New and Lost; Need Guidance on optimal treatment

[jabdoulaye]

Hi. I am new to this forum and I started my CPAP treatment less than 2 weeks ago. I did a sleep study with a RDI of 22.8; Hyp 11.8, RERA 9.1, OSA 1.2, CA 0.3, MA 0.3.

I am trying to find the optimal pressure for my therapy. I started on APAP with SoftPAP of 2, but soon found out that I cannot tolerate the treatment as I always end up taking off the mask. With some research here, I tried CPAP with a pressure of 7.5 but soon concluded that my Clear Airway apnea increased so much that my AHI was consistently above 5. I gradually reduced my pressure to 4, hoping that this would reduced my CA and get me more used to CPAP, but still my AHI was consistently above 5.

It was my understanding that CPAP treatment would get my OSA and Hyp level close to 0 but I found out that is not true for me. Moreover, my CA would be so high even on the lowest pressure that makes me lose hope that the treatment would work for me.

I come here for help and guidance because I am lost in the sea of information and I am unable to grasp the complexities of the graphs. 

I attached 2 screenshots below where my pressure is at 4 for both nights, but my AHI for the 2 nights were 6.33 and 11.39 respectively. I am so confused on how that could happen. I also inserted 1 more screenshot where my pressure was at 7.5. I also posted links to SleepHQ below if there is a need to zoom in the graphs for the tiny details. I added another link where I used APAP with pressure from 4 to 20, for reference.


Thanks again for the help and I hope that I can get this sorted so that I can at least start to live a normal life.

Link1:https://sleephq.com/public/254e837b-b457-4330-a526-3162faa0fa58
Link2:https://sleephq.com/public/304640c4-3e5a-45cf-9f68-17709f6839da
Link3:https://sleephq.com/public/5fbb44f7-1fb0-4be7-92d7-11aaf7ca0fd5
Link4:https://sleephq.com/public/f24d288b-bbbc-456e-9dc0-e872841220a6

[jabdoulaye]

Hi.

I have recently started using CPAP for my mild sleep obstructive apnea of AHI 14. I was told that for mild sleep apnea, the pressure should not go beyond 10 units because it does not require a large pressure.

However, even at pressure of 9 units, it can be observed in the screenshot that my OA and H is still not close to 0. 

Please, what do you suggest I do?

Thanks

[Sleepster]

I have recently started using CPAP for my mild sleep obstructive apnea of AHI 14.

Your AHI may drop as you adapt to therapy.

I was told that for mild sleep apnea, the pressure should not go beyond 10 units because it does not require a large pressure.

Unfortunately, most of the medical community is not anywhere near being up to speed on CPAP therapy. This sounds like nonsense to me. The anatomy of your airway determines the pressure you need. The pressure you need should have been determined in the final phase of your sleep study in a process known as titration. It cannot be determined from the severity of your sleep apnea, which is in turn detemined by your AHI.

However, even at pressure of 9 units, it can be observed in the screenshot that my OA and H is still not close to 0.

Are you tolerating CPAP therapy okay? No aerophagia or difficulty keeping the mask on all night?

What happened between 18:15 and 0:30? Did you sleep without the mask on? If you're doing that you can't adapt.

I'm not familiar with your particular CPAP machine but is it possible to change the mode from CPAP too APAP?

[jabdoulaye]

Your AHI may drop as you adapt to therapy.

I thought that only applied to Clear Airway apnea. After I read a few resources, I was made to believe that Obstructive Apnea should reduce as we increase the pressure. Once we reach a high enough pressure, the Obstructive Apnea should have been 0 or very close to 0.

Unfortunately, most of the medical community is not anywhere near being up to speed on CPAP therapy. This sounds like nonsense to me. The anatomy of your airway determines the pressure you need. The pressure you need should have been determined in the final phase of your sleep study in a process known as titration. It cannot be determined from the severity of your sleep apnea, which is in turn determined by your AHI.

There was no process of titration for me. I was sent home with APAP mode of pressure 4-10 units. That is why I was trying out a few things and see the result using OSCAR.

Are you tolerating CPAP therapy okay? No aerophagia or difficulty keeping the mask on all night?

It was hard in the beginning but I am trying my best to get used to exhaling against the pressure. I'm sorry I don't understand the meaning of "aerophagia", but I do feel sometimes uncomfortable with the pressure of CPAP. I can use the mask all night but only if the pressure is not too high and not too much varying.

What happened between 18:15 and 0:30? Did you sleep without the mask on? If you're doing that you can't adapt

I took a nap before 18:00 and woke up. Then I went to sleep again at 0:30. The machine recorded both sessions.

I'm not familiar with your particular CPAP machine but is it possible to change the mode from CPAP too APAP?

I can but I was trying to find the right constant pressure for me. When I set the pressure from 4-20 units, it was uncomfortable and had so much leak that I could not know which pressure was suitable for me. I read on this forum that it is sometimes better to have a constant pressure instead of a varying one. So, I tried it and also I felt more comfortable mentally to get used to breathing against a constant pressure.

[SarcasticDave94]

4-20 is default for most CPAP devices. There's no reason to start there. Worse, 4 is too low for adults to start therapy. Maybe try again at 7-20, 7 to give you a beginning to therapy sooner. Leaving it at 20, because we don't know yet how high you may need to treat events.

Zero events isn't the right goal. Lower events than you tested, yes. Lower than overall AHI 5, again yes. However, you also include this, lowest events while having decent comfort.

If I were you, to help with best effect with the CPAP, do not sleep without the CPAP mask and machine on. Even naps count. Do not reward yourself by sleeping without it.

[jdougc]

Please don't start new threads as we need to see your history.

When you nap, use the cpap machine, in a continuing effort to get used to the machine. Obviously napping without the machine gives you no therapy benefits and isn't helping to acclimate to using the cpap machine.

You can uncheck a session in the lower left session box in Oscar to hide early sessions.

[OpalRose]

jabdoulaye,

I've merged your two threads, as the original thread shows some of your history and results of your sleep diagnoses.

Please keep your questions and charts to this one thread, as this makes it easier for folk to see what you have already tried.

Most of us here are not knowledgeable with the Prisma cpap, but from what I've seen, the Prisma acts more like a Respironics cpap.... slow to react to apneas.  

You have a mixed bag going on.  As already stated, do not focus on obtaining a zero AHI.  Focus on comfort first and lowering the apnea.  

I believe you should be using the Auto mode along with the use of SoftPap, (Exhale pressure relief).
This is just a suggestion, as what you've tried so far isn't working. This may be easier to dial in your optimal pressure and allow you to go back to Cpap mode if you wish.

Since a static pressure of 9cm is doing nothing for you, I suggest setting the minimum to 9 and the maximum pressure to 15.  SoftPap offers a setting of 1 or 2.  Try both and see how it feels.  This should aid in more comfort and help lower the Hypopnea, Reras and Flow Limitation which is very high.  

The Obstructives should also drop.  We can keep watch on the Clear Airway events, as they may just be treatment emergent and will lower in time.

There is some aspect of Positional Apnea, as evidenced by the clumping of Obstructives on your graphs.  This is due to the way you are sleeping, allowing your chin to tuck into your chest and cutting off your air, or by using more than one pillow, which would cause your head to tilt forward.  Think of a garden hose... if you kink it, there is no flow of water.  Same with your airway.

Read through this link for a better understanding.

https://www.apneaboard.com/wiki/index.ph...onal_Apnea

[Sleepster]

I am trying to find the optimal pressure for my therapy. I started on APAP with SoftPAP of 2, but soon found out that I cannot tolerate the treatment as I always end up taking off the mask.

I would go back to that, but as others have advised, do NOT set the pressure range to 4-20. 4 is the lowest the machine can go, 20 is the highest; that's why we call 4-20 "wide open".

I come here for help and guidance because I am lost in the sea of information and I am unable to grasp the complexities of the graphs.

That's the smartest thing you could have done. Far too many people give up because they figure the medical care givers have set the machine correctly and that they simply can't tolerate CPAP therapy. As I said before, the vast majority of care givers are pretty much in the dark about the nuances of CPAP therapy adjustments. Moreover, many of the individuals think it's their job to know what they're doing so they make the claim that they know what they're doing. But they don't. They need to learn and in many cases are willfully ignorant. As one person described it, they are "often wrong but always confident". It makes them seem like they are have an ego problem, and maybe they do. 

I attached 2 screenshots below where my pressure is at 4 for both nights, but my AHI for the 2 nights were 6.33 and 11.39 respectively. I am so confused on how that could happen.

It's simple. You absolutely cannot rely on one night (or in many cases just a few nights). You have to leave the settings alone for several nights and look at trends. An AHI of 6.33, while not ideal, is pretty darn good especially for a beginner. You are just adapting so you have to give yourself time to settle in. CPAP therapy is difficult at first because the pressure in your face and the hose dangling off your face are a huge bother. It can lead to poorer sleep rather than better. But the good news is we are human. And humans have a remarkable ability to adapt. If you keep at it you will soon not even be able to notice the pressure and the hose will become as normal and familiar as your pillow. You will become so used to it that you'll have to hold your hand over the exhalation ports, feeling the air jetting out, to verify that the machine is on!

I thought that only applied to Clear Airway apnea. After I read a few resources, I was made to believe that Obstructive Apnea should reduce as we increase the pressure. Once we reach a high enough pressure, the Obstructive Apnea should have been 0 or very close to 0.

No. Reduction in AHI after adapting to CPAP therapy does apply to clear airway (CA) events for the vast majority of people, but for a newbie it can apply to obstructive apnea (OA) and hypopnea (H) events, too. The AHI is the sum of CA, OA, and H.

There was no process of titration for me. I was sent home with APAP mode of pressure 4-10 units. That is why I was trying out a few things and see the result using OSCAR.

That's a line of thought that the APAP can substitute for a titration. It's dubious at best but it does save your insurance company some money.

It was hard in the beginning but I am trying my best to get used to exhaling against the pressure.

That's the reason for SoftPap. It reduces the pressure on exhalation. I'm guessing that a setting of "1" reduces the exhalation pressure by 1 cm, and "2" reduces it by 2 cm. You can get a bilevel (better known as BiPAP) machine that can reduce it even more, but we are a long way from that right now.

I'm sorry I don't understand the meaning of "aerophagia",

Google it!

but I do feel sometimes uncomfortable with the pressure of CPAP. I can use the mask all night but only if the pressure is not too high and not too much varying.

The APAP mode is designed to keep the pressure low for comfort and raise the pressure only when a need for a higher pressure is detected. But for some people, and this is pretty rare, you can get what's call "run away", where the pressure raises well above what is needed.

Follow OpalRose's advice to set the pressure range to 9-15, and leave it there for several nights. Post the Oscar charts here for your first night so we can see if you're getting run away. If you are your pressure will rise to 15 and stay there, and if you report that it's too high and causing you so much discomfort that you can't tolerate it, then we can recommend lowering it. Often this is temporary until you adapt.

This is my basic 1-2-3 advice for starting CPAP therapy. You pay attention to these three things in this order. You don't worry about 3 until you've accomplished 1 and 2.

1. Compliance. Use the machine every time you sleep, all the time you are sleeping. Even for naps.

2. Leaks. You have to get your leaks under control.

3. AHI.

You are currently on "1". We need to make pressure adjustments to make your therapy comfortable before we start worrying about your AHI.

But, since you mention it, the target AHI is not zero, and in some cases not even close to zero. If you are tested and have an AHI that's less than 5, you will be considered "normal" and not in need of a CPAP machine or any other therapy. Therefore, that is usually taken as the target for CPAP therapy. You came close on a couple of nights, in fact close enough to be considered well treated. My son has an untreated AHI of over 100 and his doctor told him the target was 10. He is, though, doing much better than that, and you can, too, but you have to be patient and give yourself time to adapt.

Don't change your settings too frequently. Sometimes you have to leave the settings alone for a week or two to see the trend. But we are getting ahead of ourselves here. We first need to make your therapy comfortable so that you can achieve compliance, even if it means you have an AHI that is too high, because we understand that it's a temporary condition that we will improve upon as you adapt. But you can't adapt unless you first achieve compliance.

[jabdoulaye]

Thank you all for your thoughtful answers. I read all of them and as suggested, I switched to APAP with pressure of 9 units to 15 units.

I attached my result from last night.

   

It can be observed that I did not wear the mask for the entire night. That is because starting at pressure of 13 units, there was leakage of air around the mask and it was difficult for me to breathe. I tried my best to keep the mask but I just could not fall asleep so much it was hard to breathe.

   

Moreover, there was only one event of OA and 10 events of H. The OA event lasted for 39 seconds before the machine could respond, as shown in my second attachment. After some digging, I found this link about "dynamic mode" in my machine, https://www.apneaboard.com/forums/Thread...vs-dynamic. Do you suggest I switch to it?

I would welcome any other suggestions. Thank you for all the help.

[Sleepster]

It can be observed that I did not wear the mask for the entire night. That is because starting at pressure of 13 units, there was leakage of air around the mask and it was difficult for me to breathe.

I'm not sure why you think the pressure started at 13. It started at 9 and quickly rose to 15. At approximately 01:15 it suddenly dropped to 9. Did you turn the machine off and back on again because you couldn't tolerate the pressure?

After that the pressure again started at 9 and quickly rose to 15. Then it looks like at about 02:15 it looks like your mask became dislodged and started leaking badly, which probably woke you up and made you decide to give up and sleep without the machine.

Perhaps you need a better fitting mask.