Need help improving my AHI, notably reducing CAs

[pcboy]

Hello,

My CPAP journey started in March 2024. I did a home sleep test and got 19.1 AHI. I live in Japan, they do not treat sleep apnea under 20 AHI, so the doctor refused to help.
I then struggled for months trying to find ways to improve my breathing with no reliable success.  
I then went to an ENT, who found that I have a deviated septum. We did another home sleep test. And this time I had an AHI of 15, so again, the doc can't help me.
Looking at the results of my sleep test, it seems I have more frequent CA than OA. But it's a bit difficult to say for sure as I really didn't sleep well during that test.
I November 2024, I achieved to smuggle a CPAP back in my luggage while traveling in Europe. I'm now the owner of a Lowenstein Prisma Smart Max.
After some self-made titration, I found my ideal pressure to be at 7.5 cmH2O. Using APAP with a larger range does not seem to give me a better AHI so far, it is only making it worse. I have almost always 0.0 OA in Oscar already with that pressure. 
If I follow APAP algorithms, my 95% is 9.0, but clearly this is not working for me. Increasing the pressure gives me more hypopneas (which I suspect are central hypopneas, but I may be wrong) and more CAs. 
 
Overall the problem is I'm still having quite frequent CAs and hypopneas. It's not abnormal for me to get around 2.5 CA/h in Oscar. And I'm still having brain fog during the day. Of course my symptoms improved from before using the CPAP, but I have this feeling that there is still room for improvement.

I'm attaching my OSCAR results on March 21st at 7.5cmH20, and I'm also giving March 23rd, when I tried to put 9.0 cmH2O as one more "test" (last night was fairly bad btw, as the higher pressure gives me chipmunk cheeks, even with my chin strap on).
I'm a new user so can't directly post links to sleepHQ, I'm trying without the protocol:


March 21st (at 7.5 cmH2O):
sleephq.com/public/27e9b2f6-fead-4727-afa2-b010ff10d053


March 23rd (at 9.0 cmH2O):
sleephq.com/public/a7f51684-fca9-4a76-90a7-dc33a13e9679

Is there a way to improve my results and ultimately my symptoms?

Thanks for your help.

Notes: 

- The Lowenstein prisma smart has something similar to EPR called soft-pap. I do not use it. I find it super uncomfortable, as it feels like it's triggering my breath early. The few times I tried, this increased my CAs by a good margin (which is expected since it increases ventilation).

[jdougc]

Welcome to the Forum,
When you look at the SleepHQ charts, your have flow limitations where your breathing tops are not rounded.
The Soft-Pap, if it provides Pressure Support, might help with this and your CAs.
I am not familiar with this machine or the settings.
Can you show the settings that appear when you turn this option of Soft-Pap on?
The experts here can add their experience and knowledge.
You may need a new machine if these CAs are not treatment emergent.
Again welcome and good luck.

[pcboy]

Thanks jdougc for your help,

> When you look at the SleepHQ charts, your have flow limitations where your breathing tops are not rounded.
> The Soft-Pap, if it provides Pressure Support, might help with this and your CAs.

That was also a thing I noticed in the past and I also thought soft-pap could improve it as my understanding is that it was the same idea as EPR. You can see more info about it on the wiki actually (again I can't post link yet... but it's on the wiki at /wiki/index.php?title=Lowenstein_PrismaLine_optimization#SoftPap_Application_in_Detail )

Basically on my machine I can set sotfpap to level 1, and level 2 only (level 3 is only available on Prisma20A model). I tried both level 1 and level 2, and both have this problem that before the end of my expiration, it seems to already trying to trigger my inspiration. The effect is so uncomfortable to me that it's really affecting my sleep. In general I'm a bit sensitive to pressure changes. And in the end I think I never achieved to keep it longer than one hour. I will give it another try since it has been a few months since the last time I actually used it... I wasn't super used to the machine at that time.

[jdougc]

Try getting used to it while you are reading or watching TV. That's not much pressure support.

The more expensive model has more "EPR" and a boost of pressure on inhalation. Would help with those Flow Limits.

https://www.youtube.com/watch?v=o01BbOAed0I

[Dormeo]

In general, a differential between inhalation and exhalation pressure may tend to increase CAs, but it can also help with flow limitations.

Your CAs mostly come after deeper breathing, which often signifies an arousal from one sleep stage to a more shallow one, or from sleep to wakefulness. Unless such CAs are causing O2 desaturation, I think the real problem is the arousals and not the CAs. While arousals are a normal part of sleep, too many arousals can interfere with the progression of sleep stages throughout the night.

Flow limitations disturb the sleep of some people and have no effect on others. So it's hard to say whether lingering FLs are a problem for you.

One way to try to get more restful sleep, with fewer arousals, is to doublecheck your sleep habits. Here are the guidelines most sleep specialists recommend:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

[pcboy]

Thanks Dormeo,

I agree with your statement that the arousals seem to ultimately be the problem.


> One way to try to get more restful sleep, with fewer arousals, is to doublecheck your sleep habits. Here are the guidelines most sleep specialists recommend:

Sadly I'm already following all of these, beside maybe exercise regularly. I work from home which doesn't help. I have a treadmill I use around 30 minutes a day. I should likely do more.
I always had quite troubled sleep even before cpap to be honest. But I assumed it's just that I had sleep apnea without knowing for years.

Yesterday I tried the soft-pap. At level 1 (so PS=1). I achieved to sleep with it for the whole night for the first time. So I'm interested to continue for a few days and see. 
My symptoms today are not much different I would say. The AHI is better than yesterday at 2.6, but that's a AHI I often have, my CA events tend to differ between nights. 
What is really different on the results today, are the FL events, I never had so many. I'm usually at 0.0. I wonder if my machine maybe only report FL events if soft-pap is activated? Since all the other days it was 0.0 and suddenly it's 12.88/h, that seems likely that the other days it was just not reported.

sleephq.com/public/180d9ec6-71a1-4f40-8015-346fc68f2b86

I didn't increase my pressure yesterday to compensate for the PS=1. I can retry tonight with 8.5cmH2O, which would be PS=1.3 following their system. I will also try soft pap level 2 again next. 

I'm also attaching my O2Ring data if that helps. Battery died out before I removed the CPAP. But I believe my mind was already kind of woken up at 6.20. This happen quite frequently at around 5am ~ 6am that some arousal of some sort wakes me up.

Thank you

[jdougc]

Your flow limits might be due to the much lower Epap, I thought you were going to use the slightly higher pressures that you used on Sunday, 3/24/2025. My bad for not suggested those pressures. Try closer to 9cm of pressure for the next few days and monitor both you Flow limits and your CAs which might increase.
I also seem to be very sensitive to pressure swings.
Good luck.

[Dormeo]

Yes, I think you're right about your machine -- that it doesn't report FLs without soft-pap being activated.

You can certainly try a higher pressure, but for FLs, you're more likely to get help from a higher pressure difference between inhalation and exhalation. If you'd like to try both -- higher pressure and higher difference -- I'd suggest you do one at a time so you can get a sense of what helps or doesn't help in your particular case. Give it several days before adding an additional change. (For what it's worth, I'd try both changes if I were you, doing one at a time; experimenting, as long as it's safe, is valuable.)

It's encouraging that you slept longer. I'm not surprised you didn't immediately feel better; sleep deficits are a thing and may be delaying benefits for you.

[pcboy]

Thanks guys,

> It's encouraging that you slept longer

Ah, I realized my sentence may have been misleading. When I said `I achieved to sleep with it for the whole night for the first time.` I meant to say I achieved to sleep with pressure support for the whole night for the first time. I slept with CPAP for the whole night many times before. 

Yesterday I tried to increase pressure to 9.0 cmH2O while keeping the soft-pap to still level 1 (which means PS=1.3). 
The results are not great... AHI at 4.18 (CA 2.79 / H 1.16). 
First, my reported deep sleep % is very low. Usually I'm around 23% to 30%, but today was only 9.84% (50 minutes total vs usually 2h+). I think the main reason behind this is the higher pressure as it gives me chipmunk cheeks (I'm fighting with those from the beginning of my CPAP journey, and I did mewing, I have a chinstrap on etc I think my tongue is just too small at this point...). That's another reason why 7.5 cmH2O is better for me usually since at this pressure I don't have the chipmunk cheeks, that ultimately wake me up. I feel like a balloon.  
My FL events increased to 20.92/h (vs 12.88 yesterday) and my SpO2 drops to 3.29/h (vs 1.25/h yesterday). I can see on my spO2 graph around 2:55am that I got to 90% and that coincides with some FL. So I think we are clearly onto something with the FL, this is not normal to have so many is it? 

sleephq.com/public/4d8fb576-ecb2-4dc4-9f90-188d5843099b

In term of symptoms, I think there hasn't been much change yet.

I'm planning on trying again at 7.5 cmH2O but maybe this time with soft-pap level 2 (PS=2). I should likely give each setting a few more days anyway just to be sure. Will report back.

[jdougc]

Your flow limit from SleepHQ increased substantially, might be why your deep sleep % is very low. So many arousals possibly?
Your soft-pap to still level 1 is too low to treat Flow limits, try increasing it to 2.
The lower soft-pap may had made it hard to exhale also.
Try not to change too many things in one night, or make slightly lower pressure change with an increase in soft-pap.
Flow limit: 27m 42s (5.00%)
Flow limit: 44m 8s (8.55%)
Make sure you chin strap pulls straight up and not back.