Low AHI and still tired

Hello, I was diagnosed with having OSA almost a year ago now, and have been on CPAP since. I was thrilled with this at the time, since it explained the daytime fatigue I have experienced for as long as I remember (the kind that builds up when I am out of the house doing something and becomes overwhelming without taking a nap). I was in Japan at the time, where the health insurance covers a basic CPAP that you couldn't change the settings of. My Dr told me that the CPAP therapy brought my AHI down from around 30 to under 1- the only problem being that none of this was helping me to feel any better. I never had any issues sleeping with the machine on; I wear it for the full 8.5 hours I sleep every night with no discomfort. Even after 8 months, I was still not experiencing any relief from my tiredness, and my Dr just said that he had done his job and there was nothing else he could do to help.

I am now back in the UK, waiting for an appointment with the NHS, having purchased a Resmed airsense 10 to keep up with my treatment. The last couple of days I have finally began to explore the settings and begin altering the pressures from the default (after looking at my data in OSCAR). I would really like some advice for how to get started. Here is some typical data from when the settings were the default: https://imgur.com/a/FSoyAEF. I have heard to set the max pressure at the P95 and the min pressure at 4 + EPR, but opinions seem to be split on using the EPR and even whether to use it as APAP vs CPAP.

Finally, I am just searching for any ideas for why I could be continuing to experience daytime fatigue despite my perfect CPAP compliance and low AHI. I am 27 and fairly fit, but my fatigue has continued to become more overwhelming, causing me to leave my job as a teacher to take some time to work on my health. In my year of CPAP usage, I would go so far as to say I feel worse than I did before treatment (albeit I do manage to sleep about 1 hour less per night).

Thank you in advance for any advice you have - I have read many community posts and this is an invaluable resource for people with sleep apnea.

Your pressure swings are wide. I would immediately change the minimum pressure to 7.0. Post the data for the next night, and let's have a look at the results of the higher minimum. Please stick to this one thread. Please use the standard format for posting - (wiki/index.php/Sleepyhead:Organize)

Welcome!

I speak only for myself and suggest getting input from the veterans here.

I felt like dogshit with EPR off. the Epr during ramp only seems pointless but that’s just me. Either have it on or off while you sleep, I would think based on my experience only and lack of expertise. Epr off was THE worst pap sleep I ever had.

You should be able to better titrate and figure pressure settings but if what I read here is correct you would want to get a period of several days to compare.

not sure if you have mask in profile but maybe someone can help with leak advice.

We aren’t all the same but I have epr on 3 and a short 5 min ramp. many don’t use ramp but i like short one so if i get up to use the loo I can fall back to sleep in a min or two and be back up and running at full speed. Auto setting that you have can take 30 minutes to get up to pressure. (note the iirc because it’s been a while)

hth

Edited to remove a double post.

RipNationStates wrote: ↑

Wed Sep 06, 2023 3:50 pm

I have heard to set the max pressure at the P95 and the min pressure at 4 + EPR, but opinions seem to be split on using the EPR and even whether to use it as APAP vs CPAP.

That's wrong.

https://www.tandfonline.com/doi/full/10 ... DER.S70062

This is why most studies reporting the equivalence of AutoCPAP to in-lab titration recommend changing the EPAP minimum to the pressure the device is at or below 90–95% of the time.Citation2,Citation15 In our experience, many patients left on AutoCPAP 4–20 are undertreated and may present with awakenings a couple hours into sleep, residual symptoms, or difficulty tolerating PAP. Some patients are sensitive to the pressure changes, so if patients are not doing well with AutoCPAP, fixed CPAP should be tried.

Translation: Your recommended minimum pressure should be set to Inhale PAPA minus Exhale PAP pressure, at what the device is at or below 90–95% of the time.

ChicagoGranny wrote: ↑

Wed Sep 06, 2023 4:20 pm

Your pressure swings are wide. I would immediately change the minimum pressure to 7.0. Post the data for the next night, and let's have a look at the results of the higher minimum. Please stick to this one thread. Please use the standard format for posting - (wiki/index.php/Sleepyhead:Organize)

Welcome!

Exactly.
Because of the incorrect statement you believe in, your minimum is much too low for your needs. Once you've set a reasonable minimum, you may even find the maximum doesn't go as high. Most APAP machine's are programmed to drop pressure as long as there is not reason for them to push it up. And then, when something happens, they start playing catchup. You have to set you minimum to prevent those events.

Thanks for posting the journal article. Sounds quite sensible to me.

Thank you for the replies, and sorry for the late response, I did not notice my post had been approved. I made the suggested changes and have managed to reduce my leak rate in the meantime: https://imgur.com/a/nYmgezA

One thing that is still concerning me is that the flow rate data look very choppy compared to others that I've seen. Has anyone got any insight into any possible reasons for this? I am still not feeling rested and this is the biggest abnormality I can see.

Your flow rate looks pretty normal to me, at least as far as I can tell from this zoomed-out view. The places where you have an inhalation that spikes may be small arousals; you can zoom in to take a look. (Arousal breathing tends to look deeper and messier than asleep breathing.)

I do wonder, however, whether your daytime problems are due to respiration-related sleep issues. Could you clarify whether you feel fatigue or sleepiness during the day? And if fatigue, does it get worse when you exercise? Have you talked with a doctor about other possible causes for your daytime condition?

The reports show normal breathing. Of course, CPAP data doesn't measure actual sleep. Do you remember frequent awakenings during the night? Are you fatigued throughout the day? Do you have excess sleepiness during the day? Are you practicing good sleep hygiene?