Still Feeling Fatigued Despite Good AHI - Looking for OSCAR Analysis

[After]

Hello everyone,

I’ve been on CPAP therapy for about 9 months now. Originally, I was diagnosed with an AHI of 37. I’m a 30-year-old healthy male. Unfortunately, for the first 3 months, I was given a faulty machine by my provider. After that, they switched me to an AirSense 10 but without a humidifier because my provider didn't want to give me one.

I recently changed both my sleep doctor and my equipment provider. I’m now using an AirSense 11 with the humidifier set to 3 or 4, cpap range was 4-12, i changed it to 6-12. EPR is on level 3. Even though my machine shows an AHI below 2 and my provider considers my results “very good,” I still wake up feeling tired every morning. Honestly, I’ve never felt a significant improvement since starting therapy despite the improvements "on paper".

I’d like to add a few more details about my situation:

• My ENT diagnosed me with a minor deviated septum that shouldn’t require surgery.
  
• I tend to have inflamed airways, which causes nasal congestion, i was hoping the humidifier would fix that, but it seems it's not as simple as that.
  
• In France, providers are often reluctant to let patients try different masks.
  
• I currently use the Eson 2, but I have an appointment in two weeks and plan to push for a more comfortable/minimal alternative.
  
• I’m also interested in Patrick McKeown’s methods for improving nasal breathing even though i'm not a mouth-breather per-se , i saw them being recommended when searching around older posts.
  
  

I’m attaching my latest OSCAR chart, I would really appreciate any feedback, recommendations, or insights—especially regarding mask choices, pressure settings, EPR, or any other strategies that might help me finally feel more rested.

Thank you in advance for your help!

[Mosie]

I’m no expert and clicked on your post as I am in the same boat. But — it looks like your leak rate is quite high? When my leaks were that high I didn’t ever wake up feeling refreshed - regardless of what the AHI said.

[DaveSkvn]

Hi,

The pressure graph is a bit unsettled. The machine is having to spot issues and react to them. I would suggest you raise your minimum pressure to 8. Many issues would then be inherently handled without having to "wait" for the machine to detect and respond to them. There is also the flow limitations. Just to check that EPR is on 3 full time and not just for ramp... Have you tried a soft cervical collar to keep the chin up and the neck a little straighter? It certainly helped me.

If neither of that works for you, you could try and experiment. Try a couple of days with EPR 0. Check out the flow limitation graphs in Oscar. If they have got noticeably worse then you might get benefit from a higher difference between inspiration/expiration than EPR allows. i.e. EPR "5"  but that would mean getting a bi-level machine.

Good luck!

[After]

Hi,

The pressure graph is a bit unsettled. The machine is having to spot issues and react to them. I would suggest you raise your minimum pressure to 8. Many issues would then be inherently handled without having to "wait" for the machine to detect and  respond to them. There is also the flow limitations. Just to check that EPR is on 3 full time and not just for ramp... Have you tried a soft cervical collar to keep the chin up and the neck a little straighter? It certainly helped me.

If neither of that works for you, you could try and experiment. Try a couple of days with EPR 0. Check out the flow limitation graphs in Oscar. If they have got noticeably worse then you might get benefit from a higher difference between inspiration/expiration than EPR allows. i.e. EPR "5"  but that would mean getting a bi-level machine.

Good luck!

Hey, thanks for the info, i did rise the pressure to 8, just before your message, but had lowered EPR to 1, i'll post again after further testing !

I'm also testing new things to prevent leaks

[After]

Time for some updates, mask change, leaks are way lower than before, i'm usually at 0L/min on the machine screen, pretty big improvements following you guys' advice. 
AHI was higher than normal last night, but then again, it was my first full lenght night's sleep. My work/sleep schedule was all over the place and i slept shorter hours last week, might have shown me an unusually low AHI cause of the low amount of sleep ? I still notice a higher amount of events like clear airways last night.

I'll post a screenshot of last night, and a couple from a few days ago.

Can this be improved any further ?

[ChadBSr]

You can experiment with different EPR levels but other than that you should probably keep the settings here for a few days.

Have you had blood work done? Vitamin d and iron deficiencies are common in people with sleep apnea and cause fatigue.

[After]

You can experiment with different EPR levels but other than that you should probably keep the settings here for a few days.

Have you had blood work done? Vitamin d and iron deficiencies are common in people with sleep apnea and cause fatigue.

Hello there, i've done blood work. I'm in the normal values for those 2. I'm feeling generally better since we fixed the leak issues. This is a huge improvement don't get me wrong, i'm just min/maxing here.

I can't help but notice that the events on the flow rate graph completely dissapear when i'm above 9cm of pressure, would that warrant a trial at 9 or maybe a lowering of my EPR to 0 ?

[DaveSkvn]

Its good that you are feeling better.

There should be no problem with setting min 9 for a few nights when you feel ready and see how it goes.

I wouldn't ignore the effect of the flow limitations. They are what causes the machine to ramp up the pressure a fair number of times. 

   

Flow limitations tend not to respond to increased pressure. They are more responsive to EPR - but in some people EPR can trigger CAs. You can reduce EPR to 0. I would expect the flow limitations to get a bit worse and the CAs to reduce. Your flow limitations are not like mine. You have very few of them but when the appear they are significant. It may be when you roll onto a particular side or your back.

Try upping the pressure to 9 and see how you feel. Then try EPR 0 and maybe a few nights on EPR 3 and see if that makes a difference to the flow limitations - in your case it may not. If a high EPR does not reduce the effect of flow limitations & you feel the same then set it to zero and move on.

[After]

Will research further and keep comparing the results with good hygiene every night, i'll do EPR 0 tonight, and i'll compare as the week goes on. Thanks for the insight on flow limitations, i used to have epr 3 all the time, might check those out ans compare.

The one area i have not looked into are Cpap modes and response modes. I'm on the normal cpap mode and not the "for her" one, and i'm on the normal response mode and not the "soft response" mode.

On an unrelated note, masks wise:

I'm getting good results with the cara, night and day compared to the eson2, but it's leaving a mark that stays visible most of the day, might be an issue long term.
I had good results with a pillows mask that was provided to me for trial (the bmc P2, wich appears to be a cheaper resmed p10 clone), it showed promising results in oscar but it's not a good fit for my nose, i woke up with a painful nose after an hour and a half and switched back to the cara, i'd probably need somethign with a hybrid pillow like a brevida (i can get it for free if i ask nicely) or other F&P masks if i will go the pillows route. I can also get an n20 for trial if i stay in the nasal mask route.

[DaveSkvn]

I'm afraid I won't be of much help on the mask front. I've used the same type of full face mask for years. Perhaps others can offer suggestions.