Highly irregular breathing patterns

[Michael2]

Hi:

I really could use the help of the experts here. My sleep quality has been very poor recently. I am suffering greatly.

About six years ago, I was diagnosed with sleep apnea (I had a sleep study three months ago, and my untreated AHI was 15.1). Shortly after being diagnosed, I started PAP therapy, and it dramatically improved the quality of my sleep (currently, I use a ResMed AirCurve 10 VAuto with EPAP=19 and IPAP=23). About two years ago, I started suffering from chronic nasal congestion that resulted in terrible insomnia. Due to being unable to breath through my nose, I would struggle to fall asleep, and I would wake up repeatedly. I have been undergoing various surgical procedures to improve my nasal breathing: first, VivAer; currently, EASE expansion; and maybe in the future, a turbinate reduction. In the meantime, I have learned to cope with my nasal congestion by forcing myself to be a mouth breather while I sleep. To do so, I use a full-face mask (a medium ResMed F20), I plug my nose with nose plugs (the HC452 nose plugs), and I use a mouthguard for snoring and sleep apnea to keep my mouth slightly open (the SleepTight mouthpiece). If I do not use the nose plugs, I find I try to breath through my nose and then wake up due to the nasal congestion. If I do not use the mouthguard, I find I close my mouth and then wake up due to being unable to breath.

While I can sleep roughly eight hours with the full-face mask, nose plugs, and mouthguard, I do not think I sleep well. My AHI is low, and I can remember dreaming, but I wake up feeling very unrefreshed. Using SleepHQ, I have examined my PAP data, and I often see unusual flow rate patterns that may signify breathing issues that may be interfering with my sleep. I am hoping some people here may better understand what is going on.

Here is a link to my PAP data from last night:
sleephq.com/public/6fa2c2d9-4286-4526-813d-182bb0898c2f
I know most people here use OSCAR, but I am hoping you are okay with me using SleepHQ. The user interface for SleepHQ is pretty intuitive. You can zoom in and scroll across the various charts. 

Here is a link to a portion of the night:
sleephq.com/public/9786a2e7-04db-466e-a83d-9eb6455f59ce
Is the flow rate pattern normal for mouth breathing with a full-face mask?

Here are links to other portions of the night:
sleephq.com/public/98ddf3d2-293f-4ae8-ae32-235e64ed30ce
sleephq.com/public/4efe9b80-7e67-4d11-b963-a50466935fcb
sleephq.com/public/d02ff679-916c-4334-ab9b-222414a27f93
What could be causing this flow rate pattern? It looks like that for palatal prolapse. However, I do not think it can be palatal prolapse because I am breathing through my mouth and so am bypassing the soft palate. When I am still awake with the PAP machine on, I sometimes feel a kick when I exhale, but I am unsure what causes it. Maybe it is also happening when I am asleep.

Here is a link to another portion of the night:
sleephq.com/public/e5d4ea6b-49b2-4027-8e64-e4c8920cafdd
What could cause this highly variable breathing?

Thanks a lot,
Mike

[verysleepy2]

Following, I have a very similar issue. Also using Vauto with full face mask

[Sleeprider]

You are using very high pressure with your Vauto and your flow rate shows a very disrupted expiratory flow limitation and continuing obstructive apnea at a mild level. Considering the techniques you are using to alter your normal airway, it's not surprising, but I think you are plugging your nose and using a mouthguard all to your own detriment. Even with an obstructed or flow limited nasal pattern it seems you would be better off without this. I prefer interpreting therapy from OSCAR charts, and while I realize SleepHQ has used Oscar in its proprietary software, some of the respiratory statistics and presentation is missing details that might help understand what is going on. Your expiratory pattern may include palatal prolapse, but with so many surgical and physical modifications, it's hard to know.

Have you read any of the threads on this forum by members using the Alaxo Stent? It seems you might find relief using something like that instead of surgery. https://www.apneaboard.com/forums/Thread...A-Approved

[Michael2]

I have the 3'' Alaxo stents. Thus far, I have been unable to make them work. When the stents are in my nose, my nose generates so much mucus that I become very congested. I realize the 6" Alaxo stents are used to treat palatal prolapse. I may try them in the future.

Thanks to my EASE procedure, my nasal breathing has improved a lot. During the day, I have no issues breathing through my nose. On some nights, I can sleep comfortably with PAP while breathing through my nose. On those nights, my flow rate is very regular.

On other nights, I run into a problem I do not understand. I will describe the problem here in case anyone has insight to offer. I find I cannot breathe through my nose when I relax. It is as if my diaphragm does not generate enough force to overcome any resistance. I can breathe through my nose when I make an effort by engaging not just my diaphragm but also other muscles. The problem only occurs when I relax. My nose feels clear and afrin doesn't resolve the problem, suggesting the issue is not nasal congestion. The problem occurs whether I am standing up or lying down. The problem occurs with or without PAP. Increasing my pressure support helps a bit but not a lot. Perhaps I have an issue with my diaphragm or lungs, or perhaps there is a blockage not in my nose that is nonetheless affecting my nasal breathing?

[Michael2]

Recently, I underwent a spirometry test. Here is a link to the results:
drive.google.com/file/d/1qYeBw-JuJEQukzknhZs_LFsPl0Po8C6T/view?usp=sharing

It seems there is a possibility I could have a restrictive ventilatory impairment. I am still waiting for my primary care physician to review the results with me. He seems to take a very long time to get around to things, maybe because he is overwhelmed with patients. Maybe there is an expert here who could comment on the results.

[Sleeprider]

Michael, have you ever considered just taking on your nasal restriction by using a nasal pillows mask? I know it sounds counter-intuitive, but pressure applied directly to the nares may actually breakthrough the restriction, and with pressure support might be useful. PFT shows FEV1/FVC ratio is 88% and normal criteria for diagnosing COPD is less than 70%. On Apnea Board, we do not offer medical advise, and I don't think you will receive an interpretation of your test that is better than your doctor's, so I'll leave it at that.

[Michael2]

Thanks for recommending a nasal pillow mask. I just ordered the AirFit P30i Nasal Pillow CPAP Mask. Hopefully, it will help with my remaining nasal congestion.

With my spirometry results, my concern is that my FVC is 78% and so below the 80% threshold. Could you make a general comment about a FVC of 78%? I am waiting for my primary care physician to review the results with me, but it is taking a very long time. The wait times for the clinic I go to have gotten longer and longer. I am unsure why. Things seemed to have degraded during the covid epidemic and never rebounded. Maybe they have a staff shortage. I may have to find a new clinic.

[Sleeprider]

I think nasal pillows are the best thing to ever happen for nasal flow restrictions. I also use Flonase to reduce inflammation and allergy symptoms.

Many of us deal with test results that fall just below or above “normal”!test standards and I would never presume to speculate on a conclusion to something that close without more information and knowledge of your health history, and more importantly, this is your doctor’s role, and you should not assume that I or anyone else on this forum is qualified to offer an opinion.

[Michael2]

I, too, use flonase. I am also undergoing allergy shots. Why do you think nasal pillows work so well for nasal congestion as compared to a full face mask? Is it just because the pressure is concentrated at the nose?