Decent AHI but TERRIBLE sleep quality

[Kurth]

        I started APAP 12/13 and struggled with mask issues for the first month. I now have a mask (ResMed AirTouch F20) that does not cause leaks or comfort/fit issues. Since finding the right mask on 1/9 my AHI has been in the low single digits, but I feel like the quality of my sleep has been extremely poor. I am awakened many times, with several prolonged awakenings lasting 30-60 mins. I feel like I'm awake for most of the night and that my overall sleep quality is worse now than pre-APAP. 

I'm new to all of this and have spent a lot of time on this forum etc trying to educate myself on interpreting the data so that I can figure out why I'm not sleeping better. Here is my newbie theory:

Although my 95% flow limits are within reason at around 0.06, they happen fairly frequently throughout the night with individual events ranging from 0.10-0.40. In OSCAR I can see the machine reacting to these events by increasing pressure each time it sees a limit above a certain value. I suspect the frequent changes in pressure are waking me up....whether I wake with each incremental pressure increase or if I wake once the pressure reaches a certain cumulative level. 

Separately, most of my AHI comes from CA clusters that happen 1x nightly. It is my understanding that these are not something I should worry about.

Not sure if I am on the right track, or if this is just part of the normal "adjustment period" as my body gets used to APAP?  If I am on the right track, not sure what to do about it? If not on the right track, any clues as to what may be happening and/or pointers on where I should be looking?

[G. Szabo]

You should increase your minimum pressure to 7 cm, suitable for adults. This will reduce the number of pressure adjustments. For now, keep EPR=1 full-time.   Turn the ramp off. 
After you report the outcome, further refinements might be needed. Turn the calendar off and ensure we can see all the instrument settings and statistics.

[Kurth]

    Thanks for the quick reply and guidance!  In case it helps or changes anything...I have re-attached my data with the calendar hidden and all data visible (per your advice). Will report back tomorrow.

[Kurth]

I increased my minimum pressure from 4 to 7 which seems to have resulted in several blocks of improved & less disrupted sleep. There was one big exception: I had a pressure spike from 12:15 - 1:00 that was extremely uncomfortable, as it was significantly more air than I have previously ever experienced (last night's max pressure was 14.94 and my previous max was 9.68). 

Not sure what next steps and refinements are appropriate, but I'd think that putting an upper limit on the pressure might make sense...somewhere in the vicinity of 10-ish? Also, I would have expected that the increased minimum pressure would result in an improvement in flow limits, but this did not happen...I'm wondering if they are positional?

Any thoughts or suggestions?


       

[SarcasticDave94]

It appears the time you want to focus on, the higher pressure area, this was likely due to an increase in flow limits during this time.

Flow Limits are untimed yet are obstruction based like Obstructive Apnea. To reduce this FL, your EPR will need to be turned up from the current setting of 1. Note this may increase the CA.

[Kurth]

Thanks SarcasticDave94....so something like the following adjustments: change EPR from 1 to 2, and decrease max pressure from 20 to 10?

[G. Szabo]

I suggest you set EPR=2 and maximum pressure to 12 cm. HIgher EPR reduced FLs. 
As for position, it is always good to use a cervical collar and try to sleep on your side with a CPAP pillow because of your FF mask.

[Kurth]

Last night I changed my EPR from 1 to 2 and decreased max pressure from 20 to 12. It seems like I was awake for most of the night. I am predominantly (90% of the time) a side sleeper and have ordered a C collar. Do I need more adjustments to my settings? Should I wait a while to allow my body time to adjust to the ones made so far? Unplug the machine and re-purpose as a paper weight?

       

[G. Szabo]

If the CAs were not predominant in your sleep study, then your current CAs are caused by the treatment and will eventually disappear under the current settings. If you had significant CAs in your sleep study, you should return EPR=1. 
Because your CAs are clustered, there is a chance that they are misclassified obstructions. Hence, a C collar is a good idea.

[Kurth]

None of my studies showed significant CA, they have increased since starting treatment and are predominantly in clusters that occur roughly 1x per night. My poor sleep is not limited to the time of night that the clusters happen. Any additional settings refinements/suggestions?