[CPAP] Are these flow patterns arousals? or just normal breathing?

[holycarrots]

Hello.

I've been diagnosed with UARS and recently started CPAP therapy. 

Please see attached pictures. I get this flow rate pattern where my breathing spikes periodically, but very few events are ever recorded. I have a low AHI and 0 RERAs. The pattern happens very frequently during consolidated periods, but is interspersed with long periods of calm breathing with no spikes. 

This pattern happens the most on low pressures (4-7). However, I feel subjectively much worse on high pressures, and the pattern seems to merely morph into a waxing and waning appearance that looks more like central apneas. 

My question is, do the attached flow rate patterns look completely normal, or could these be arousals that are just not being properly flagged by the cpap machine?

Thanks

FYI my leak rate is quite good. I've tried EPR too.

[Ardeo77]

We are very similar but the response I got on here was it doesn't look like UARs because my lack of RERA's however I have heard some machines and or Oscar, not sure which one, are not very good at picking up RERA's. I could be wrong and probably am. But one things for sure, my breathing is off and im having frequent arousals that nobody can explain, with all the symptoms of UARs and a high RDI on my sleep study. So im going to assume I do have it. Switching to CPAP setting and getting closer to my 95 % seems to be working, just haven't got to the ideal pressure yet.

[holycarrots]

We are very similar but the response I got on here was it doesn't look like UARs because my lack of RERA's however I have heard some machines and or Oscar, not sure which one, are not very good at picking up RERA's. I could be wrong and probably am. But one things for sure, my breathing is off and im having frequent arousals that nobody can explain, with all the symptoms of UARs and a high RDI on my sleep study. So im going to assume I do have it. Switching to CPAP setting and getting closer to my 95 % seems to be working, just haven't got to the ideal pressure yet.

I've watched a lot of lankylefty27 videos and he seems to think that arousals can be too subtle sometimes and not picked up by the machine. He has UARS and never gets any RERAs on his cpap. 

When bad breathing is picked up on mine I usually get flow limitations, Hypnopneas and sometimes apneas but never RERAs. I've started to focus on how smooth the flow rate looks vs number of events. 

Currently I'm experimenting with a Mandibular advancement device and subtle pressure changes. I'm hopeful that it will be smoothed out, but we'll have to see. I'll post and update if it works.

[EddyDee]

A few questions which might help you to get good answers on this forum:

Can you give some details about how the diagnosis of UARS was made?
Did you have a sleep study? What were the results?

Is there a reason why you are using fixed CPAP mode, rather than Automatic mode?

Also note that in general, home CPAP machines are not reliably able to identify RERAs. Some do report them sometimes, in certain situations, but I don't think it can be taken as accurate.

[Sleeprider]

Holycarrots, what I see in your breathing is a persistent flow limitation as indicated by a flattened inspiratory flow wave. This is very typical of UARS and while cpap pressure can help, we are going to do something to actually resolve it. When flow limitation is present, we see airflow is restricted which affects tidal volume and minute vent. This is often associated with longer inspiratory time as more effort is required to satisfy the breath volume needs. The variable breathing arises out of restricted airflow followed by increased respiratory drive caused by a buildup of CO2 that causes deeper larger breaths. Your zoomed chart clearly shows flattend, jagged peaks on inspiration, so there is likely snoring there, and quite a bit of soft tissue resistance. If you were using autoset pressure, your CPAP would increase pressure significantly in response to these flow limits to better stent the airway.

I recommend some significant setting changes as follows and we are going to switch from CPAP fixed pressure mode to Autoset variable pressure and use the exhale pressure relief (EPR) feature. Recommended settings:
Mode: Autoset Standard
Minimum Pressure 7.0
Maximum Pressure: 10.0
EPR: On Full-Time
EPR setting: 3

Try this, show the results and tell me how it feels.

[holycarrots]

Holycarrots, what I see in your breathing is a persistent flow limitation as indicated by a flattened inspiratory flow wave. This is very typical of UARS and while cpap pressure can help, we are going to do something to actually resolve it.  When flow limitation is present, we see airflow is restricted which affects tidal volume and minute vent. This is often associated with longer inspiratory time as more effort is required to satisfy the breath volume needs.  The variable breathing arises out of restricted airflow followed by increased respiratory drive caused by a buildup of CO2 that causes deeper larger breaths.  Your zoomed chart clearly shows flattend, jagged peaks on inspiration, so there is likely snoring there, and quite a bit of soft tissue resistance.  If you were using autoset pressure, your CPAP would increase pressure significantly in response to these flow limits to better stent the airway.

I recommend some significant setting changes as follows and we are going to switch from CPAP fixed pressure mode to Autoset variable pressure and use the exhale pressure relief (EPR) feature.  Recommended settings:
Mode: Autoset Standard
Minimum Pressure 7.0
Maximum Pressure: 10.0
EPR: On Full-Time
EPR setting: 3

Try this, show the results and tell me how it feels.

Hi, thank you for the advice. I've implemented the pressure settings you suggested and I've attached the Oscar results. At the same time I've been experimenting with a MAD which has helped both subjectively in terms of how I feel, and also in Oscar. Since changing the pressure I don't feel subjectively any better than before however. I have pretty bad fatigue symptoms, having had problems with CFS for 10 years or so. I'm pinning my hopes on treating UARS for alleviating some of this fatigue. 

Thankfully with the MAD + pressure changes the flow rate seems to have calmed down somewhat, with less flow limits and less hyponeas. However, there seems to be large chunks of time where my breathing is quite variable/choppy with large waxing and waning patterns. I assume this is verging on central apnea but I dont know. I've attached some screenshots of what I mean. Do you have any advice for this? i.e. do you think its a cause of for concern or is there anything I can do to alleviate it?

I'm also still having a fair amount of obstructive apneas seemingly out of nowhere. I wonder if you have any thoughts on this.

thank you!
I appreciate the help!

[holycarrots]

A few questions which might help you to get good answers on this forum:

Can you give some details about how the diagnosis of UARS was made?
Did you have a sleep study? What were the results?

Is there a reason why you are using fixed CPAP mode, rather than Automatic mode?

Also note that in general, home CPAP machines are not reliably able to identify RERAs. Some do report them sometimes, in certain situations, but I don't think it can be taken as accurate.

I was diagnosed privately after a home sleep study - mostly based on high flow limitations and paradoxical breathing. It was the NOX T3 HST. I'm awaiting a full lab PSG and DICE but the waiting list is very long. So I don't have the comprehensive results that I would like, but I did get the diagnosis. 

I've moved on to APAP after the advice on this thread.