New CPAP user, a few questions

[Tec5]

...Unlike a CPAP machine, a WatchPAT does know when you're asleep and when you're awake. It was It was developed for that, and was shown to be sufficiently reliable for that....

Thanks for your detailed response, which makes a lot of sense. I especially appreciate your insight into the relative costs of different approaches, and why 'give them an APAP to try' makes some sense.

I have just one question about your comment above; I looked up the WatchPat device online, and it comes with a finger sensor and (optionally) a chest (heart?) monitor - a second wire. However, 'my' WatchPAT device didn't have the chest sensor, it only had the finger sensor. So - do you know what you get / don't get with/without the chest sensor component?

My general concern with all this is that I don't seem to have a baseline condition to measure against.

Thanks again.

Regarding your (highlited) question about the chest sensor....
You can refer to the following two articles:
https://www.itamar-medical.com/wp-conte ... P_mail.pdf
https://www.sleepapnea.org/diagnosis/wa ... st-review/

The chest sensor detects snoring via a microphone and body movement via an accelerometer (similar to that of the accelerometer in your smart phone). It is clearly helpful to detect body position (supine, lateral, prone.

With regards to chest wall expansion take note of the following in the sleepApnea.org review:
Chestwall movement is best measured by a combination of EMG (Electromyography) and RIP (Respiratory Inductance Plethsmography) belts. These belts will actually measure the change in chest circumference brought about by inspiration/exhalation.

So, without the chest sensor, it would seem that you do not get, snoring detection or chestwall effort.

Apparently the the awake/asleep detection is based on the same technology used in smartwatches:

It primarily uses the gyroscope or accelerometer to track your movements and also detect which stage of the sleep cycle you are in. Some smartwatches use heart rate sensors to monitor your heart rate reading. Your heart rate lowers while sleeping also varies when you reach the different stages in the sleep cycle.

https://www.intex.in/blogs/blogs/sleep- ... p%20cycle.

I suspect the finger probe (on your watchPat) did not have an accelerometer incorporated , it would seem that the watchPat analysis of sleep/awake is based on the heart rate.

Ultimately the WatchPat (and similar) are a cost compromise between the gold standard NPSG, where everything is directly measured, recorded and analyzed.

[Steerpike58]

You would benefit from keeping track of your 50% pressure as well.
That's the pressure at which, or above which you spend 50% of your time (statistically known as the median).
When your minimum pressure is too low to keep your airway clear, you have events (including flow limitations) that drive the pressure up.
On your machine, the algorithm only waits 20 minutes for stable breathing before it starts dropping the pressure - the pressure drops too low, it gets driven up quickly - possibly too high, stays there for 20 minutes, and son on. Now you have a roller coaster of changing pressures.

Keeping track of the effect changes have on your median pressure will teach you a lot.

OK, I added "median pressure" to my chart - the new green row. Pretty consistent in the region of 10-11 it seems.



Last night I increased the lower pressure from 8 to 9 (to get the lower pressure closer to the median, which is what I think you were getting at) but - I also reduced the upper pressure from 12 to 11 because I'm still getting mask leaks. As can be seen from OSCAR, last night was a disaster (worst numbers so far; I gave up after just 1hr 57m) so I will undo that change and only that change) tonight - pressure range will be 9 to 12.



I'm going to really focus on the mask fitting, because when the pressure gets high and I wake up, I can feel air blowing into my eye and also I get loud 'trumpet' sounds as the air escapes at the bottom corner ('mask farts' as I call them). I've already tightened things to the point of near-discomfort. I don't have another session with my specialist till end of month, so no obvious access to different fitting masks unless I just start buying them randomly on Amazon ... How do people experiment with masks - rely on a supplier or just buy them? Are masks 'controlled' like CPAP machines or are they more like typical retail commodities? I'll spend more time reading about how to size a mask to my face. I have a feeling mine is slightly too large. I have a F&P Vitera Full Face, medium size. (Mask says Vitera, paperwork from Kaiser said Simplus!).

Just found this on Amazon - https://www.amazon.com/Fisher-Paykel-Vi ... ref=sr_1_5 - looks genuine, only costs $17 - does this look genuine? That's not too bad for an experiment. (Update - Yuk - the 'small' size model is NOT amazon prime so I won't get it quickly, and there's not even an option to pay extra for quicker shipping. Medium and Large are Prime ...).

Edit To Add: I now see that there are three 'parts' to the F&P Vitera mask; there's the headgear part, which in my case says 'M-L' (medium / large). Then there's the 'frame' part, which in my case says 'M', and then there's the 'seal', which in my case says 'M'. I need to search around to see if I can attach a 'small' seal to a 'medium' frame; or do I need to match the seal size to the frame size? And further, do I need to use a different headgear if I want to use the 'Small' seal (and possibly frame)? (M-L headgear and frame seem just fine; it's just the seal part I want to try the smaller of). Update - this page - https://www.fphcare.com/us/homecare/sle ... -fit-pack/ - suggests S, M, L seals will all work with one 'frame'.

[Steerpike58]

This is an attempt to show how my FF mask fits. I removed the 'seal' from the holder so there's more clarity in the photo. My feeling is, the bottom part of the mask is too low - closer to the bottom of my chin rather than just below the lip. If I move it any higher on my face, the air starts leaking at the top of my nose and blows into my eye.



I've given up trying to get a new mask (seal) online (trial will be over by the time I get it) but I did call my sleep clinic and asked for a smaller one; left message Friday morning, no call back that day so Monday will be the first opportunity.

I tried again last night, but after 35 minutes, I was woken (or prevented from sleep) by the air leaking at the lower left / right corners of the mask, creating the typical 'trumpet' sound. Nothing I did could stop it so I ripped off the mask and gave up. Oscar doesn't reflect these leaks; they aren't significant (I guess) to register on the chart, but - they sure are powerful enough to create a lot of noise!

[dataq1]

Just a comment on my experience ( being a long time - uncontrollable mouth opener)
FOR ME, the best mask has been the Fischer-Paykel 431.
In particular, because it has a chin "shelf". In otherwords, the leading edge of the chin (aka mental protuberance) is supported and restrained by the seal.
(as contrasted with the location on your mask the seal is between the mental protuberance and the lips)

While the 431 mask doesn't prevent me from opening my lips, it does inhibit me from opening my jaw, and obviates the need for a chin strap.

[Steerpike58]

I called my clinic as noted above, and on Monday they called me back and offered me three new masks (seals) - the F&P Vitera 'small' seal, and a new mask, Resmed Airfit F20 with Small and Medium seals. The 'small' Vitera was a slight improvement for me over the medium, but I still get 'trumpets' and air in my eyes, so I then moved on to the Airfit F20; the small was a very good fit (the soft silicone layer does a great job of fitting the face), so I've been using that for several days now; you can see that my 'durations' have increased since I'm not being woken up by the noises. I don't like how the 'Airfit' exhausts air (side vents) compared to the Vitera (straight out) but I can probably get used to it.

I had a brief discussion with the clinic person about my high 'Clear Airways'/'Centrals', and she said it's looking like I'll need to come in for a proper overnight in-clinic test. She said their general approach is to give everyone the simple 'WatchPAT' home test, then (for those with high numbers) put them on a CPAP (APAP) to start, and if that works, great; and if not, then go for the extended in-clinic test. A bit upside-down for me, but - at this point, I'll go with it.

This is my ongoing summary:


and this is last night's Oscar run:


Bottom line seems to be, I'm getting way more CA's than OA's and H's (14 CAs vs 1.1 OA and 1.5 H last night, quite typical). And I'm seeing a lot of 'CSRs' on many (but not all) nights. In some ways, the nasal mask was the best fit/comfort, and the numbers during the first week were the best also (when I was using nasal). But - during that period, I was also getting horrible dry-mouths, and never had a single session over 3 hours. I didn't have a humidifier attachment during that period, though. I'm slightly tempted to give the nasal one more try, now that I've got the humidifier.

Regarding 'open mouth' issues - I see this as a two-part problem. For those who cannot stop breathing in through the mouth, I can see that forcing the mouth closed seems like a logical solution. But for me, I'm pretty sure I have no desire to breath IN through the mouth ... but ... the pressure coming in through the nose (using nasal mask) does give rise to air escaping OUT through the mouth. I can't see how using any kind of strap to force the whole mouth closed would 'fix' that, since the air can still escape easily through the lips, even with jaw fully closed. I did see an ad for some kind of tape that will force the lips closed; do they work to prevent air escaping outwards through the mouth? I would imagine the cheeks would just puff out until it got uncomfortable, then escape through the tape perhaps.

I'm due to go back to the clinic for a 'review' later this week, so we'll see what the next steps are. I'm going to be on vacation for most of October, and I need to decide on Medicare enrollment starting November 1, so September really needs to be productive. If Kaiser (current) put me quickly into a proper sleep study test, I may be tempted to stay with them into Medicare, but if they schedule me for (eg) a November study, I may just decide to cut and run from Kaiser, and restart the whole process with a new insurance company and a new doctor. I don't know if they'll 'honor' or 'respect' the existing results or want to put be back to step and do their own set of tests and trials.

[ozij]

I had a brief discussion with the clinic person about my high 'Clear Airways'/'Centrals', and she said it's looking like I'll need to come in for a proper overnight in-clinic test. She said their general approach is to give everyone the simple 'WatchPAT' home test, then (for those with high numbers) put them on a CPAP (APAP) to start, and if that works, great; and if not, then go for the extended in-clinic test. A bit upside-down for me, but - at this point, I'll go with it.

Good.

This is my ongoing summary:

I removed the URL codes from the image, so you get the full image in the message

and this is last night's Oscar run:


Bottom line seems to be, I'm getting way more CA's than OA's and H's (14 CAs vs 1.1 OA and 1.5 H last night, quite typical). And I'm seeing a lot of 'CSRs' on many (but not all) nights.

I was also getting horrible dry-mouths, and never had a single session over 3 hours

.
That's a direct result of air blowing out of your mouth - it's like wind drying laundry.

Regarding 'open mouth' issues - I see this as a two-part problem. For those who cannot stop breathing in through the mouth, I can see that forcing the mouth closed seems like a logical solution. But for me, I'm pretty sure I have no desire to breath IN through the mouth ... but ... the pressure coming in through the nose (using nasal mask) does give rise to air escaping OUT through the mouth. I can't see how using any kind of strap to force the whole mouth closed would 'fix' that, since the air can still escape easily through the lips, even with jaw fully closed. I did see an ad for some kind of tape that will force the lips closed; do they work to prevent air escaping outwards through the mouth? I would imagine the cheeks would just puff out until it got uncomfortable, then escape through the tape perhaps.

Not exactly. The pressure isn't that high, and once your lips are firmly taped, and the air can't escape through them, in will build up to the pressure necessary for opening you airway, and not more. The word around here (haven't tried it personally) is that CPAP pressure isn't even high enough to blow a balloon. What I have tried personally - and have been doing happily for many years - is mouth taping. It works. Don't buy special tapes with slits -- the slit defeats the purpose if you're using a nasal or a pillows mask.

If the lab test is not going to happen soon, there are two things I'd try, based on the data you've shared.
Not both at once:
I'd try raising the min pressure to the median, in the hope of avoiding the drop to where flow limitations appear. The flow limitations make the pressure go up. After a while, your breathing stabilizes, and then the pressure drops too low again, flow limitations appear, and the whole cycle starts again. Preempting the flow limitations and those pressure changes may help, it may even keep the maximum pressure from being driven as high as it is being driven now.
Once you see the effect of a higher minimum. you may want to consider dropping the EPR to 1 or even 0 see how that affects your CA's. EPR makes you blow off CO2 more easily (by making exhale easier) and that can cause the CA's.

[Steerpike58]

...
I removed the URL codes from the image, so you get the full image in the message

Interesting - I thought the guidance was to use the 'Linked BBCode' button to copy, not the 'BBCode' button. The 'Linked BBCode' has the extra URL codes. But for me - in my browsers (Chrome and Edge) when I preview or view the post, either approach has exactly the same result - I see the image in the body of the post without needing to click (using the 'Linked BBCode' ADDITIONALLY provides a link to imgur, but it's not necessary to use it). What were you seeing when you read my post, before making the change?

The pressure isn't that high, and once your lips are firmly taped, and the air can't escape through them, in will build up to the pressure necessary for opening you airway, and not more. The word around here (haven't tried it personally) is that CPAP pressure isn't even high enough to blow a balloon. What I have tried personally - and have been doing happily for many years - is mouth taping. It works. Don't buy special tapes with slits -- the slit defeats the purpose if you're using a nasal or a pillows mask.

Do you have a quick pointer to a product I can buy at a local 'CVS' type store, or, get online at Amazon, that I can try? I have about 4 more days before my next meeting with the clinic and I'd be interested to try it but don't have time to do too much research. Alternatively, is there a good focused post on this forum that would give me a specific product recommendation? The nasal mask was infinitely superior in so many ways, I'd love to get a chance to try it again (without the desert mouth!).

If the lab test is not going to happen soon, there are two things I'd try, based on the data you've shared.
Not both at once:
I'd try raising the min pressure to the median, in the hope of avoiding the drop to where flow limitations appear. The flow limitations make the pressure go up. After a while, your breathing stabilizes, and then the pressure drops too low again, flow limitations appear, and the whole cycle starts again. Preempting the flow limitations and those pressure changes may help, it may even keep the maximum pressure from being driven as high as it is being driven now.
Once you see the effect of a higher minimum. you may want to consider dropping the EPR to 1 or even 0 see how that affects your CA's. EPR makes you blow off CO2 more easily (by making exhale easier) and that can cause the CA's.

Sounds like good advice - thanks! My median pressure is showing as 11, so I would set the min pressure to 11, leaving max at 14 (but expecting this not to be reached). Later, drop EPR to 1 or 0. Note - I did turn off EPR for one evening, but it was so bad without it I turned it back on so the 'chart' doesn't reflect that. I did also set EPR to '1' on 13-Aug, but again, it was so unpleasant I set back to '2' the next night. I'll try doing this again if I get to keep the machine for longer.

[ozij]

...
I removed the URL codes from the image, so you get the full image in the message

Interesting - I thought the guidance was to use the 'Linked BBCode' button to copy, not the 'BBCode' button. The 'Linked BBCode' has the extra URL codes. But for me - in my browsers (Chrome and Edge) when I preview or view the post, either approach has exactly the same result - I see the image in the body of the post without needing to click (using the 'Linked BBCode' ADDITIONALLY provides a link to imgur, but it's not necessary to use it). What were you seeing when you read my post, before making the change?

On Edge I thought I saw the link without the image yesterday. But now I do see it with...
Some people don't link to the image itself, but rather to the imgur HTML, but since you know how to link the image page itself, (the page that has the extension .jpg or .png } an img code is enough.

Do you have a quick pointer to a product I can buy at a local 'CVS' type store, or, get online at Amazon, that I can try?

BSN Medical Cover Roll Stretch, 2" x 10 yds,
And there's a more expensive, gentler silicone tape. "Medvance" used to have rolls on Amazon, 3M has "Kind Removal" blue tape .

If the lab test is not going to happen soon, there are two things I'd try, based on the data you've shared.
Not both at once:
I'd try raising the min pressure to the median, in the hope of avoiding the drop to where flow limitations appear. The flow limitations make the pressure go up. After a while, your breathing stabilizes, and then the pressure drops too low again, flow limitations appear, and the whole cycle starts again. Preempting the flow limitations and those pressure changes may help, it may even keep the maximum pressure from being driven as high as it is being driven now.
Once you see the effect of a higher minimum. you may want to consider dropping the EPR to 1 or even 0 see how that affects your CA's. EPR makes you blow off CO2 more easily (by making exhale easier) and that can cause the CA's.

Sounds like good advice - thanks! My median pressure is showing as 11, so I would set the min pressure to 11, leaving max at 14 (but expecting this not to be reached).

I hope the lab test happens soon. If it doesn't, make the changes gradually.

I did turn off EPR for one evening, but it was so bad without it I turned it back on so the 'chart' doesn't reflect that. I did also set EPR to '1' on 13-Aug, but again, it was so unpleasant I set back to '2' the next night. I'll try doing this again if I get to keep the machine for longer.

See how you handle the higher minimum, consider fixed pressure, leave the EPR as it is ;comfort is important, and at these pressures, EPR, or possibly another machine may be necessary.

[Steerpike58]

Do you have a quick pointer to a product I can buy at a local 'CVS' type store, or, get online at Amazon, that I can try?

BSN Medical Cover Roll Stretch, 2" x 10 yds,
And there's a more expensive, gentler silicone tape. "Medvance" used to have rolls on Amazon, 3M has "Kind Removal" blue tape .

Found "3M Kind Removal Silicone Tape 2" x 5.5 yds" on Amazon; https://www.amazon.com/gp/product/B00ZV ... ct_image_1 so may try that. I'll look at my local CVS also.

If the lab test is not going to happen soon, there are two things I'd try, based on the data you've shared.
Not both at once:
I'd try raising the min pressure to the median, in the hope of avoiding the drop to where flow limitations appear. The flow limitations make the pressure go up. After a while, your breathing stabilizes, and then the pressure drops too low again, flow limitations appear, and the whole cycle starts again. Preempting the flow limitations and those pressure changes may help, it may even keep the maximum pressure from being driven as high as it is being driven now.
Once you see the effect of a higher minimum. you may want to consider dropping the EPR to 1 or even 0 see how that affects your CA's. EPR makes you blow off CO2 more easily (by making exhale easier) and that can cause the CA's.

Sounds like good advice - thanks! My median pressure is showing as 11, so I would set the min pressure to 11, leaving max at 14 (but expecting this not to be reached).

I hope the lab test happens soon. If it doesn't, make the changes gradually.

I did turn off EPR for one evening, but it was so bad without it I turned it back on so the 'chart' doesn't reflect that. I did also set EPR to '1' on 13-Aug, but again, it was so unpleasant I set back to '2' the next night. I'll try doing this again if I get to keep the machine for longer.

See how you handle the higher minimum, consider fixed pressure, leave the EPR as it is ;comfort is important, and at these pressures, EPR, or possibly another machine may be necessary.

So by 'fixed pressure', that means setting min and max to the same, which makes the machine essentially a set pressure device, although still with the EPR feature helping the exhale cycle?

Thanks for all the info!

[ozij]

So by 'fixed pressure', that means setting min and max to the same, which makes the machine essentially a set pressure device, although still with the EPR feature helping the exhale cycle?

Yes.

[Steerpike58]

Had my follow-up meeting at the sleep clinic today. They concluded that the CPAP machine was not working for me and took it back from me. They let me keep the 5 different masks they'd given me as they could be useful in the future. They said the next step is to do an overnight, possibly 'split', sleep study on their premises, and after that, a possible outcome would be that I would need an ASV machine. They said they are backed up 3 months for such an overnight study, but there are cancelations. So my next step now is to wait to see what kind of schedule they can come up with.

Thanks to everyone here for their interest and assistance so far.

[ozij]

Had my follow-up meeting at the sleep clinic today. They concluded that the CPAP machine was not working for me and took it back from me. They let me keep the 5 different masks they'd given me as they could be useful in the future. They said the next step is to do an overnight, possibly 'split', sleep study on their premises, and after that, a possible outcome would be that I would need an ASV machine. They said they are backed up 3 months for such an overnight study, but there are cancelations. So my next step now is to wait to see what kind of schedule they can come up with.

Thanks to everyone here for their interest and assistance so far.

Please keep us updated.
I hope you can find a slot soon!

[Steerpike58]

Had my follow-up meeting at the sleep clinic today. They concluded that the CPAP machine was not working for me and took it back from me. They let me keep the 5 different masks they'd given me as they could be useful in the future. They said the next step is to do an overnight, possibly 'split', sleep study on their premises, and after that, a possible outcome would be that I would need an ASV machine. They said they are backed up 3 months for such an overnight study, but there are cancelations. So my next step now is to wait to see what kind of schedule they can come up with.

Thanks to everyone here for their interest and assistance so far.

Please keep us updated.
I hope you can find a slot soon!

They called me already with a cancellation for next week, so that's good news. The latest 'start' they have is 8pm, which is a bit crazy for me as I typically don't go to bed till 2am (I've been a night-owl my entire life). So I guess I'll try to start going to bed sooner (and getting up sooner) for the next week so I'll be more inclined to sleep early. They said I also need to wear 'pajamas', while I always sleep with just a tee-shirt on, so that will be another source of difficulty in sleeping. But things are moving along!

[Steerpike58]

Had my follow-up meeting at the sleep clinic today. They concluded that the CPAP machine was not working for me and took it back from me. They let me keep the 5 different masks they'd given me as they could be useful in the future. They said the next step is to do an overnight, possibly 'split', sleep study on their premises, and after that, a possible outcome would be that I would need an ASV machine. They said they are backed up 3 months for such an overnight study, but there are cancelations. So my next step now is to wait to see what kind of schedule they can come up with.

Thanks to everyone here for their interest and assistance so far.

Please keep us updated.
I hope you can find a slot soon!

They called me already with a cancellation for next week, so that's good news. The latest 'start' they have is 8pm, which is a bit crazy for me as I typically don't go to bed till 2am (I've been a night-owl my entire life). So I guess I'll try to start going to bed sooner (and getting up sooner) for the next week so I'll be more inclined to sleep early. They said I also need to wear 'pajamas', while I always sleep with just a tee-shirt on, so that will be another source of difficulty in sleeping. But things are moving along!

OK, sleep study "completed". Sort-of. I had a dreadful night in the lab, and only got 2 hours sleep out of 7h 22m trying. So obviously the 'part 2' never happened.

Just got the call today from the sleep doctor to discuss results. She said that based on the limited 2 hours of data, I had no centrals, no OAs, and around 18 Hypopneas per hour. She said the Centrals that we saw in the CPAP trial were all "Treatment Emergent Centrals" - caused by the CPAP machine (I think I've read about that likelihood in this forum). She claims I don't have 'Central Apnea'. So now she wants to schedule me back for the phase 2 sleep study, and see how I respond to an ASV machine. The strange wrinkle she raised was, she wants me to have an Echo Cardiogram, something about how ASV machines can cause problems if you have heart problems ... so that was also scheduled. So - as of now, my original 'Watchpat' test showed 31 AHI (unspecified types); the CPAP trial showed around 18 AHI (14 Centrals, 4 OA / H), and my sleep study showed around 18 AHI, all Hypopneas. So now we wait for the next in-lab torture session/sleep study! She said she'd see if she could get me back in 'soon', and not wait the 3 months backlog.

[Steerpike58]

Had my follow-up meeting at the sleep clinic today. They concluded that the CPAP machine was not working for me and took it back from me. They let me keep the 5 different masks they'd given me as they could be useful in the future. They said the next step is to do an overnight, possibly 'split', sleep study on their premises, and after that, a possible outcome would be that I would need an ASV machine. They said they are backed up 3 months for such an overnight study, but there are cancelations. So my next step now is to wait to see what kind of schedule they can come up with.

Thanks to everyone here for their interest and assistance so far.

Please keep us updated.
I hope you can find a slot soon!

They called me already with a cancellation for next week, so that's good news. The latest 'start' they have is 8pm, which is a bit crazy for me as I typically don't go to bed till 2am (I've been a night-owl my entire life). So I guess I'll try to start going to bed sooner (and getting up sooner) for the next week so I'll be more inclined to sleep early. They said I also need to wear 'pajamas', while I always sleep with just a tee-shirt on, so that will be another source of difficulty in sleeping. But things are moving along!

OK, sleep study "completed". Sort-of. I had a dreadful night in the lab, and only got 2 hours sleep out of 7h 22m trying. So obviously the 'part 2' never happened.

Just got the call today from the sleep doctor to discuss results. She said that based on the limited 2 hours of data, I had no centrals, no OAs, and around 18 Hypopneas per hour. She said the Centrals that we saw in the CPAP trial were all "Treatment Emergent Centrals" - caused by the CPAP machine (I think I've read about that likelihood in this forum). She claims I don't have 'Central Apnea'. So now she wants to schedule me back for the phase 2 sleep study, and see how I respond to an ASV machine. The strange wrinkle she raised was, she wants me to have an Echo Cardiogram, something about how ASV machines can cause problems if you have heart problems ... so that was also scheduled. So - as of now, my original 'Watchpat' test showed 31 AHI (unspecified types); the CPAP trial showed around 18 AHI (14 Centrals, 4 OA / H), and my sleep study showed around 18 AHI, all Hypopneas. So now we wait for the next in-lab torture session/sleep study! She said she'd see if she could get me back in 'soon', and not wait the 3 months backlog.

Had the Echo Cardiogram this week; got the results, all good. So now I just need to wait for them to schedule the overnight test for the ASV titration. I'll be off traveling for the next 3 weeks so not much is going to happen till November at least ... yawn ...