CAs, RERAs, APAP Machine

[KingKongBingBong]

KingKongBingBong

You're in a situation where your personal opinion and assumption can set you up for a big disappointment unless your complete surgical venture is backed by a knowledgeable and helpful surgeon. It's one thing to look at OSCAR data and edit PAP settings, and quite an extremely different thing to determine this or that surgical action is best, and further to assume the results are what you're hoping they'll be.

From what I hear a majority of these ENT surgeries for breathing are 50% successful at best. Then after the surgical patient heals they're on PAP.

Anyway that was my 2 cents on it. Good luck.

Yeah ENT surgeries are junk though. I wouldn't touch a septoplasty. Maxillary skeletal expander and maxillomandibular advancement are the golden standard, depending upon whether your issues lie in your airway or your nasal passages (many cases both). Probably some better treatments to come in the future, but not soon enough.


Ty for your input.

[KingKongBingBong]

I struggle to understand this principle, given that a RERA event has a certain classification for which certain criteria should be met, and these do not seem minor.

Respiratory Effort-Related Arousal (RERA)
A RERA is defined as an arousal preceded by any of the following:
1. An apnoea or hypopnoea of <10seconds in duration
2. The nasal pressure signal excursions drop by 20-50% of the baseline breathing amplitude, for a duration of ≥10seconds
3. A sequence of breaths lasting ≥10seconds characterized by increasing respiratory effort or flattening of the nasal pressure waveform, when the
sequence of breaths does not meet the criteria for an apnoea or hypopnoea.

Given these conditions I don't see how a RERA could be a 'minor breathing problem'.

But let's presume that the nervous system is overreacting, what can I even do about that? There doesn't seem to be a good next step. I have only been suggested CBTi (I am not an insomniac, I am not anxious etc.) and SSRIs (which barely move the needle once you account for placebo). TBH right now I am done with PAP therapy and am looking at what I believe to be a more effective treatment, MSE.

Different levels of breathing issues cause RERA's in different people. 

You do not have apnea or hypopnea. Your views posted were zoomed in but I am assuming the amplitude of those breaths is similar to the majority of the night (tidal volume chart will tell you this) and if so I do not believe you have the level of nasal pressure drop or flattening of the nasal pressure waveform mentioned in other options as I believe it would show up in the flow rate data that you posted and appear as a flow limited breath. Your breathing prior to these arousals appear to be normal breaths. Sometimes RERA's can be hard to distinguish though so I am not writing off the potential completely, I am just saying that on these PAP settings you don't show signs of the typical breathing issues that would cause a RERA. 

Lets say you have RERA's because your effort levels are high because you have a small airway size. If so there are only two options.

1) Increase flow through the small airway. PAP treatment does this and I already explained how you can see if it is helping by looking at your own data or by getting a titration study done. As a side note if your breaths appear normal but take excessive effort then the only aspect of PAP that will probably help is pressure support. Increasing pressure is not likely to help significantly as collapsing airways do not appear to be an issue for you (if it was an issue you should see signs of collapsing airways in the form of apnea, hypopnea or flow limitations in your flow data). 

2) Enlarging airways. The surgery you are thinking about affects only a small portion of that airway. I would be getting an experienced and knowledgeable doctor/surgeon to confirm that you do have a small airway and that this surgery would make a noticeable difference in your overall airway size and therefor have a good chance of making a noticeable impact. If he does not see any noticeable restrictions or small airway size that make him think this surgery would improve your specific case then I wouldn't think of proceeding. 

I would do what myself and others have recommended and give PAP a fair chance and work to determine if it is actually helping or not. If PAP does not help you then imo surgery also has a low chance of helping (and this will remain my opinion unless an experienced doctor states otherwise for a valid reason). 

If it is your nervous system it could be very hard to determine the cause and potentially even harder to solve, it is unlikely to be as simple as needing to do CBT or take an antidepressant. You are free to chase surgeries if you like just know you may end up like some of the other posters that have had 1 or more surgeries but are back asking for PAP titration help because the surgeries didn't fix the problem. 

If you haven't figured it out yet I am a strong proponent for figuring out what is wrong before you attempt to fix it. You have some evidence that RERA's are an issue with no treatment. Before proceeding further you need to determine if you still have RERA's or if your SDB indicated on sleep study is already effectively treated.

 
Yeah mate I have the same mindset. Given that MSE and MMA have other benefits I don't see it as wasted investment to get them. I'm having a doc who knows about UARS looking into my PAP data soon, so hopefully he can provide further insight. Will report back if I see improvements.