AHI < 1.0 now, but still tired? Is it UARS, RERA, arousals or FL in your FR peaks?

[2SleepBetta]

I continue injecting my own illustrative stuff in this thread, contra my earlier denial I would put personal stuff here. But I am not seeking (nor discouraging) therapeutic suggestions as I experiment. I'm trying to understand and want to share about my A10 Autoset and A10 Aircurve differences in handling what seem to be my EPR resistant and luxuriant FL's. Those almost go away with PS4 of my Vauto. But my sleep quality now seems indifferent to the large FL flagging differences. Comments within these lines are most welcome, solicited even.

I'm still experimenting with my Aircurve Vauto, running it in cpap mode PS=EPR=3, and for that reason I am delaying follow up of my two related, just prior posts. I may eventually switch and again try the Autoset in both apap and cpap modes. 

It's probably a one-time placebo effect, but I was pleasantly surprised with a rarity, a dream, last Thur-Fri night. At Friday's workout I could do resistance reps more easily, even added one military press and might have done two, shoulder permitting. It seemed leg strength and stamina were better, too.  Maybe I can get to dreaming and have REM sleep and dreams again. There may be something to those who would insist straight cpap pressure, sans EPR and PS support, is best FOR ME after 9 years of EPR and then PS. I've been skeptical, got my first Vauto running away from FL and a sleep test qualified me for one later. 

Is the 50% flow drop criterion Gideon and PizzaLoveAndFreedom state for a Flow Limitation in, say, an AASM manual?

Flow Limitation: <50% reduction in airflow for >= 10 seconds

Somehow, I've not seen that criterion documented, but don't question it, must have been blind to it. It now seems to be the default for flow limitations that didn't rise to the earlier hypopnea level, 50-80%. Nevertheless, for my—most of our—purposes it suffices without complications of the new criterion.

I've seen conference presentations and study group reports of the kind that establish criteria for MC and private insurance coverages. It would be good to review the "legislative history" for establishment of FL cutoff and other SDB cutoff criteria for insurance eligibility. After covid, Fauci and the Food Pyramid it's hard to know health significance of any official pronouncements. 

Is it reasonable to infer credible respiratory studies show that exceeding the 50% restriction at least begins to affect health adversely, depending on excesses over 50% and density of FL's? Again, I ask because I believe cutoff criteria are negotiated between medical professionals and Medicare and Health Insurance administrators, both affected by DME's and other lobbying providers. 

FL are a bugaboo with me because most of my I-parabola inspiration waves have a notch at peak I-flow and those are preceded by cardio ballistic notches from just after peak E-flow to the start of I-flow. All of those notches are, in my view, quite uniformly spaced cardiogenic effects, considering that I have PVC's. The A10 Autoset has to be flagging as FL, say, at least half of the cardiogenic notches in both auto and cpap modes. A10 Aircurve flags of FL have always been relatively very few in vauto mode at PS4. I haven't yet tried PS3 much in vauto mode, but think its FL will be rife. 

Have my FL long been prevented by more effective pressures and control of my Vauto or are FL data simply being filtered out in vauto mode, er, for Resmed's marketing purposes?

Related, and crudely put from defective memory (of the Sao Paulo study and not squarely on point) another cutoff criterion is FL up to 30% of a sleep session are shared by up to 95% of people without OSA and that level is not considered a health threat, other things and aberrations being equal. Yet another cutoff criterion in a credible study was for four successive reduced excursions or (was it four reduced areas?) under four successive inspiration curves to be a certain reduced size or percentage.

So much for "the numbers", my sense of restful sleep presently refutes or, at least, rebuts bad numbers and I-wave shapes. After years of Autoset and Vauto use I cannot presently say I now feel less rested with high FL density and flag heights than with lesser amounts of them. A surprise from trying cpap mode once again after my short use of it when I started therapy.

[THEVGE]

First time I chip in, did a rough read on this thread, I am in exactly the same boat as you. Went from CPAP to bi-level, huge improvement in the numbers but zero improvement in sleep quality. Like you I am data-driven, but also like you, the more "I know", the more I think "I know less".

In short I have a few comments/questions based on my personal experience. They may or may not be helpful for your and my quest.

- Do you have data on # of awakenings/arousals during diagnosis, CPAP and bi-level? My awakenings/arrousals during my first PSG where 3 while on CPAP when I did a PSG I had a whopping 40 (with comparable sleep duration and awake percentage). I am still flabbergasted my doktor did not mention this, he only looked at AHI. Seems the CPAP is/was suffocating me, and I have the same feeling with bi-level.
- Could stress be a factor? I always ignored this but today I think my bodies nervous system (not my brain) is completely over-stimulated. I read you have PVS and I had Afib (now sort of gone without medicine by breathing exercises focussed on relaxing the nervous system).
- I found my Google Pixel Watch 3 very helpful in quickly finding awake moments (but I am experienced enough in OSCAR I can also find them without the watch). I wake up on average 2 times/hour (so in reality a lot more) and the pattern is always the same, no matter what setting I use. The number is highest in the second half of the night where there is more REM. Basically every day I wake up, aware, coming from REM remembering part of the dream. Drives me crazy.
- Since using bi-level I have huge SpO2 dips at sleep onset and a more thorough analysis makes me believe I have significant therapy induced CA's. I never noticed this because I have set trigger to very high (tip from this forum) so I think I push them al away. This might indicate I would be better of with ASV? When I checked old data, I never had this with CPAP, but I did when I tried EPR even at 1.

Only things I have not properly tried yest and that I am planning:
- High EPAP (even though I have 0 AHI at 6) based on a succes story somewhere here on the forum. I already accidently noted high EPAP relaxes my heart and I believe the hart rate fluctuations are the biggest hint for good or bad therapy.
- ASV (I have one already but need verification my heart is OK for ASV).

I will monitor this thread......

[SeePak]

"There may be something to those who would insist straight cpap pressure, sans EPR and PS support, is best FOR ME after 9 years of EPR and then PS. I've been skeptical, got my first Vauto running away from FL and a sleep test qualified me for one later. "

2sleepbetta

Your thread is detailed, thoughtful, all encompassing, insightful, respectful, FACTUAL  and Tiring!  LOL
I have had to heat up my 1st coffee 3 times already cause i cant stop reading!

I want to participate in your thread, though i DO NOT ascribe to the conditions you made about <1 AHI and still no restful sleep.

AFter 35 years of pure CPAP, many years of good/great sleep, i DREAM ( not often anymore) of figuring out how to recreate great sleep night after night!

Your history is very helpful, and i suspect your credentials ( dont know what they are, but your writing is impressive) i suspect, will make others take notice.

Me, I am one of those who espouse sans EPR , forget FL and waveforms etc. etc.

Not just to oppose but because experience has proven, to me, that no matter what change i make in my therapy, i can get good and bad nights!
And others are stating the same.
I just had a night with an Oscar chart that looked like a dart board with so many dents and holes filled with events, OA, CA and H etc.
But i was rested when i awoke and stayed that way all day! ( not always that way, but thats the point)

So what gives, how can so many of us swear to relief using practices that other experts say dont work etc. etc.

I think some of it is confirmation bias, placebo effect, some of it is not being conscious of what is really going on with our sleep and day to day feeling.
I have read that even filling out the Epworth Sleepiness questionairre for sleep quality we can often NOT be aware of being tired thru the day.

Your thread had a 2021 post that talked about how you found out that mouth breathing causes deformities in airways, facial structural changes, and i will add tooth crowding, jaw displacement, and much much more.

I just discovered this in the last 4 months, reading about Patrick McKeown and Breathwork, which lead me to all the studies from years ago ( 1900's and even earlier people took note of these effects)

So, for me, with the experience in Measurement and Controls and thought process i have , i reach this conclusion....

I must try to undo what has been done physically etc. to me by re-learning how to breathe , step up my sleep hygiene routine, 
diet and STRESS/ Anxiety reduction.

I am currently OFF of CPAP ( my Resmed is giving out the 'campfire smell'! ) and i feel just as good, at times better than on CPAP.

I am wary of causing problems to my health, but pretty sure it cant be any worse at this point, will see.

And what will get me the results will be the Breathwork!

I hope others will be motivated to check this out!

And keep reading your posts and discoveries.

Thank you so much, this site has given me so much information, including discovering Patrick McKeown, and i am truly grateful to everyone for sharing their trials and tribulations!

Peace!

[2SleepBetta]

A Hello and a Thank You, THEVGE, for your comments, especially the fact you prompted me to review all three of my sleep tests at one sitting—for the first time—and take overdue notice and do more analysis. Your words, below, are in bold font. 

Additionally, at the foot of this post are links to my and several other's threads and posts all about flow limitations and related matters—deep dives in one lengthy thread, particularly into finding a better way to summarize a sleep session's flow limitations. Included are bits from Resmed's patents explaining their approach and clues to recognizing arousals in OSCAR.
  
New conclusion: I'd best get back to wearing my supine block. There was a lot in my 2024 test (see listing below) about need to avoid supine sleep. My block (see link) would likely do wonders with FL I have been concerned with in my most previous few posts in this thread. I have no problem with AHI: have frequent zeroes, few 1.0's and rarely higher values. The block and pictures of mouth seal elements and position: note that the brown elastic band alone holds the Gel-E-Roll piece to the face and only those and that block continued in my use until I quit using the block.

The block: https://www.apneaboard.com/forums/attach...?aid=33700

I lapsed into not using the block, can't remember when but am guessing I didn't look for or pay attention to any increase in FL then. 'Felt fine. AHI could not have suffered much from quitting that block, because I always watch it and Leak each day. I had gotten away from obsessive OSCAR updating, etc., and rested well on long time laurels of my attained low AHI, er, one of "those numbers". Could be my "rested well" standard is way substandard and that I'm used to it as my best.

That 2024 PSG write up of test metrics (referred to below) was so fragmented it took time, now, to piece all the fragments together in a way I understood a lot (not all) of the fine detail for the first time. Foolishly, I did not do that before—just asked for a new Vauto, to replace my long-used used one I bought years ago and liked...and had to have that sleep test to qualify. 

My Medicare-Blue Cross-provided  Autoset was age 9 by 2024 and had been on the shelf 3 or 4 years by then. Its DME had hounded me to replace the Autoset at age 5, but I "beat 'em off" being more satisfied with my used Vauto (one bought through Offerup with 300 hr) and its PS4 as is needed to suppress my actual—or are they simply signaled?—FL.

Conjunction of the 80 RDI of that home test, the much lower 2024 RDI and the cautionary 2024 words about supine sleep, makes sense. The 2015 home test was done in a recliner, supine in effect. Patency of my airway may have deteriorated after my 2010 test with lower RDI. I do have CMT, a degenerative nerve condition that, after noticing it at age 45 (as a high Sierra backpacker), has destroyed all muscles below my knees (braces keep me ambulatory) and it can and may affect swallowing, if not the airway.  Hands have become weak, thumb to index finger muscles are grossly atrophied, gone. 

Airway patency has deteriorated, too? Dunno. Am blessed to have no pains nor injuries from falls occasioned by stupidly trying to continue lifting, carrying, pulling and doing some high and low sucker pruning (from one citrus tree).

After my ongoing experiments I'll go back to old baseline pressure settings for a week or two; then will attempt a sleep quality test using the supine block to keep me sleeping lateral. I'll see if it noticeably improves sleep. It would be a great benefit if the trial helps me identify arousals brought on, say, by FL  

- Do you have data on # of awakenings/arousals during diagnosis, CPAP and bi-level? 

Some summary of my PSG details:
*11/29/2010 PSG, 29 arousals, RAI (index) 5.9, Spontaneous arousals 9, index 1.8
*08/18/2015 In home, Snap Diagnostics LLC, RDI (AHI) Max Dens. Index (>10 min) 80.0,
*03/24/2024 PSG,  RDI (AHI) 51.6, RDI 18.7 
*Key commentaries, largely common to all the tests: desats to 80 but little time <90, little to no REM, plus the major pinpointed problem with supine sleep in 2024. 

-- Could stress be a factor? I always ignored this but today I think my bodies nervous system (not my brain) is completely over-stimulated. I read you have PVS and I had Afib (now sort of gone without medicine by breathing exercises (Buteyko's breathing methods?) focussed on relaxing the nervous system). 

I know a deep breath, when exhaled slowly through pursed lips, steadies one's firearm aim and firing on target.

- I found my Google Pixel Watch 3 very helpful in quickly finding awake moments (but I am experienced enough in OSCAR I can also find them without the watch). 

How about doing a separate post explaining/showing how you find those awake moments? I know I'd like schooling on that as others would. 

I wake up on average 2 times/hour (so in reality a lot more) and the (OSCAR-graphed pattern?) pattern is always the same, no matter what setting I use. The number is highest in the second half of the night where there is more REM. Basically every day I wake up, aware, coming from REM remembering part of the dream. Drives me crazy.

Only things I have not properly tried yest and that I am planning:
- High EPAP (even though I have 0 AHI at 6) based on a succes story somewhere here on the forum. I already accidently noted high EPAP relaxes my heart and I believe the hart rate fluctuations are the biggest hint for good or bad therapy. 
Has that been studied or been commonly known or is it anectodal for you? It strikes me as unintuitive unless it would be your "goldilocks" EPAP pressure for apnea and, hopefully, FL control.

Regarding the links below. I could find them because I posted somewhere in each thread and could do an AB search of my posting handle. Shameless, maybe, but listings after each final post in a thread will suggest similar links will extend users' reach. Readers should not fail to look for answer's first in AB's wiki. Buried in one or more of these threads, THEVGE, are one or more hints and methods for spotting arousals. I see, having looked at some of all these threads just now, I need to revisit them to refresh my mind on what is good or been forgotten and note what may be wrong or in need of clarification: caution! This stuff is not gospel. Below, I offer some rough hints about what you may find at the linked thread or post. Perhaps someone can point us to something better in AB than the one word search facility this excellent site has. Google Image searching of  "x"+"y" ..... site:apneaboard.com will bring up hits on many posted AB images and an opportunity to visit the post it appeared in.

https://www.apneaboard.com/forums/Thread...#pid389057 (the deepest and lengthiest dive into pro and con arguments about FL)
https://www.apneaboard.com/forums/Thread...#pid348362 (quite a mixture, related relevant stuff, Sleep med focus on AHI<5) 
https://www.apneaboard.com/forums/Thread...#pid286581 (C-collars, my and other blocks, struggles)
https://www.apneaboard.com/forums/Thread...#pid273243 (motion clues to arousal and the block)

[THEVGE]

As for breathing exercises: it is indeed the "sniper breathing" that has helped me most. Second is box breathing. This helped me to convince myself stress/anxiety is part of my sleeping issues.

As for the Google Pixel Watch 3: Too tired to put effort in it. I did do a WatchPAT analysis this week (while on bi-level), and I do not know how reliable it is but the WatchPAT shows a lot more REM (> 50 %), more deep sleep (~ 25 %) and about the same awake. SO maybe it is not that good, but a lot better than Garmin/Huawei devices. Basically I look at the "awakes/hour" as a sleep fragmentation index. And that does not help me, because it is always crap.

I decided to stop testing. It is pointless. No matter what I do, Resmed tells me all is good (WatchPAT was AHI 5 and RDI 17 while on bi-level P 7 PS 5,4) and I need a whopping PS of 5 or more to get OK-ish inspiratory flow curve with decent rounding at trigger high (else I die from centrals). Docters ignore this fact and therefore I get no support from e.g. ENT (skeletal scan, DISE) so it feels like shooting in the dark with a hail gun. And all this experimenting is stressing me out so I will hard stop today. Monday I have an appointment with my sleep center but I do not expect much. I am ready to privately pay for DICE, MRA, Velumount mouth brace, CBCT/MRI scan just to get somewhere. But getting anything done privately in The Netherlands is near impossible so I probably have to look to neighboring countries. I currently have no life......

[2SleepBetta]

   

This post belatedly and feebly follows up item no. 1 of post no. 59 above: comparison of cpap and vauto mode performances of my AirCurve10 Vauto (Vauto) at same pressures. It does not yet address later-posted indications of intent to compare Vauto results to results of the AirSense10 Autoset (Autoset). The attachment, depicting recent unsurprising Vauto results, alone, will be discussed little here. So far as it has value, it does indicate that the vauto mode likely out performed cpap mode in reduction of flow limitation flags my Vauto reported. But I can neither affirm nor deny that there was a notable difference in how restful my sleep was in either mode, nor am I sure greater prominence of FL flagging in the Autoset result is actual flow limitation or are an artifact of differing Vauto algorithms for the two modes of operation.

Half the motivation for all planned comparisons was my growing skepticism that the Vauto provided better therapy for my high flow limitations than the Autoset —that despite my belief, in my early years of PAP therapy, that the Vauto was more effective. Now I perceive no real difference in restfulness of two models’ therapies, though the Autoset presents dense and high flow limitations as the Vauto shows less. It seems Vauto virtues controlling flow limitations are overstated, at least for my case of not sensing its superiority.

My goals still are (a) within the threads’ OP topic – to learn, probe and respond with sleep trial results, in this case, to show how my Autoset and Vauto agree and differ in depicting and controlling (my) flow limitations in their cpap and automatic (apap) modes, (b) to use the one guinea pig I have—myself and my sleep disordered breathing (SDB)—use them to address these device matters. I might even improve my sleep, a hoped-for no. 1 collateral benefit: start dreaming in sleep once again, my long-departed indicator of healthful, restorative rest. Never one to feel chronically deprived of sleep and rest, I may not be aware of what I’m missing, but health may have suffered (implants: five in the heart, one in netting for hernia reduction, not to mention dental crowns and a partial plate).

I'm long tardy following up here. Ignorantly, I thought simple sleep trials were feasible as I wrote about device comparisons in my most recent posts here. Remarks that follow deal with why I have been stalled out in advancing this thread, not making progress on my naive plans, as expressed in a few of my recent preceding posts. I've come to appreciate how insightful experiment pre-planning and design are necessary if a significant outcome is to result. Getting it done meaningfully, as better envisioned now, will take many more months. Worse, there is only one experimental subject: me.

My overly simpleminded approach was to emulate bench testings that have compared brands of PAP machines. Test the Autoset and the Vauto with both devices using the same pressure settings and pressure support (PS 3, EPR3) in all trials. I began by comparing cpap and vauto (vpap) modes of the Vauto, as in the attachment. Unsurprisingly (and arguably) for my SDB, the Vauto’ vauto mode reduced indications of FL a bit better than the cpap mode, assuming differing FL burdens/loads were equal in all significant respects.

Never having attempted such a study before, I was late in realizing the complications of experiment design. Late but soon, it occurred to me that night-to-night variations in my sleep metrics would impair and confuse comparison of OSCAR sleep graphics. Sleep trial of modes and machines would face a different flow limitation load each night.  Only already-obvious differences between machines and modes would stand out and be actionable items I’ve been working to correct anyway. In addition, if comparisons are conducted at the same IPAP, EPAP and PS settings, then Vauto performance will being handicapped by limiting its PS to the Autoset’s EPR 3 pressure reduction when a higher Vauto pressure might clean up FL and still provide the same minimum exhalation pressure as the Autoset, that thanks to a higher PS, say 4 cmH20 instead of 3 cm provided by the Autoset.

The attachment shows my four representative 30-minute samples from four different “experimental” sleep sessions showing differences in Vauto handling of FL in its vauto and cpap modes. All said, the exercise indicates the Vauto does reduce FL better in vauto mode than in cpap mode—pressure and pressure support being set to the same values for both modes. That may indicate significant differences in the algorithms handling EPR and PS for cpap and vauto/apap modes in the same Vauto—possibly an artifact of different years Resmed’s EPR and PS models were placed on the market

Were it possible for me to record PAP pressures at my nares during a sleep session, and then play those pressures back to two differing machines or two modes of action for each machine, then real technical differences in machine performances would be evident and more convincing in OSCAR presentations. Bench tests of several different manufacturers’ machines have dosed them with the same pressure series in order to meaningfully rate and compare various machine performances. Here are two instances of bench tests comparing machine performances.

Comparative assessment of several automatic CPAP devices' responses: a bench test study
A part of the Abstract: "Bench testing is a useful method to characterize the response of different automatic positive airway pressure (APAP) devices under well-controlled conditions. However, previous models did not consider the diversity of obstructive sleep apnea (OSA) patients’ characteristics and phenotypes. The objective of this proof-of-concept study was to design a new bench test for realistically simulating an OSA patient’s night, and to implement a one-night example of a typical female phenotype for comparing responses to several currently-available APAP devices. We developed a novel approach aimed at replicating a typical night of sleep which includes different disturbed breathing events, disease severities, sleep/wake phases, body postures and respiratory artefacts."
https://pmc.ncbi.nlm.nih.gov/articles/PMC4792477/; see AB’s SleepRider also
https://www.apneaboard.com/forums/Thread-Comparative-Analysis-of-8-APAP-Machines?pid=175789#pid175789

2015 peer reviewed article comparing (a bench test of) 11 APAPs:
Apneaboard’s“robysue”:https://www.apneaboard.com/forums/Thread...#pid183924

[SeePak]

2sleepbeta and VGE.

Please check out my recent post below...

https://www.apneaboard.com/forums/Thread-Oscar-CPAP-Optimization-Results-Awesome?pid=542474#pid542474

I was tentatively going to title it,   AHI>5, but still refreshed and not tired!!

or

Try something you know wont work!  APAP, Higher pressure and VCOM in my case

I ended up with AHI<1 and still tired later in day, though i always wake up refreshed.

I got rid of clusters of CA/OA/UA events.

And i do not think it was positional, though not yet positive.

Please check out and give your opinions!?

spoiler alert, I am now thinking that getting rid of all the events and using higher and higher pressures is causing a lot of our problems.
Depending probably/possibly on our Phenotype and Endotypes