CPAP therapy ineffective (new user)

[phatline]

I was diagnosed with moderate sleep apnea (AHI=18, RDI=26) in 2024 by a home sleep study (Watermark ARES). In early 2025 I decided to try the prescribed CPAP therapy (AirSense 10 AutoSet). After 56 days of use (with some gaps), my average treatment AHI is still ~17. 

TL;DR: 

CPAP in Auto does not seem to be helping my apnea (not objectively in AHI, nor subjectively). My apneas are mostly Central, and CSR is detected. A "real" lab sleep study is coming in July.  What can I do to self-titrate in the meantime? I already tried lowering the pressure and eliminating EPR. This reduced my CSA by 40% and did not change my OSA.

More details:

I started with an Evora Full mask on 3/11. It was uncomfortable and produced leaks whenever I moved in my sleep, so I switched to a DreamWare nasal mask on 4/22. I find that works a lot better for my tossing and turning.

Over the entire treatment period it's clear that my AHI varies widely from under 5 to over 30. (Also true of the 3-night home study; AHI=24,20,12.) There is a pattern to that--the more I exercise, the lower my AHI tends to be that night. I put AHI and Active Calories into a spreadsheet and found a correlation of -0.68. It's apparent when visually looking at the data as well. The AHI isn't always *low* but it is almost always *lower* than the surrounding days. And on the really big days (active calories > 1000) my score is always low.

Unfortunately I signed up for wireless data collection thinking that I would be able to see the fine grained data. I only discovered the need for an SD card later, so I have fine grained data only from 5/9 on. From that point I noticed that my apneas are almost entirely CA according to my AirSense. And there are frequent CSR. 

At this point I met with a pulmonologist and she said I have treatment-emergent CSA with Cheyne-Stokes. She said I have primary obstructive apnea and the machine is (mostly) resolving that, but the CSA is emerging due to treatment. She prescribed a split sleep study at the sleep lab. 

The sleep study won't happen until mid July. Until then I'd like to do whatever I can to titrate the CPAP therapy myself. From reading on this board, it seems that TECSA might be alleviated by reducing the high pressure setting and eliminating or reducing EPR. My default was Auto 5-15 cm EPR=2. I adjusted it over the course of a few days to 5-9, 5-7, and finally 4-4. This did reduce my CSA from ~13 to ~8, but OA stayed stable and low (<1).

I mentioned this to the pulmonologist and she said "4-4 is a subclinical setting and won't help your OA". But:

1. My OA did not increase with lowered pressure
2. My CSA is still present at the lowered pressure, including CSR episodes

She encouraged me to increase the pressure settings to at least 5-12. I don't understand why I would want to do that, given the data we have. Higher pressures increase my CSA, don't decrease my OSA, and disturb my sleep more often. I don't understand why she thinks I have primary OSA when the home sleep study did not include an effort belt, so it scored me as purely OSA by default (correct?).

Results of the home sleep study     
Overview of the treatment period [attachment=79187]

I will follow up with screenshots of days at default settings and 4-4.

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Default settings of 5-15 w/ EPR.
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[phatline]

With max=4, min=4.

[attachment=79194]
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Finally, I would like to add that I live at altitude (6600') and the sleep study will have to be done at 4500'.

[Deborah K.]

The point is not low numbers, especially at first, but to have good therapy and comfort.  Your sleep study does not mention CAs, so they may be treatment-emergent, but some studies do not deal with CAs.

You need to turn your pressure settings up.  Try 7 to 20.  The machine won't go higher than you need, so don't worry about the 20.  4 is a pressure put on the machine for small children, and is completely insufficient for an adult.  That's why you need to start at 7, at the lowest. You will probably need more.

You also show Positional Apnea.  PA shows up when you see clusters of obstructives and/or hypopneas clustered together on your chart.  No setting can fix these.  They are caused when your chin drops toward your chest, causing an air blockage, much like a kinked hose causes a water blockage.  Some can fix this by sleeping on a flatter pillow, but most wear a soft cervical collar.  Most drugstores carry a few, and Amazon offers loads of them.  Many like the Caldera Releaf Collar because it's quite comfortable, but some with long necks find it too short. Others like the Velpeau and other collars.  Lowering or eliminating PA will also cause your AHI to drop.

Your Oscar charts need a fix.  The easiest way to do that is to press the F12 key (FN+F12 for Mac) to copy your chart.  That usually shows us what we need to see.  It will include the left panel, and should show the following, and only the following, in the order listed on the first page:

Event Flags
Flow Rate
Pressure
Leak Rate
Flow Limits

Again, welcome, and best wishes for achieving great therapy and comfort!  

[SarcasticDave94]

Correct if there's not an effort belt, unless I'm missing something, the home sleep study likely cannot include, detect, or grade Central Apnea.

Your high elevation can be a source of the Central Apnea showing. The lower elevation during the test might throw off the accuracy regarding this. Besides, Central Apnea are consistently inconsistent. They will vary all the time.

You should in my opinion​ get the Central Apnea recorded, a split study will likely do it. I would complain my head off about the Central Apnea. Ask for the test to include Titration with bilevel and ASV. If they refuse, switch to demanding it. If they still refuse, fire them. Look elsewhere for another team that understands Central Apnea better. Another item that helps improve the test results accuracy is getting it done closer to your living elevation.

[jdougc]

SarcasticDave94, is right the high elevation can be a source of the Central Apnea.
Also pressure swings and ramp can be a source of the Central Apnea.
You can try a tight pressure range of 7 to 8 cm for a few nights.

You have positional apnea, if you are a side sleeper, tucking your chin to your chest cuts your airway off, see around 12:50 on the 9th.  
If you are sleeping on your back then your tongue and soft palette are falling back and closing your airway. 
No increase in the pressure can open up the airway.

You might want to get a soft cervical collar.

[phatline]

Deborah: thanks for the welcome. I wasn't clear in my post but I was running default/auto mode, min=5 max=15 up until mid-May. You can see the min=5 and max=15 in the Overview chart up until May 13. I've only been running min=4 max=4 since May 19.

My subjective experience in the first ~1.5 months at default settings was not good. My sleep was highly disturbed (especially when pressure ramped up to 15) and my AHI did not decrease. At 4/4 I'm sleeping better and my CA numbers are down (OA unchanged). 

Are you suggesting that 15 was too low and I need to go to 20? I'm willing to try that. But I find it odd that at 4/4, which is not expected to be therapeutic, I'm seeing the same (low) OA level and a *lower* CA level compared to 5/15. The H level did increase. 

My pulmonologist didn't remark on the PA aspect at all! I'll give that a try during my waiting period for the full sleep study.

I will attach F12 screenshots, thanks for pointing that out.

Dave: I did request a split study and the pulmonologist relented even though she doesn't think I have primary CSA. My main concern here is that the study has to be done at a lower elevation as there is no lab where I live. I recently traveled to sea level and my AHI dropped below 5. 

jdougc: I sleep on both sides and my back and change positions in my sleep.

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PS: Thank you everyone!

[SarcasticDave94]

For what it's worth, Central Apnea have a mind of their own and will behave mostly the opposite of the Obstructive Apnea. That plus you might have low Obstructive Apnea compared to Central, or that Positional Apnea patterns inflate the Obstructive Apnea numbers.

By the way, medicals don't typically recognize this user defined Positional Apnea pattern. When they test your sleep Apnea and say so much was left side, right side, back, that's so to speak a full body position. This is not Positional Apnea. PA is a chin tuck typically only or something akin to the infant curl which leads to chin tuck. This then kinks off your airway and gives event clusters. Your CPAP has zero chance of blowing through kinked airways.

Please note also if you get them to test ASV in the Titration, it'll record ASV therapy working on your Central Apnea. Personally I don't think they know much about Central Apnea treatment, or much of the rest regarding any Apnea. I'm hearing conceited book learning and doctor know it all when in practice they're doctor do nothing to help but cash your check. Look for options to fire them.

[phatline]

Dave: Thank you. I do tend to curl up in a fetal position when I'm on my side as that feels better for my back and hips. I don't think I tuck my chin in severely, but not sure, and I will give the collar a try to see what happens.

My pulmonologist did say she expects the titration study to result in an ASV Rx for me. It will be a split study and if I'm lucky will catch CA (if it's not treatment-emergent) in the first phase before they do the ASV titration. I'm not sure what I can do with that information--there isn't any treatment I'm aware of except for the Remede system, and my CA doesn't seem severe enough to warrant that--but I just want to know.

FWIW I've been using the "non-therapeutic" 4/4 setting because I can still get the sleep data from the CPAP machine. I'm hoping that I can find some lifestyle changes that might lower my score low enough that I don't need a machine at all. I really dislike sleeping with the machine. I can imagine putting up with it for better sleep, but as of now I'm just getting worse sleep with a machine so it's all downside.

Last night I used 7/7 (AHI=22) and will continue to do that for a few nights to see how it goes. Then increase to 8/8 for comparison. Based on previous data, I would expect my AHI to increase.

[jdougc]

Can you post last night chart?

Was the "AHI = 22" comprised of Hypopneas and Clear airway events?
If mostly CAs then try 6 minimum  and 6 maximum.
If mostly Hypopneas then try the 8 minimum  and 8 maximum. 

Did you turn off ramp?

Hope you get some restful sleep.

[phatline]

CA=17.4, H=3.5, OA=.75

Ramp has been off since I started reducing pressures.