you going to lower your upper pressure limit to 5 or 6 TONIGHT?  You really should.

Hi Deborah, thanks for looking at my data. I'll lower the pressure tonight and see how I do. I upped the pressure for lack of noticing any reduction in my daytime symptoms at the lower pressure, but it's possible I'll feel better as I get more used to sleeping with air blowing into my nose!