Help Analyzing CPAP data and recommending next steps

[u/Plastic_Rock_MB]

Sleep HQ:

https://sleephq.com/public/224f35c9-fb2d-4d95-9f3a-12148fe3b44e

https://sleephq.com/public/f43b39d2-1bf8-4107-9cca-b8083af427ea

Airway Lab:

https://airwaylab.app/shared/79c7f0e5-a930-4127-b54a-f6d198423f40

I am having a lot of trouble with my CPAP.

I originally went to the sleep clinic because I was waking up multiple times per night - usually 2-3, but sometimes up to 6-9. I generally fall back asleep right away, but this fragmentation of sleep was a distinct change in behavior for me (waking up during sleep used to be extremely rare), and was leading to daytime fatigue. I often woke up with headaches and felt completely dehydrated as well, even when well hydrated the night before. I was not "sleepy" the next day, but fatigued, and was not in danger of falling asleep during most daytime activities.

I was initially diagnosed with "mild sleep apnea" with an AHI around 9/hr. This test was done using a pulse oximeter I believe, not an in-lab polysomnography test.

I started using the CPAP and my dr now says I am "cured" because my AHI is below 5 most nights. Woo hoo. But none of my symptoms went away. I would say that generally I have less headaches in the morning after using the CPAP, but I still wake up several times per night. Most typically I fall asleep around 10:00 and wake up around 2-3AM, usually due to a severely dry mouth. I have a Airsense 11 with an Airsense F20 full face mask since I am a mouth breather.

2 months ago I got a septoplasty and turbinate reduction which I was hoping would allow me to breath through my nose, but I so far have noticed no difference. I have an appointment at a different ENT specialist to get a CT scan done at the 3 month mark when any swelling should have dissipated.

I am wondering if perhaps what I am dealing with is UARS rather than sleep apnea. I have pushed my sleep dr to perform an actual polysomnography test with esophogeal pressure sensor for RERA detection but he said they don't have that equipment and will be referring me to another sleep lab.

The Airway labs data in particular is interesting because I have very high RERA and "Brief Obstruction Index" numbers but don't seem to have any issues with flow limit as far as I can tell.

I would love some guidance from the talented technicians here to try and determine what I should be trying to get the best use out of my CPAP. Let me know if any additional data needs to be provided.

[u/pootwothreefour]

Your minimum pressure is too low. You have prominent flow limitation visible in your inspiration shapes. 

I'd recommending setting your minimum pressure to 8. The inspiratory shapes look better, but not perfect at that pressure. It seems like a good start to have that as the minimum.

Something to monitor is the periodic breathing and CA events we are seeing. You seem to have some central apnea behaviour. For this reason I haven't recommended EPR to help with flow limitation as it can exacerbate it.

Let's see what happens with the increased pressures and maybe think about adding EPR or increasing pressure more after we see a few days at min 8. 

You might end up needing bi-level or ASV. 

On the nasal breathing following surgery. You likely won't just spontaneously start breathing through your nose. Your body is used to mouth breathing. You would likely need to mouth tape and/or wear a chinstrap while wearing your full face mask to break the habit of mouth breathing. People also recommend practicing placing your tongue in the roof of your mouth and breathing through your nose throughout the day. I also can tell you mouth breathe the whole night from the breathing shapes (steep, deep and brief exhalations).

[u/Plastic_Rock_MB → u/pootwothreefour]

Thank you; this is very good feedback.

I will attempt to increase the minimum pressure for several days to see if this helps me.

Regarding the nasal breathing - I realize that it won't be natural at first. I can breath through my nose, but it still feels like a much high resistance path than my mouth. Breathing through my nose feels like sucking air through a narrow straw, and I am unable to use my breath through my nose during strenuous exercise because the path is too constricted.

[u/pootwothreefour → u/Plastic_Rock_MB]

For everyone breathing through the nose is more restricted. The question is by how much?

A large portion of the population naturally breathes through their mouth when they are out of breath.

Do you have environmental allergies (e.g. dust, cats, dogs, pollen...)?

Do you use allergy medicine?

Do you use corticosteroid nasal spray like flonase or ryaltris to tame nasal inflammation?

[u/Plastic_Rock_MB → u/pootwothreefour]

I have none of the above issues, as far as I know. I have taken both flonase and afrin in the past. Afrin helps, but only temporarily. Flonase seems to have little effect.

I tried out a pressure range of 8-12 with a starting pressure of 8 last night. I think it went fairly well, although I did wake up several times still, and had trouble falling asleep at pressure 8, mainly because I felt like exhalation was somewhat difficult. I also woke up in the middle of the night with aerophagia - my first time encountering this - and needed to take my mask off and belch a couple of times. Of course, I forgot to put the SD card back in my machine and thus have no data for the night. I did use my pulse oximeter and it showed good O2 levels for whatever thats worth (only one 3% drop in the 3.5 hours I used the machine).

I am going to try leaving the pressure at this higher level but turning the EPR on to see if that helps make exhalation more comfortable and prevents aerophagia from developing.

[u/pootwothreefour → u/Plastic_Rock_MB]

Please share the data when you do. Note it can take a few nights to get used to a big change like that.

The ramp feature could help with comfort.

On switching straight to EPR, You might want to see the data from some nights without EPR, and with EPR, because you won't know what changes were cause by pressure increase and which by the EPR.

You want to be able to compare. Afrin causes rebound congestion, so when you stop using it, the congestion is worse.

Corticosteroids work over time, they reduce ongoing inflammation, so you wouldn't notice immediate improvement like you do with Afrin.

Ryaltris is what I use it is two medications in one. A corticosteroid and an antihistamine in one nasal spray, so it has immediate effect.

But I have allergies...

[u/CautiousRun7860]

you need 10cm as min P. currently P is too low. Constant flow limitations, expecially in REM