Trying to Understand Waking

[Cruisin4Snoozin]

Hi all.  I'm 51M and diagnosed with OSA with an AHI of 12 back in December.  I always slept through the night uninterrupted, but my partner complained of serious snoring.  I started CPAP in January and my AHI immediately dropped below 1.  The problem is that since starting CPAP, I now wake up 4-5 times per night and generally feel much less rested throughout the day.  The therapist started me with pressures ranging from from 4-20.  When I complained of waking up, she tightened that range.  Then I continued to complain of waking up the same amount, and she switched me to CPAP with pressure of 8, and removed the EPR.  Still, no change to waking up multiple times per night and taking off the mask.  The therapist threw up her hands and said my AHI is great and she doesn't know why I'm waking up so she thinks its "fine".  I read a few posts and turned my EPR back on at 1, but again no changes.  

I use the ResMed AirSense 10 with N30i nasal cushion mask and am happy with the comfort.  I sleep on my back with a TempurPedic Cloud pillow.  (I have issues with both rotator cuffs, so sleeping on my side is a problem).  I'm pretty good at sleeping with my mouth closed.  I don't know what is triggering my wake-ups.  I'm posting a chart, but my charts are also kind of all over the place from day to day so I wouldn't even say the chart is representative of a typical night, and I can't find any pattern to the arousals from night to night.  ChatGPT says it has to do with flow limitations, but I don't trust her!  

Hopefully some of you with more experience can help me understand why I'm waking up.  There are so many variables, that I don't know which things to try in order to sleuth it out.

         

[jdougc]

Part of the problem is your ramp pressure is still at 4cm, your therapist should have notice that.
I like to set ramp pressure to 0.2 under my minimum pressure for 5 minutes. In your case that is 7.8 cm. I think it makes the off and on stand out, not as much as yours does now.

Your flow limits are very high, we use EPR to work on that so raise EPR to 3.
If you feel air starved raise your pressure to 8.6cm or a bit higher if needed.
But raise your ramp pressure also.

Don't make to many changes, let your body get used to these and let us know how you feel when you wake up and how you feel during the day.

We don't need that 2nd chart with snore and other items, just the first like you have it

[super7pilot]

There is a pillow that is made for folks with bad shoulders and also works great for Reflux. Medcline pillow  They are spendy.  Apnea treatment and side sleeping are generally a very symbiotic thing.  That pillow works very well. But it does aggravate my lumbar nerve stenosis. 

You are still snoring and your Flow Limits are high.  Flow Limits are just as they sound. A limit to the flow of air. It can be because of a stuffy nose and/or (much, much more commonly) the tongue falling back (back sleeping), soft palette and/or tracheal collapse. It can be all the above as well. 

It is very common that folks can take time to adapt to breathing and sleeping under higher than atmospheric pressures. It just isn't natural for us. So it can take time. And because of this, the treatment itself can create some awakenings until you adapt. 

The RERA's you had are Respiratory Effort Related Arousals. Yep, you woke up four times from those. You also likely woke up during those two Hypopneas as well. So that's 5 times (at least) your sleep was disrupted. There are likely others in your flow chart when you zoom in and have a closer look. 

Hypopnea's are a partially obstructed airway. Which requires more pressure to treat. 

So I would suggest going back to APAP mode. Ditch the auto-ramp, set the min pressure to 8 or 9cm and max at 12cm and EPR to 3. Then see where your average pressure goes to prevent any events. Then set your minimum to that.

It's a process and there are lots of folks here willing to donate their time to help.

[Cruisin4Snoozin]

Thank you for the info and advice.  Can you help me understand your comment on ramp pressure?  I thought the ramp was at the beginning after putting your mask on?  How would changing the ramp pressure keep me from waking up an hour later?

[jdougc]

Every single time that you turn your machine off and back on, ramp is used. 
Every time, all through the night if you turn it off and on.
You get no therapy increase of pressure during ramp as ramp is a "comfort" feature.
For me, I use it only as a tool to make my chart look better, IMO, that is why I use 0.2 cm under my minimum pressure

[super7pilot]

Ramp won't make you not wake up. Ramp simply doesn't treat apnea's and is just wasted time you can be treated. Using EPR always on with no ramp is generally considered the best option for comfort with treatment.

[Cruisin4Snoozin]

Ramp won't make you not wake up. Ramp simply doesn't treat apnea's and is just wasted time you can be treated. Using EPR always on with no ramp is generally considered the best option for comfort with treatment.

Oh ok thank you.  So it's not related to my question of what's waking me up.....it's just additional "good to know" information.  Got it...thanks.  Sounds like EPR is potentially the main culprit here.

[Sleeprider]

Flow limitation is why you are aroused from sleep. While you have treated apnea, there remains airway resistance that causes increased respiratory effort. We can easily treat that and probably make significant progress on how you feel. Your 95% flow limitation is 0.18 in the chart you posted. Let’s get that below 0.05.


Setting recommendations:
Mode Autoset Standard.
Minimum pressure 8.0
Maximum pressure 12.0
EPR on fulltime Setting 3
Ramp off

These settings give you bilevel pressures between 8/5 and 12/9 (inhale/exhale) and will increase pressure as you inhale making inspiration easier and eliminating respiratory effort related arousal (RERA). Good luck. Give that a try and post an updated chart.

[jdougc]

Last night a little after 1 am, you finally reached 8cm of pressure. 
Since you turn the CPAP machine off and on and off and on again, you might have been air starved at that very low ramp pressure.
Then you took a big breath, maybe from the pressure increase.
Many of us are sensitive to pressure changes. 
This last part is purely speculation.

We want to minimize the awakenings. We can't eliminate microarousals, that is part of normal sleep, but a goal is certainly to minimize them also.

[Cruisin4Snoozin]

Flow limitation is why you are aroused from sleep. While you have treated apnea, there remains airway resistance that causes increased respiratory effort. We can easily treat that and probably make significant progress on how you feel. Your 95% flow limitation is 0.18 in the chart you posted. Let’s get that below 0.05.


Setting recommendations:
Mode Autoset Standard.
Minimum pressure 8.0
Maximum pressure 12.0
EPR on fulltime Setting 3
Ramp off

Good luck. Give that a try and post an updated chart.

Thank you for the clear explanation and settings.  I’ll give that a shot for two or three nights and report back in.  Hopefully getting the flow limitation down will also keep me knocked out for the full night.