New"ish" CPAP user. OSCAR review

[tippmann87]

I was diagnosed with sleep apnea back in 2016 and prescribed a CPAP with a pressure of 8. I attempted to use the CPAP, but had a very difficult time sleeping with it and didn't see any improvement for my symptoms, so I gave up on it. Fast forward to now, I am re-attempting to use the CPAP as my exhaustion and brain fog have gotten to a level where I am just downright miserable. My snoring has also caused my wife to get little to no sleep. This is my first week of trying to sleep with the CPAP, and was wondering if there are any settings/adjustments I should make to help me successfully continue my therapy and actually see relief of my symptoms. It's been hard for me to continue the therapy when I'm not seeing any relief of my symptoms. The main thing I'm wondering is if I just need to suck it up for a time period for my numbers to get better and start feeling better, or are there settings I need to adjust to help.

I pasted a summary of the initial sleep study and CPAP titration below. The main thing I noticed was by AHI wasn't very high (3.1) vs my RDI (30.8)


36 yr old male
5'7"
165 lbs

Philips DreamStation Auto CPAP (waiting on recall replacement)
DreamWear Nasal Cushion


REPORT: The patient slept for only 180 minutes. The sleep efficiency was reduced. The sleep latency was quite prolonged. The sleep architecture revealed that only 11% of the total sleep time was spent in REM sleep. The patient did not demonstrate significant periodic limb movements of sleep.

In NREM and REM sleep, the patient demonstrated late appearing sleep related breathing events. Occasional mixed apneic events, hypopneic events and very frequent RERA events were noted. These events were not associated with significant oxyhemoglobin desaturation. Snoring was noted.

In the 180 minutes of diagnostic sleep time, the patient demonstrated 68 sleep related breathing events. This achieves an RDI of 23 which is elevated and is an indication for a CAP titration.

REM AHI: 3.1
REM RDI: 30.8
NREM AHI: 2.6
NREM: RDI: 21.7
TST AHI: 2.7
TST RDI: 22.7

CPAP Titration
REPORT: The patient slept for 300 minutes. The sleep efficiency was only 70%. The steep latency was prolonged at 105 minutes. The sleep architecture was felt to be within normal limits.
The patient did not demonstrate significant periodic limb movements of sleep.
As this was a CPAP titration, the patient was started on PAP at 4on of water pressure and this was eventually increased to &cm. At this level of CPAP support the patient slept well.
During this time the patient demonstrated 4 RERA events and only I central apneic event was identified. This achieves an AHI of 0 and an RDI of 2. Both of these indices are well within normal limits and represent improvements as compared to the patient's previous diagnostic study.
At this level of CPAP support, supine REM sleep and slow wave sleep were both identified and oxygen saturations were normal.
ASSESSMENT: This overnight polysomnography with CAP titration demonstrates that at 8cm of CPAP, the patient's previously documented obstructive apnea/ hypopnea syndrome resolves. Would recommend 8cm of CPAP at bedtime.

THANK YOU!!!

[PeaceLoveAndPizza]

Given the clustering of OA and H events, I suspect positional apnoea (chin tucking, not supine vs prone). A soft cervical collar should help. Consider a flatter (or CPAP specific pillow) to help as well.

I also suggest increasing flex from 1 to 2 (and possibly 3 later). We may need to increase pressure a bit, but let’s see how you do with the SCC and a bit more flex first.

[BoxcarPete]

My take: find a good ENT who specializes in sleep medicine and get yourself scoped. Here's why:

1. RERA>>AHI in initial study
2. No O2 desaturation
3. Primary symptoms are mental
4. You're under 40 years old
5. Tidal volume a little low for size and T_inspiration>T_expiration
6. CPAP is only helping a little

These points all lead me to think you have a restriction in your airway that is not easily shoved aside with a little pressure. It's fragmenting your sleep and preventing your brain from truly resting, though the rest your body is not suffering from hypoxia. I am 33, felt much the same as you describe, and also tried a handful of things after my diagnosis at age 30: briefly tried CPAP, gave up, swapped to MAD for a year, but that little bugger caused all sorts of other problems (wife reported less snoring though), back to CPAP again. Finally woke up one morning and remembered that when I had my tonsils and adenoids out as a kid it changed my life, went to an ENT and within a minute of getting his camera out, he had read off a litany of minor maladies within my nasal cavity and pharynx that all added up to trouble. I came to him with all sorts of questions prepared, and he answered each one saying, "Let's fix your nose now, and talk again later." Well, later is now, got a 3-in-1 nose rebuild (septoplasty, submucosal turbinate resection, and adenoidectomy [yes, again]) last week and so far so good!

[tippmann87]

Interesting, thanks for the info! I do have a small nasal/airway and have noticed that even breathing while awake can feel restrictive. After your nose procedures, do you still need the CPAP?


My take: find a good ENT who specializes in sleep medicine and get yourself scoped. Here's why:

1. RERA>>AHI in initial study
2. No O2 desaturation
3. Primary symptoms are mental
4. You're under 40 years old
5. Tidal volume a little low for size and T_inspiration>T_expiration
6. CPAP is only helping a little

These points all lead me to think you have a restriction in your airway that is not easily shoved aside with a little pressure. It's fragmenting your sleep and preventing your brain from truly resting, though the rest your body is not suffering from hypoxia. I am 33, felt much the same as you describe, and also tried a handful of things after my diagnosis at age 30: briefly tried CPAP, gave up, swapped to MAD for a year, but that little bugger caused all sorts of other problems (wife reported less snoring though), back to CPAP again. Finally woke up one morning and remembered that when I had my tonsils and adenoids out as a kid it changed my life, went to an ENT and within a minute of getting his camera out, he had read off a litany of minor maladies within my nasal cavity and pharynx that all added up to trouble. I came to him with all sorts of questions prepared, and he answered each one saying, "Let's fix your nose now, and talk again later." Well, later is now, got a 3-in-1 nose rebuild (septoplasty, submucosal turbinate resection, and adenoidectomy [yes, again]) last week and so far so good!

---

Given the clustering of OA and H events, I suspect positional apnoea (chin tucking, not supine vs prone). A soft cervical collar should help. Consider a flatter (or CPAP specific pillow) to help as well.

I also suggest increasing flex from 1 to 2 (and possibly 3 later). We may need to increase pressure a bit, but let’s see how you do with the SCC and a bit more flex first.

Thanks for the reply! I will try to increase the flex, use a thinner pillow and order a SCC. I’ll report back with the results.

[tippmann87]

I increased the flex to 3 and used a thinner pillow. My AHI jumped up to a 12 after that. Anyone have any suggestions or idea what's going on? I attached my latest OSCAR report. Thank you all!

[BoxcarPete]

I'm only 6 days past the surgery, and just had my one week follow-up today. Doc said days 4-10 are the worst because I had the adenoids zapped: they are sloughing off in bloody mucous chunks which I need to spit out. It's every bit as disgusting as it sounds. There's no question that breathing is easier for me now and I have not been using CPAP this week, but it's too early to say if I will still need it. I am not too worried about jumping back to it, even before the surgery my sleep study showed no O2 drops, so I'm guiding myself based on how rested I feel which should directly correspond to how fragmented my sleep is from breathing problems.

No idea why your results got so much worse overnight, but I suspect that the advice to have you increase flex was based on the fact that it's a similar function to ResMed's EPR. EPR is secretly a bi-level therapy setting with a limited scope of adjustment for the APAP machines, but Flex might work on a different principle that doesn't provide the same benefits. I would try turning it off and possibly even setting a fixed pressure at 10 to see how that goes.

Another thing I'd be curious to see is what Respironics thinks is periodic breathing, where you have the green bars. Can you show a couple 3-5 minute zoomed in segments from those times, maybe including a CA if it's in the mix?

[PeaceLoveAndPizza]

There is definitely positional apnoea going on there, along with not enough pressure. There are also no real flow limitations to be concerned about. You need a soft cervical collar and/or a pillow that supports good neck alignment.

I suggest setting flex back to 1 and increasing the pressure range to 9-14 to give more support when starting and a bit more headroom on the top end.

What we are trying to find is the proper settings to manage the apnoeas along with the pressure and flow limitations that drive it up, all while giving a better nights rest. It is a fine line we have to walk.

A word on your replacement machine. If you are buying a replacement for your Dreamstation out of pocket I recommend getting a Resmed Autoset (APAP/CPAP) or a ResMed AirSense (APAP/CPAP/Bilevel). The bilevel is more capable, but is more expensive. If it is insurance replacing it, then push for a ResMed. If it is a Philips replacement, you have no real choice.

[tippmann87]

I'm only 6 days past the surgery, and just had my one week follow-up today. Doc said days 4-10 are the worst because I had the adenoids zapped: they are sloughing off in bloody mucous chunks which I need to spit out. It's every bit as disgusting as it sounds. There's no question that breathing is easier for me now and I have not been using CPAP this week, but it's too early to say if I will still need it. I am not too worried about jumping back to it, even before the surgery my sleep study showed no O2 drops, so I'm guiding myself based on how rested I feel which should directly correspond to how fragmented my sleep is from breathing problems.

No idea why your results got so much worse overnight, but I suspect that the advice to have you increase flex was based on the fact that it's a similar function to ResMed's EPR. EPR is secretly a bi-level therapy setting with a limited scope of adjustment for the APAP machines, but Flex might work on a different principle that doesn't provide the same benefits. I would try turning it off and possibly even setting a fixed pressure at 10 to see how that goes.

Another thing I'd be curious to see is what Respironics thinks is periodic breathing, where you have the green bars. Can you show a couple 3-5 minute zoomed in segments from those times, maybe including a CA if it's in the mix?

Man that sounds horrible....I wish you a speedy recovery! I attached a couple 5 min zoomed in segments.

---

There is definitely positional apnoea going on there, along with not enough pressure. There are also no real flow limitations to be concerned about. You need a soft cervical collar and/or a pillow that supports good neck alignment.

I suggest setting flex back to 1 and increasing the pressure range to 9-14 to give more support when starting and a bit more headroom on the top end.

What we are trying to find is the proper settings to manage the apnoeas along with the pressure and flow limitations that drive it up, all while giving a better nights rest. It is a fine line we have to walk.

A word on your replacement machine. If you are buying a replacement for your Dreamstation out of pocket I recommend getting a Resmed Autoset (APAP/CPAP) or a ResMed AirSense (APAP/CPAP/Bilevel). The bilevel is more capable, but is more expensive. If it is insurance replacing it, then push for a ResMed. If it is a Philips replacement, you have no real choice.

Thanks for the feedback! I will give these settings a try tonight. I'm still waiting on the collar to arrive.

[BoxcarPete]

That's two hours, I was looking for a handful of minutes to view the flow rates of individual breaths.

[tippmann87]

That's two hours, I was looking for a handful of minutes to view the flow rates of individual breaths.

Apologies, read that wrong. Thought you were asking for 5 min increments. I'm tracking now...attached what you were actually asking for.