help - new to CPAP - severe OSA - poor sleep duration

[qed.]

Hi!  I'm on night 28 of CPAP therapy, and I'd be very grateful for any help getting CPAP to work better for me.  At this point, I’m sleep deprived to the point of being seriously impaired and not able to function normally, or go about my day.
 
One major issue is sleep duration.  I had a good 6 days early on with my CPAP machine, sleeping close to 7 hours a night.  Then total sleep duration started to decline.  Now I’m down to about 5 hours, and sometimes less than 5 hours, per night.
 
I’m having trouble waking up after too few hours of sleep – I sleep fine from 11 PM to about 4 AM, and then I wake up and can’t go back to sleep.  Or sometimes I wake up in the early morning hours, and am awake for an hour or two before I can get back to sleep again.
 
I have no trouble with sleep onset, or with the first part of the night.
 
Some details:
 
1. I adjusted my pressure range to 10-15 (from 5-15) because of difficulty breathing at the lower levels.
2. Mask is either Resmed N30i or P30i.  Device (Airsense 11) settings in the attachment.
3. No prescription sleep meds.  I take Ashwagandha for sleep.  I very recently started taking Celebrex (an NSAID) for something else, but the problems I’m describing predate Celebrex.
4. I wear a custom dental device, a MAGO (a mouthguard), on my upper teeth at night.  This is not for sleep and predates my diagnosis.
 
OSCAR chart for last night + stats + redacted sleep study are attached.  Thank you so much for any guidance!  I really appreciate it.

           

[Sleeprider]

qed, welcome to Apnea Board. You have pretty straight-forward obstructive sleep apnea, and your pressure range of 10-15 looks good. The main problem is that you have excessive leaks and your pressure varies pretty widely and rapidly, mostly due to flow limitation. As a result, your sleep is very disrupted in spite of a significantly improved AHI from your diagnostic test.

Let's start with a very simple change to your settings. Turn EPR (exhale pressure relief) on, full-time and use EPR setting 3. This change will turn your CPAP into what is effectively a bilevel (BiPAP) device with inhale pressure (IPAP) 3 cm higher than exhale (EPAP) pressure. This is both more comfortable, and effective in eliminating flow limitation which is an increasing airway resistance as inspiration progresses. If you look at a zoomed view of your flow rate chart you will see the flattened inspiration peaks, but with EPR, those will smooth out. As a result, you will use less respiratory effort to get a normal breath, and your arousal rate from respiratory effort (RERA) will be reduced. Give that a try tonight. The other problem is leaks. You need to prevent loss of air pressure through your mouth. There are a few tricks we can use to train you for better control of that, but let's get the EPR on, and if you can, tuck a corner of your pillow between your shoulder and jaw to help keep your mouth closed.

[charlie*M]

1. I adjusted my pressure range to 10-15 (from 5-15) because of difficulty breathing at the lower levels.

One thing I've noticed is that the size of the mask cushion can affect perceived breathing difficulty.  With both the F40 (a hybrid mask I used for about a year) and the P10 (a nasal mask, using  about 2 months now), I had to move to a large size cushion.  While a medium size was a better physical fit on my face / nose, in both cases I had trouble falling asleep due to the breathing effort with the medium.  I also tried increasing the pressure, but especially with the F40, that caused increased leakage and arousals.  With the large size, breathing is much easier for me.

Maybe I'm an outlier (my median tidal volume overnight is around 540), but I don't see this mentioned often here.

[qed.]

@Sleeprider, many thanks for this advice!  I tried to follow this guidance last night -- and failed.  I turned EPR to on, full-time, and level 3 in the clinical menu.  I was surprised to see in my Oscar data this morning that EPR was still set to "Off."

I think the issue is that I failed to also hit the toggle for "Pressure Relief" in the patient menu.  So, I'm very excited to try this settings change, but will need to wait for tonight.

But I think you're on to something. When I woke this morning at the usual time (around 430 AM), I noticed that I was sucking (through my nose) on the outlets from the mask, like through a straw, and was working pretty hard.

---

@charlie*M, Thanks so much for this suggestion.  My face is small and narrow, and I thought I might actually need the small size of the pillows or cradle.  It turns out medium worked much better.  But I'm definitely willing to give large a shot!

[qed.]

qed, welcome to Apnea Board. You have pretty straight-forward obstructive sleep apnea, and your pressure range of 10-15 looks good. The main problem is that you have excessive leaks and your pressure varies pretty widely and rapidly, mostly due to flow limitation. As a result, your sleep is very disrupted in spite of a significantly improved AHI from your diagnostic test.

Let's start with a very simple change to your settings.  Turn EPR (exhale pressure relief) on, full-time and use EPR setting 3.  This change will turn your CPAP into what is effectively a bilevel (BiPAP) device with inhale pressure (IPAP) 3 cm higher than exhale (EPAP) pressure. This is both more comfortable, and effective in eliminating flow limitation which is an increasing airway resistance as inspiration progresses.  If you look at a zoomed view of your flow rate chart you will see the flattened inspiration peaks, but with EPR, those will smooth out.  As a result, you will use less respiratory effort to get a normal breath, and  your arousal rate from respiratory effort  (RERA) will be reduced.  Give that a try tonight.  The other problem is leaks.  You need to prevent loss of air pressure through your mouth.  There are a few tricks we can use to train you for better control of that, but let's get the EPR on, and if you can, tuck a corner of your pillow between your shoulder and jaw to help keep your mouth closed.

Thank you so much again for taking the time to help with this!  Unfortunately, I didn't see much improvement with these new EPR settings.  I'm attaching my OSCAR results from last night.  I'd be grateful for any additional advice re settings or strategies.

I tried the pillow between jaw and shoulder, but only managed it a few times.  I will keep working at it.

I woke up in the early morning again.  I noticed that one nostril was congested.  I tried switching the humidifier from auto to the highest setting, which helped initially -- but ended up causing the tubing and mask to crackle and pop.  I have the ClimateLine heated hose.  Based on reading other posts here, I've now also ordered a hose hook from Amazon.  

Device settings on OSCAR show "Full Face" as my mask setting, but this is only because I tried a full face mask briefly in the morning to see if it would help with the crackling.  I am still using the Resmed N30i as my primary mask.

Latest OSCAR readouts attached.  So grateful for having someplace to go for advice!

       

[Sleeprider]

Almost all results of your therapy last night were unchanged, except you experienced overall lower pressure due to EPR. Flow limits were statistically the same between the two nights, except last night they were mostly in 3 clusters, while without EPR flow limitation was steady all night. Your leak rate is still a major impediment to good sleep and therapy results. Let's keep the EPR as-is, and try a minimum pressure of 8.0 and maximum pressure of 12.0. Hopefully with lower pressure you can better resist the air blasting out your mouth. You need to learn how to control that air, and there are a few exercises that can help you learn to manage air with the back of your tongue to block the airway. With the pressure on, try to sip some water from a straw and swallow. Practice talking while under pressure. Try opening your mouth and inhaling orally while under pressure and exhale through your nose. All of these skills help you to develop a mastery over your airway while under pressure and will translate to the subconscious with repetition. You can try supporting the jaw with support like a chin strap that does not pull back, using a soft cervical collar or your pillow as support as suggested before. You must learn to control your pressurized airway, or you will need to switch to a full-face mask. The Resmed Airfit F40 is an example of a hybrid mask that works like nasal pillows and also covers the mouth.

[qed.]

Thanks again for all the guidance!  In some ways, I'm making progress -- my leak rate is progressing down!  But unfortunately I'm still having pretty much the same problem.  I wake up at about 4 AM and can't return to sleep.  My sleep duration continues to trend down, and I slept for only 4 hours 40 minutes last night.

On the leaks, I think one major issue was that I had the mask on too tight.  The mask guide on this website was super helpful.  

I've ordered a new mask to try (a bleep).  I'm hoping the bleep will require less effort from me to keep the seal during the night.  I'm wondering if the effort of manually adjusting a finicky mask throughout the night to keep the seal is what is keeping me up.

When I woke up this morning, I was still having difficulty breathing through my left nostril notwithstanding it having been under pressure for several consecutive hours.  Not sure what is causing this.  

Given that there has been some improvement in the leak rate, do you still think that mouth leaks are the main issue for me to work on?  Or I'm wondering if this data reveals any other information about what's keeping me from staying down for longer during the night?

Thanks so much!

       

[charlie*M]

I've occasionally been awoken by a single nostril congestion since I've moved to a P10 (nasal) mask.  For immediate relief when that happens I try a nasal spray with oxymetazoline hydrochloride (Afrin, Dristan, or generic), or I take 30mg of pseudoephedrine (not the more potent extended release one), but that takes a little longer to kick in.

As an experiment, you could try the oxymetazoline spray before going to bed.  It lasts 12 hours nominally, but don't use it more than 3 consecutive days due to rebound effect (worse congestion when you stop using it).  That may help you figure out if your poor sleep is related to congestion or fiddling with your leaking mask.

Side note, I'm not sure why your pressure graph (8-11 cm H2O) does not agree with the pressure range in the side bar header (Min 10 Max 15).  Perhaps that's an Oscar software issue.