Are these RERA's or obstructions and how to resolve them?

[THEVGE]

I have been on PAP therapy for 3.5 years now and still trying to understand why I feel like crap all day long. Relatively new, and relevant, insight is that due to circumstances my nervous system is over-stimulated so this might be the root-cause for the crap sleep (ultra sensitive to everything). I take no medicine for sleep or my nervous system today. 

My typical OSCAR data is already "near perfect" for a long time, meaning AHI < 0.1, FL 99,5 % < 0.1, 0 leaks (full moth tape) and most of the time nice rounded tops in my flow rate. I also varied a lot on my current bi-level, like EPAP 4-11 and PS 0-6. No significant change in anything when I look at data (OSCAR, finger pulse oximeter and Google Pixel Watch 3), but subjectively I can make my sleep quality worse by high PS 6 or high EPAP. Also lower EPAP (I have perfect data at EPAP 4, 5 or 6) feels worse than 7. My best subjective sleep today seems to be EPAP of at least 7 and PS of 5,4. I still wake up aware frequently (3-4 times per night) but according my Google Pixel Watch I wake up ~ 20 times per night (in OSCAR I can see this is correct). So this high frequency of awake moments seems to be the main issue. I often remember fragments of dreams (I guess I was waken up in REM sleep) and sometimes my body is completely numb (I guess I woke up in deep sleep). 

Detailed analysis, and now we come to my question, shows 2 typical events during my sleep and the second one is the culprit I think as often I wake up shortly or permanently after this event.

Event 1: I would estimate this to be a typical RERA. I have been unable to resolve these with pressure or pressure support and I have on average about 2 events/hour. I do not think these are very important, but I do want to show it because I might be wrong. I would guess this is normal?

   

Event 2: It looks to me like an obstruction at the exhale, but it is 99 % of the time to short to be detected by the Resmed VAuto. Pressure support does not seem to impact this at all, and I typically have 4-5 events/hour. When I wake up and aware, typically I will find this event just before. Also, when I look into OSCAR, I often see a short (unaware) awake as well. This is my best guess for my current sleep issues. If this is an obstruction, I would say my EPAP has to increase even with my on-paper-near-perfect therapy?

   

Any opinions and/or advice how to improve on event type # 2 are appreciated!

[PeaceLoveAndPizza]

No comment on settings as there are a lot of posts to work through to get an understanding of where you are at and why. It seems you have a good understanding of things.

For the events, both look normal to me. They are arousals, but nothing significant. We all have them, but how they affect sleep depends on their frequency. 

One thing to remember is that a CPAP machine will not solve for things that cannot be affected by pressure or pressure support. Years of bad sleep hygiene take time to correct, but that is outside the scope of a CPAP machine.

And finally a comment on smart watches. They are at best 80% correct, at worst far less. They are a good directional indicator, but they are not medical grade equipment. They all work much the same way using a 3-axis accelerometer to measure movement, an SpO2 measurement, and skin temperature measurement. Slight movements whilst asleep, a slight tensioning of the arm muscles, etc, all may be measured as an "awake" time whether it is or is not correct. The best accuracy would be in a sleep lab, but that has its own challenges.

[THEVGE]

So you state the events and frequency are normal and probably "unsolvable" with settings? I do have to admit no setting impacted these so you are probably right.

This means my over-stimulated nervous system becomes suspect number 1.

As for smart watches, I totally agree.....however......the Pixel Watch 3 is pretty, pretty, pretty good (use Larry David voice over) compared to anything else I tried (and I tried a lot).

[SeePak]

Hey VGE.

I have been on CPAP for 35 years and i too am still trying to figure out why, why why !!?

No settings are perfect and one day a setting is great, another it is terrible!

Anxiety, for me, must be at top of the list. That is equivalent to nervousness i think?

I am putting my eggs in one basket .....

Breathwork.....

Let the chips (apnea events) fall where they may fall! LOL

Time will tell.

day to day however, is definitely better for me, i can stop anxiety dead in its tracks with Breathwork.

"Try something you know wont work !"  
I will be doing a thread on that, check it out.