Can flow limitation stem from congested nose with nose mask?

[40plus]

As someone who often has partial congestion in my nose where one nostril is often partly or fully shut im wondering if the flow limitations showing in Oscar can be, atleast in part, due to restrictions in the nose rather than in the throat?

My 95% flow limitation is usually around 0.2 to 0.5. I cant use epr since it makes me feel like the machine breathes for me, a feeling of it sucking the air out on exhale. And because i liley have palatal prolapse and snoring on exhale that seems to get worse when pressure is lowerd on exhale.

I dont know if my flow limitations are bad, i have no idea what numbers are considerd normal vs abnormal. I also dont know if they cause an arousal. As far as i understand flow limitations without arousal is not that bad to have.

I know FL can drive up pressure but i have a tight range (10.2-12) and am now trying fixed cpap on 10.2.

Male, 46 yo, lightly overweigt, cervical collar, airsense 11 with humidity, Dreamwear nasal pillow mask.

[Sleeprider]

Nasal congestion can reduce peak flow and is a form of flow limitation that the Airsense Autoset might respond to with higher pressure. When I have allergies or seasonal congestion, I use Flonase to reduce inflammation in the nose, and that works well without adverse side-effects. A larger nasal pillow can help improve airflow. Your reasons for not using EPR make sense, although at low settings, it seems almost imperceptible to me. We're all different I guess.

[BoxcarPete]

My answer to you is to find a good ENT who cross-specializes in sleep medicine. I had some of the same complaints as you: persistent 95% FLs in the 0.07-0.15 range, mouth breathing on exhale, sometimes even with tape if I didn't get my mouth cinched tight enough. I also had trouble using EPR and found it unnatural and discomforting, in addition to my personal reservations of submitting myself to a lifetime of low-grade mechanical ventilation.

Specifically, do you get long strings of flat-topped breaths? That's what I would see repeatedly, and the worst segment was when I was sick and had a 40-minute long string of flat tops rated around 0.2-0.3 FL, culminating in some real gnarly ones and then a RERA.

Once I got scoped, I was surprised to find out that I had a moderately deviated septum on both sides because it deviated to the left and shot a bone spur off to the right, with turbinate hypertrophy and 50-70% of my nasopharynx occupied by adenoid tissue. I had never really noticed the issues because neither side was much better or worse than the other, they just both never really worked as they should. Doc said I was a good candidate for surgery and I'm still recovering from that now but I can tell it's made a difference. I have to remind myself of that this week because I ran out of steroids on Monday, and through the miracle of inflammation have pretty much backtracked almost to the point of having my old nose back.

The takeaway is that you don't know what's up there until it's looked at, and there may be something that can easily be addressed. My ENT told me that based on what he saw there was a chance I could go off PAP for a little while, but more likely that I would find CPAP much more tolerable once my nasal breathing issues were addressed.

[PeaceLoveAndPizza]

As SleepRider said, Flonase and Azelastine are excellent for nasal congestion. Both are approved for nightly use and are OTC.

If you want help adjusting things, post some OSCAR charts for review.

[40plus]

   
Thanks for all replies. I do use a spray called mometasone, its similar to the ones you suggested. And sometimes i do one puff of normal nose spray (the kind that is not for long term use) in each nostril before bed and that keeps my nose fully open all night. Here in sweden its cold now so the air is dryer than usual further making noses congested.

I am now experimenting with clean cpap mode and raising pressure slowly to one that hopefully wont give me palatal prolapse and at the same time not be so high that it blows my mouth open. Once i find a presssure worth staying on longer i will post some Oscar data and ask for advice if my sleep is still bad. My AHI is always below 2 since day one months ago, but sleep quality is pretty crappy.

As for my breathing curves in Oscar (flow rate) on epr they were beautiful with rounded tops (apart from the episodes that looks like the pic). Now without epr they are litte more pointy or flat but not fully flat. My plan is to try and cure the wierd breaths first, then ask advice here and go for comfort. I will have several episodes in my sleep, somtimes up to an hour long, that looks almost exactly like the pic. And my gf says i sometimes snore loudly on exhale even with the machine on.

[Sleeprider]

Expiratory snore may be related to palatal prolapse.

[40plus]

Yes. That is the reason i dont think its just experiatory mouth breathing when trying to identify the wierd pattern but rather palatal prolapse. I know others here have struggled with it. Some guy tried a thing in his mouth to hold stuff open (german/swiss thingy) and some guy got success with straight cpap at a pressure of 13. I will try and find a pressure that helps me too.

Strangly i have never woekn up during these breathing periods. So it seems that it doesent lead to arousals in me.

[dwedward]

I would reiterate Boxcar Pete's suggestion of an ENT that is cross-trained in sleep medicine.  I have had similar responses to CPAP therapy since I started it.  My AHI is consistently below 1, and is often even 0.  However, I was plagued by low-level flow limitations that would interrupt my sleep (using sleephq software i was able to correlate my sleep stages from an apple watch with my detailed data from the PAP).  Thus, my "stats" looked good, but I was still tired during the day.

My sleep doctor (who is really good) suggested I see an ENT, and recommended one who is cross-trained.  It turns out that I have a significant deviation in my right nostril, and enlarged turbinates.  He believes that the FLs, as well as the problems with mouth leaks are due to me NOT getting sufficient air through my nose, and thus being forced to mouth breathe.  I'm going for a CT scan of my nasal cavities as he wants to make sure there's nothing else going on (either that could be fixed at the same time as a septoplasty or some type of sinusitis) on saturday morning.  My follow-up with the ENT is in 2 weeks.

In the meantime, two things have significantly helped.  First, I've moved to a BIPAP to increase the pressure support as well as moving to a FFM instead of nasal pillows.  The second is I now use a nasal dilator which is a piece of plastic you stick up your nose that opens up the nasal passages (it's like that nose tape but more effective and on the inside).  Those two things have knocked down my flow limitations to almost nothing, and suddenly I'm getting multiple cycles of deep sleep every night with usually over an hour of cumulative deep sleep.  I feel much better.

If you post some charts, the group can look at them and make some good suggestions of how to improve your sleep.  Don't worry about "getting lots of data" for now.  There's lots of data in the chart itself.  Just post something from one of your nights and let the improvements begin!

[BoxcarPete]

Yes. That is the reason i dont think its just experiatory mouth breathing when trying to identify the wierd pattern but rather palatal prolapse. I know others here have struggled with it. Some guy tried a thing in his mouth to hold stuff open (german/swiss thingy) and some guy got success with straight cpap at a pressure of 13. I will try and find a pressure that helps me too.

Strangly i have never woekn up during these breathing periods. So it seems that it doesent lead to arousals in me.

That "some guy" in both of your statements is one in the same, if I recall correctly. He was able to resolve his PP only on CPAP pressures over 13cm H2O, and consulted with a Swiss company who make oral appliances that are effectively a hoop of wire to constrain the palate. It seemed to work well for him.

More importantly, just because you are not woken up does not mean you are not experiencing arousals. There are several phases of sleep that we must move smoothly between at somewhat regular intervals in order to achieve a restful night of sleep. If this is not happening for you because you are bumped out of REM or N3 into N2 or even wakefulness that's too short to remember, your sleep will never be restful no matter how good your stats look.

[PeaceLoveAndPizza]

If you could post some OSCAR charts, we may be able to help figure out what you are experiencing. Start with an entire eventings chart and we can ask for zoomed views as needed.

If you need help with the formatting, the links are in my signature below…