Sierra

My wife and I both use CPAP but were retired before starting. Our son uses a CPAP too and is still working. I think your questions are quite individual although there may be some patterns. I got into CPAP because I failed an apnea screening test. I felt fine and in my opinion slept fine without it. However I did snore and that was affecting my wife's sleep. I continue with the CPAP treatment because of the other health benefits of controlling the apnea frequency, and of course to control snoring.

My wife on the other hand was not sleeping well before diagnosis and has experienced a huge improvement in sleep and energy. If she was working at the time, I'm sure there would have been benefits there. My son also reports significant improvements in sleep and I'm sure work performance as a result.

Lessons learned? Well I think first one needs to pay personal attention to their CPAP therapy and take ownership of it themselves rather than depending on health care providers. While an Auto CPAP can do a lot with just the basic setup, it can be improved with careful analysis of the data and adjustment of the setup to each individual. Health care providers seldom will take the time to do that. My son got a ResMed AirSense 10 Autoset and part of the package was supposed to be a wireless monitoring of his results and adjustment of his setting to suit him. He has been on it for over two years, and I recently just looked at his SD card with SleepyHead. His setup was originally as he bought it with 5-15 cm pressure, no Auto Ramp, no ramp start pressure, and not one adjustment to the settings. I spent some time looking at the data and set the machine up properly with a start pressure of 7 cm, EPR at 3 on ramp only, and a min max of 8-10 cm. Lesson learned? If you want the best treatment you have to do it yourself, or push the health care providers to do it.

A second less is that you have to try different things if your treatment is less than satisfactory. My wife has been using the same make and model of mask for over 3 years (ResMed FX Nasal) but was starting to have excessive leakage. It took some time but I convinced her to try a F&P Brevida nasal pillow mask instead. She went from a % time over the leak redline of 35% at times to now a consistent less than 1% over the red line.

For myself a big learning was that one has to consider comfort as well as numbers. It took me a long time but I have finally concluded that lack of comfort (too hot, uncomfortable bed, pillow, poor fitting mask, leaking mask, etc) actually causes your AHI to go up. If you don't sleep well and keep waking up during the night your numbers will suffer. Lesson learned is that you have to be comfortable to get good numbers. And on numbers one has to also realize that not everyone can get the same degree of AHI reduction. Central apnea if it is a problem cannot really be reduced with a basic Auto CPAP. But, as long as AHI is under 5 it is acceptable. Over that and you need to be considering a different type of machine.

I could go on, but that is what immediately comes to mind...

You may want to consider talking to your sleep doctor about your condition and ask if the pressure settings on your machine could be set to limit the maximum pressure (lower) and minimum pressure (higher). These machines can be fairly aggressive in trying to stop the very last bit of snoring and flow limitation which may need more pressure than what is needed to address the apnea events. On my wife's machine I limit the pressure for her comfort and allow a bit of snoring (which only the machine hears). On the minimum side if it is increased the fluctuation of pressure during the night can be minimized too. May be helpful for your glaucoma condition. If your doctor does not have access to your data wirelessly, you may want to take out the SD card and bring it with you to the appointment so they can see your detailed data.

Your post generates a lot more questions than answers. SnuzyQ has asked more of them, but I will throw in my 2 cents.

You talk about using a ResMed with CFlex+... ResMed does not use that terminology. Their expiratory pressure relief is called just that EPR. Phillips Respironics (DreamStation) uses the Flex terminology. So which manufacturer and model of a machine do you have? I am not trying to be picky with words, as there actually is a difference in the two methods. The ResMed EPR provides actual pressure relief approximately equal to the setting. If you have a pressure setting of 10 cm, and EPR is set to 3, then you get 10 cm pressure in inspiration, and 7 cm on exhale. That can make breathing out against higher pressures quite a bit easier. Respironics on the other hand with their Flex technology shape the pressure reduction to make it feel a little better, but it really does not reduce pressure equal to the Flex setting. It is less.

Can you tell us more about your pressures? What is the minimum pressure, the maximum pressure, and what actual pressure do you get during the night.

It really does matter exactly what mask models have worked the best and the worst. Nasal pillow masks where part of the mask goes right into your nose, if poorly fitted can collapse under exhale and you can't breathe out. My wife has had that issue with a F&P Brevida mask. The small size collapses on her. The larger size works better but it has to be correctly placed or it can be a problem too.

So if you can give us some more information I may be able to help you if it is a CPAP related issue.

"I don't mind increasing the minimum pressure, but would that be for the best if it's not uncomfortable?"

In some people more pressure can increase the frequency of central apnea (clear airway) events. Your low numbers would suggest you are not in that category. One benefit of increased minimum pressure is that it makes it easier to breathe in. The negative is that it makes it harder to breathe out. That is the reason that the expiratory pressure relief can be helpful. But if you find it annoying then it is not. In the bigger picture breathing out against 6 cm is not that hard. Many people are forced to breathe out against pressures as high as 20 cm or even higher in some cases. The ResMed machines allow you to use the EPR relief feature on the ramp only, so that is what I do. I have a ramp start pressure of 8.4 cm because that is what I find comfortable and then use an EPR of 3. That means I get 8.4 cm in inhale and 5.4 cm on exhale. For me that is very comfortable. Once I go to sleep the machine detects that and turns off the EPR. I have a minimum of 11.4 cm and a maximum of 12.6 cm, and I seem to be able to handle breathing out against that while sleeping.

The other benefit of increasing the minimum is to stop the apnea before it happens. The auto CPAP is a reaction based machine. It has to detect apnea before it increases pressure. If you have your minimum high enough then it may not need to increase very often if at all during the night. That can improve comfort levels by maintaining a more constant pressure level during sleep rather than having one that is jerking pressure up and down as the machine responds to events or lack of events.

But it is all personal. Do what works best for you. Your numbers look very good.

A few comments:

1. Your sleep study must have actually been a titration test. Does the test result specify the type of apnea events your were having at the various pressure levels tried? In some people the central apnea or clear airway events tends to rise with higher pressures. That could account for why the AHI (which is the total) went up with the 12 and 14 cm pressures. However, a CPAP uses pressure to treat apnea, and pressure does not reduce or prevent central apnea because the airway is already open. Normally when a titration test is done they select the lowest pressure that reduces the obstructive apnea while avoiding the higher pressures if they induce central apnea. In any case I think you are correct in being suspicious about the selection of the higher pressure.

2. I am not sure what restrictions you are on with your insurance company, but I would suggest you try to get your primary care doctor to prescribe an Auto CPAP or APAP instead of a fixed pressure CPAP. That way, if you do not need the higher pressures the machine will not go there, and you will still be in compliance. Future sleep studies should also be unnecessary as the machine will auto adjust. And they really do not cost that much more than a fixed pressure machine at least in Canada and the US. And a good auto CPAP will not increase pressure if central apnea events are detected. It will only identify and count them, but not try to stop them.

3. Again if you have any control and are successful in getting a prescription for an APAP, I would recommend the ResMed AirSense 10 AutoSet for Her machine as the first choice (even if you are male). It has an additional optional setting that works well in people needing pressures up to the 12 cm range. Second choice would be a Dreamstation Auto. If you could get your doctor to specify the ResMed For Her machine in the prescription, it should make dealing with the DME easier...

I have been on an Auto CPAP for about 6 months now, and I still will doze off occasionally in the afternoon when watching TV. I have not had any drastic improvement in my daytime energy level or wakefulness. However, I certainly have apnea and continue treatment with it while sleeping about 8 hours per night. There are numerous downsides to leaving apnea untreated, so that motivates me to continue regular use. I have not missed one night since I got a machine.

My thoughts are that you first need to try and improve the quality of your sleep. 7-8 hour are enough for most people, and it sounds like you are getting that much. However the quality of the sleep you are getting may have room for improvement.

First, I would have a good discussion with your pharmacist and then your doctor about the Provigil. Yes, it can help with the daytime sleepiness, and I have seen some information that suggests it may even reduce apnea. However it is doing that because it is a stimulant to keep you awake, and during sleep you remain more alert. The muscles controlling the tongue and throat don't relax as much and apnea may be reduced. However the downside is that you probably do not get as much REM sleep and your sleep quality is reduced due to that. So, I would ask about the dosage, and time of day it is taken. It is a long acting drug, but it would seem if taken first thing on waking on an empty stomach it would start quicker, and more importantly be less active at sleep time. I would ask about alternative such as coffee. I find if I limit coffee and caffeine drinks to 3:00 PM or earlier in the day they keep me awake but don't affect my sleep.

Second, you may want to take a close look at your CPAP machine setup. Are the minimum and maximum pressures set right for comfort and effectiveness. Do you use the expiratory relief feature? It may be increasing your treatment pressure, and reducing your comfort. I find that if your machine is supported by SleepyHead you can find out a lot about how the machine is performing, and what can be done to improve it. This software is free and can be downloaded here:

SleepHead Download

Last you may want to look at your whole approach to sleeping to see what can be done to improve your sleep quality outside of using prescription drugs and the CPAP. I have found that all the information and tools at the site below to be quite helpful in evaluating my views about sleeping and what I can do to improve sleep quality. The site was developed by a pharmacist and university professor that is interested in treating sleep disorders without or with a very minimum of drugs.

https://mysleepwell.ca/cbti/

Hope that helps some. If you post some specifics about your CPAP machine make and model and how it is set up, I may be able to make some more specific suggestions.

The overall objective in setting Auto CPAP pressures is to get AHI under 5 as a minimum, and as much as possible under that while maintaining sleeping comfort. Normally you start with a wide pressure range, and narrow it up. You will get the most benefit from increasing the minimum pressure. The last step is to reduce the maximum so it is not going too high unnecessarily. From your data of "P95=8.5, Pmean=6.5, AHI=.02, SNI=2.3, and Leak=3.1" I would set your minimum at 6 cm or possibly even 6.5 or 7 cm, and your maximum at 9 cm. You may find you can reduce that maximum to as low as 8 cm. A final setting may be as narrow as a minimum of 7 cm and maximum of 8 cm. The other aspect of the minimum pressure is comfort. If it is too low like 4 cm you can feel starved for air when you are trying to go to sleep. That will all depend on you and your mask to some degree. So factor in your own comfort.

I'm guessing that SNI may be a snoring index? If so that may be what is driving your pressure up. So when reducing maximum pressure you should keep an eye on it as well as the AHI. That article I gave you a link to, suggests this machine may be overly aggressive in increasing pressure in response to snoring. So, you may want to control that by reducing max pressure until you see the SNI start go up.

Hope that helps some,

I can't find much detail on how the Luna is different from the ReSmart machines. I kind of think it is mainly in the wireless features and app to report sleep data to a smart device. I see that ResMed and 3B Medical (US arm of the China company) have been in a legal battle over patent infringements. ResMed attempted to ban sales in the US but eventually lost. Now 3B is paying royalties to ResMed, and are continuing sales. There did not seem to be much detail on what specifically was said to be copied or infringed on. But, there must be some similarities between the two machines.

ResMed Dispute

I don't know much about the specifics of Reslex compared to the EPR of ResMed and Flex of Phillips. How they can differ is in how they switch from exhale to inhale. The ResMed senses the patient initiation of a change, probably from flow. The Phillips (Dreamstation) tries to time it. I did my trial after the sleep study with a F&P SleepStyle. I'm sure it was using the timed approach, as at time I felt rushed into taking the next breath, and as a result they turned the setting down for me. I will include a link to an article on how the various systems work, but little information on the 3B Reslex system.

Comparing Expiratory Relief Systems

The thing to keep in mind with this feature is that it is for your comfort only. At least in theory breathing out against less pressure should feel better. But exactly how they do it, may negate the benefits. It depends on the individual. It is something you may get used to, or not.

Just heading out to dinner, and I will give you a more detailed response later. For tonight I would set the auto range at 6 minimum rather than 4 cm. Reslex at 3 is good. 12 cm is fine for max. I think your machine is going to do OK for you. It would be nice to know what the max pressure is during the night, but the 95% number is going to be close, so as long as you know that, you should be fine.