Help dialing in settings

Hello, I'm new to OSCAR and new to this forum. Currently in the second week of using APAP. I should say I started therapy before getting a proper sleep study/diagnosis ( which is due in september ).

Current problems I'm facing:
1. Flow limitation spikes ( even when using APAP )
2. Waking up 6-8 times per night.
3. Constant flat peaks in flow rate throughout the night.

OSCAR screenshot: https://imgur.com/a/utG4heo

Now I may be paranoid about the flat peaks, but as I understand they should look like a cow's utter and be consistent throughout the night, which mine mostly look like the one's shown in the screenshot. Regarding the pressure, I am still experimenting with it ( used CPAP because of LankyLeft's video stating APAP causes arousals ) . Turned off EPR as I read they cause CA's. The main culprit of waking up is the pain I'm experiencing with Swift FX nasal pillow masks. I've read the skin toughens up in 3-4 weeks, so I'm sticking with it. Also, is it normal for the mask to lift my nose up just a little bit? I think thats the cause of pain. I tape my mouth each night.

What is the cause of the flow limitations? How do I know if I dialed in my pressure settings? Do you guys still wake up each night even after dialing in the settings and using preffered masks?

damndenis wrote: ↑

Sat Mar 30, 2024 5:15 am

Hello, I'm new to OSCAR and new to this forum. Currently in the second week of using APAP. I should say I started therapy before getting a proper sleep study/diagnosis ( which is due in september ).

Damn! British citizen? Criminal to wait that long (6 mos?). You're using CPAP, not APAP, btw.

Current problems I'm facing:
1. Flow limitation spikes ( even when using APAP )
2. Waking up 6-8 times per night.
3. Constant flat peaks in flow rate throughout the night.

OSCAR screenshot: https://imgur.com/a/utG4heo

Now I may be paranoid about the flat peaks, but as I understand they should look like a cow's utter and be consistent throughout the night, which mine mostly look like the one's shown in the screenshot.

Little footballs, or boobies, depending on which Jason video you've watched recently... yes.

Regarding the pressure, I am still experimenting with it ( used CPAP because of LankyLeft's video stating APAP causes arousals ) . Turned off EPR as I read they cause CA's. The main culprit of waking up is the pain I'm experiencing with Swift FX nasal pillow masks. I've read the skin toughens up in 3-4 weeks, so I'm sticking with it. Also, is it normal for the mask to lift my nose up just a little bit? I think thats the cause of pain. I tape my mouth each night.

See your leak graphs? See the rising leak rate? Your tape job is failing. You can test it in the morning... after waking, relax your tongue and jaw and allow the pressure to inflate your cheeks and mouth. I think you'll find air leaking from one corner. Before I moved to FF, I found I had to use three pieces (CRST, right?)... two vertically across the corners and one horizontally to connect them across the tucked-in lips. Tape starting in the deep places and work outwards... the tape should conform to the skin, not bridge across gaps. Chapstick on the lips helps removal, wetting the whole mess helps removal... you can suck water through the tape, that helps too.

Myself, I hate anything touching my nose! Everyone should have a full-face mask in their arsenal for times of illness, irritation etc... I don't think you should have to callous your nose to enjoy CPAP... but mask choice is entirely subjective. Someone here recently (Zonk? ozji?) suggested nipple cream... no, not that kind! The kind nursing mothers use. I tried the FF Evora, tried to like it... but the nose touching thing got me.

What is the cause of the flow limitations? How do I know if I dialed in my pressure settings? Do you guys still wake up each night even after dialing in the settings and using preffered masks?

FL's are caused by obstructions. 9cm is not enough to stop them... your machine wants to take you higher. Given your good AHI score I'm not sure that's necessary... we aren't seeing O2 data. Going to be depending on your quality of sleep. My settings are 14-20cm APAP... I let it hunt, but I am near my ideal therapy pressure, so it only goes to 14.5cm most nights using a MAD before bed and staying off my back. When I started I was given 10cm, as you age and gain weight those pressures will climb.

I toss and turn... side sleeper, with high BMI, arms go to sleep, waking me up (damn arms!). I had a titration recently, where you go in the lab and someone manages the pressure for you. They found my ideal CPAP at 13cm (just below what my experimentation found) and when allowed supine (on my back) the pressures went up to 18-22cm! If you're on your back that explains a lot of the FL's. The goal is not to pop 0's every night, the goal is restful sleep. If you want those peaks to round out you have to have more pressure... I suggest a night at 9-14cm and see where the machine takes you. The FL algorithm does FFT on your breath waveforms and develops the FL as it senses the distortion, in tech-speak... this drives the pressure up quickly, which is then allowed to fall back slowly... in effect, you have to have problems to get pressure rise. The best effect is when you're near enough to your ideal pressure that the machine doesn't want to move you much higher... unnerstan?

Damn! British citizen? Criminal to wait that long (6 mos?). You're using CPAP, not APAP, btw.

Lithuanian, but yeah, that should be a criminal offense lol. For this night specifically I disabled it, thought it would reduce wakefulness, but it was to no avail.

See your leak graphs? See the rising leak rate? Your tape job is failing. You can test it in the morning... after waking, relax your tongue and jaw and allow the pressure to inflate your cheeks and mouth. I think you'll find air leaking from one corner. Before I moved to FF, I found I had to use three pieces (CRST, right?)... two vertically across the corners and one horizontally to connect them across the tucked-in lips. Tape starting in the deep places and work outwards... the tape should conform to the skin, not bridge across gaps. Chapstick on the lips helps removal, wetting the whole mess helps removal... you can suck water through the tape, that helps too.

Thanks for the suggestion! Definetly gonna triple tape that sucker now and come back with the results. I couldn't get the proper mouth tape everyone recommended in time so it's a bit painful to remove it in the morning hence why I was keeping the tape job to a minimum.

Myself, I hate anything touching my nose! Everyone should have a full-face mask in their arsenal for times of illness, irritation etc... I don't think you should have to callous your nose to enjoy CPAP... but mask choice is entirely subjective. Someone here recently (Zonk? ozji?) suggested nipple cream... no, not that kind! The kind nursing mothers use. I tried the FF Evora, tried to like it... but the nose touching thing got me.

a FF mask seemed uncomfortable for me considering I'm a side sleeper. But if CPAP does improve my extreme fatigue over time I'll gather my own arsenal of masks to fight these apnea monsters.

FL's are caused by obstructions. 9cm is not enough to stop them... your machine wants to take you higher. Given your good AHI score I'm not sure that's necessary... we aren't seeing O2 data. Going to be depending on your quality of sleep. My settings are 14-20cm APAP... I let it hunt, but I am near my ideal therapy pressure, so it only goes to 14.5cm most nights using a MAD before bed and staying off my back. When I started I was given 10cm, as you age and gain weight those pressures will climb.

During previous days with APAP mode on my 95 procentile pressure was 11 with peaks at 13, so I'll switch it back to APAP and increase the min. pressure. Quality of sleep is the same as before starting PAP, should the difference be noticable immediately ( I read only those with severe apnea notice the change more quickly ) ?

I toss and turn... side sleeper, with high BMI, arms go to sleep, waking me up (damn arms!). I had a titration recently, where you go in the lab and someone manages the pressure for you. They found my ideal CPAP at 13cm (just below what my experimentation found) and when allowed supine (on my back) the pressures went up to 18-22cm! If you're on your back that explains a lot of the FL's. The goal is not to pop 0's every night, the goal is restful sleep. If you want those peaks to round out you have to have more pressure... I suggest a night at 9-14cm and see where the machine takes you. The FL algorithm does FFT on your breath waveforms and develops the FL as it senses the distortion, in tech-speak... this drives the pressure up quickly, which is then allowed to fall back slowly... in effect, you have to have problems to get pressure rise. The best effect is when you're near enough to your ideal pressure that the machine doesn't want to move you much higher... unnerstan?

Wow that's a lot of pressure when supine! So the APAP mode shines when presented with ideal pressure? I honestly don't know if I'm sleeping on my back, because I always wake up on my side. Would the old tennis ball behind a shirt trick work for finding out?

The goal is not to pop 0's every night, the goal is restful sleep.

My perfectionism's trying to pop those zeros, while my body is fighting for the latter and ironically none of them are winning.

damndenis wrote: ↑

Sat Mar 30, 2024 5:15 am

Also, is it normal for the mask to lift my nose up just a little bit? I think thats the cause of pain. I tape my mouth each night.

No...the mask shouldn't move the nose at all. If it is moving the tip of your nose....you have things too tight.
I used to tell people that if they look at themselves in the mirror with the mask on and the first thought through the mind is "piggy nose"....you got things too tight.

Take one of your nasal pillows (not attached to mask at all) and gently place it up on your nostrils and breathe....that's how tight it should be.

Remember....tape failure isn't the only cause of leaks....mask movement is also a cause.
So if your tape is still secure in the AM and you are seeing leaking then mouth opening/breathing isn't the cause. Look at mask movement or fitting or whatever. Maybe even a different mask if you are seeing a lot of mask movement leaks.

Your flow limitations may or may not be contributed to unrestful sleep. The best tool you have to reduce FLs is EPR. It drops your pressure when you exhale; by the same token it increases pressure when you inhale. This little increase can help reduce FLs if they originate in sagging tissues in your pharynx; if a stuffy nose is the culprit, the EPR won't really help and you need instead to work on unstuffing your nose.

I know LL doesn't like EPR (or auto settings). I don't fully understand why. True, for a small number of people, EPR can increase the number of CAs, but often those CAs are happening after arousal breathing, and it's the arousal, not the CA itself, that's problematic.

I would recommend that you set your EPR to 1, 2, or 3. Maybe start with 1 and go from there.

Miss Emerita wrote: ↑

Sat Mar 30, 2024 12:33 pm

Your flow limitations may or may not be contributed to unrestful sleep. The best tool you have to reduce FLs is EPR. (snip)

Here's some other opinions on EPR:
viewtopic/t187298/AirSense-11-and-Flow-Limits.html

EPR on Resmed machines is different than most others... it reduces pressure support during the entire exhale cycle, only re-establishing it on the inhalation trigger. When used it is found to decrease your effective pressure by the EPR setting... if you want 12cm, set 15cm and EPR 3. Here's Uncle Nick with some sciency papers:

https://www.youtube.com/watch?v=GaXA0ZIWj1Y

Note that at the end of the video Nick shows an example of how EPR reduced the FL's... 'Pandora's Box', he says. There is the added complexity of two different models (10 and 11) of machines. Also, one night does not a setting prove.

Here's LL... talking about EPR... and us!

https://www.youtube.com/watch?v=zlsB9E0iAEk

Note that he does not mention it helping with FL's.

Miss Emerita wrote: ↑

Sat Mar 30, 2024 12:33 pm

I know LL doesn't like EPR (or auto settings). I don't fully understand why. True, for a small number of people, EPR can increase the number of CAs, but often those CAs are happening after arousal breathing, and it's the arousal, not the CA itself, that's problematic.

What is true for a small number of people may be 100% true for the single person that you are.
That's why you have to try things out patiently and methodically to see what works for you.

As Pugsy says, your nose should not be pushed up.

Don't let any mask give you a sore, and if you see the beginnings of redness / swelling, give that part of your face a rest so that it can toughen up.
Some people's breathing and apnea control are much better when they use a nasal mask or a pillows mask.

Don't make rapid changes, don't change more than one thing at a time.

Just wanna thank everyone who responded! I've switched to APAP mode, set EPR to 1 and my flow rate seems better as well as flow. I'll continue to play with EPR settings. Although sleep looks good on OSCAR, I'm still very much fatigued and struggling with extreme brain fog, maybe the problem lies elsewhere.

OSCAR: https://imgur.com/a/tcNlgSE

Yes, bumping your EPR up sounds like a good next step.

You're still pretty new to PAP therapy, and sometimes it takes a while before it provides restful sleep. So I'd recommend you have some patience and see how things look a month or two from now. There's a decent chance you'll be feeling better.

If at that point you still feel fatigued and fogged, it would be good to ask your primary care physician to run some tests, if that hasn't happened already. Those include testosterone if you're a man, thyroid, iron and other vitamins and minerals that can cause fatigue if you're not getting enough of them*, auto-immune disease, especially in the connective-tissue disease family, and Lyme disease. If there's a chance you're having long covid, that should be investigated. If you suffer from depression, you should follow up on that too.

* Just came across this hefty study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019700/

In the meanwhile, give thought to these guidelines for better sleep and consider making some changes in your habits if you need to:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.