[Diagnosis] Excellent AHI, poor sleep quality --> palatal prolapse?

[aquamike]

Hey folks!

First time poster here.  We’re all so lucky to have such a supportive and active community.

I’ve been on CPAP therapy for 3 months now and I’ve been experimenting with different settings- fixed, auto, different rates, etc.
I think I found a sweet spot, but still have poor sleep quality and wanted to get the community’s input on what might be happening.

I realized two days ago that I might be having a palatal prolapse when I exhale, based on the flow rate patterns. In fact, this even happens sometimes when I’m relaxing awake with my chin tucked on my couch- sort of a ‘reverse snore’ when exhaling.  FYI- athletic, reasonable BMI, exercise, etc. 

Then I realized that I had the EPR set to 3, which was allowing the soft palate to swing shut on exhale.  I turned EPR off, maintaining therapy pressure on exhales, which it seemed to help, but still felt a bit crappy in the morning. I thought maybe this was because the pressure was too high, and reduced it, with the max pressure set the 95% mark.

Last night, nasal mask, mouth taped, Autoset 7-10.6, I’ve had the best AHI in 3 months, but still feel like I didn’t sleep well.  

   

I then zoomed in on the flow rate and identified three areas that seemed funky. (see attached photos)

1:34:35-1:39-56                5 minutes
4:59:08-5:01:07                2 minutes
5:05:07-5:08:00                3 minutes

[attachment=53440]

Based on the attached photos, are the flat spots between positive flow peaks palatal prolapses, and if so, what’s happening to my exhaled air if there aren’t any mask leaks?  Is this pattern enough to ruin sleep quality and/or cause C02 rebreathing issues?

Aside from correcting this in some way, and all other variables aside, are there any other machine settings or techniques that might be contributing to poor sleep quality?  I’m stumped.  I just don’t feel right in the morning.

Thanks for your help!

Michael

[aquamike]

(Reposted with correct image)

Hey folks!

First time poster here.  We’re all so lucky to have such a supportive and active community.

I’ve been on CPAP therapy for 3 months now and I’ve been experimenting with different settings- fixed, auto, different rates, etc.
I think I found a sweet spot, but still have poor sleep quality and wanted to get the community’s input on what might be happening.

I realized two days ago that I might be having a palatal prolapse when I exhale, based on the flow rate patterns. In fact, this even happens sometimes when I’m relaxing awake with my chin tucked on my couch- sort of a ‘reverse snore’ when exhaling.  FYI- athletic, reasonable BMI, exercise, etc. 

Then I realized that I had the EPR set to 3, which was allowing the soft palate to swing shut on exhale.  I turned EPR off, maintaining therapy pressure on exhales, which it seemed to help, but still felt a bit crappy in the morning. I thought maybe this was because the pressure was too high, and reduced it, with the max pressure set the 95% mark.

Last night, nasal mask, mouth taped, Autoset 7-10.6, I’ve had the best AHI in 3 months, but still feel like I didn’t sleep well.  

   

I then zoomed in on the flow rate and identified three areas that seemed funky. (see attached photos)

1:34:35-1:39-56                5 minutes
4:59:08-5:01:07                2 minutes
5:05:07-5:08:00                3 minutes

   

Based on the attached photos, are the flat spots between positive flow peaks palatal prolapses, and if so, what’s happening to my exhaled air if there aren’t any mask leaks?  Is this pattern enough to ruin sleep quality and/or cause C02 rebreathing issues?

Aside from correcting this in some way, and all other variables aside, are there any other machine settings or techniques that might be contributing to poor sleep quality?  I’m stumped.  I just don’t feel right in the morning.

Thanks for your help!

Michael

[WayTooTired]

Good morning Michael. I hope you are getting a good night sleep.  Palatal prolapse isn't as rare or isolated as people once thought it was (ref: research by the Harvard Brigham folks). Have you resolved your problem? From a quick scan of your results some consideration should be given to addressing mask leakage.  I'd question the pros/cons of taping your mouth shut and using something like somnifix which has a breathing vent.  At higher expiratory blockages and expiratory effort the expiratory flow would try shut out the mouth.  If you perceived some benefit with reducing EPR you could consider changing the mask type to full face which would reduce the machines compensation for pressure variations/flow resistances.  There is a low cost flow resistance device which inserts in cpap tubing which reduces inspiratory pressure below expiratory pressure.  Unfortunately, it is not recommended for use with automatic devices such as yours (then again you could run your machine in cpap mode). I'd also question whether or not the device would be beneficial or detrimental to expiratory blockages.  It does not appear to me that you have a significant expiratory component (I'd also question whether or not there is a positional component). There are some unique considerations associated with the abruptness of palatal prolapse which can keep you from having a restful nights sleep. So, have things stabilized and has you sleep quality improved?

[zaienk]

I have also quite often the "Palatal prolapse" like respiratory schema.
What I found is that below an EPAP of 10, it happens quite often, below 12 it happens but less often, and above 12 of EPAP, it prevents to happen.
I tape my mouth and was using ResMed P10 mask. but to sleep properly with these high pressure without being disturbed by leak above 12 of EPAP, I had to change mask and use bleep dreamport with additional blenderm occlusive scotch to secure the tapping and make sure I will not be disturbed by leak during the night.

[PeaceLoveAndPizza]

I have been doing reading on this exact issue and unfortunately so far have not found anything that stands out as being “THE” solution to palatal prolapse. Most scholarly articles are informative, but not any closer to a medical solution. Some things like AlexoStent, more or less pressure, etc, offer hope but I have not read anything definitive on them as the results vary by patient.

Simply put, there is a lot of anecdotal and parenthetical conclusions and recommendations, but nothing definitive. 

Some readings…

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915321/

https://erj.ersjournals.com/content/51/2/1701419

https://www.atsjournals.org/doi/10.1513/...2007-864ST

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355408/

[BoxcarPete]

I must say this is entirely speculation based on an offhand comment by my ENT, but he seemed to believe that PP could be improved by an orthodontic expander.

The actual comment was, in response to my question whether my mouth breathing pattern might be PP, (paraphrased) "you do have a high arched palate, but let's fix your nose first. If it's not improved, there are things we can do with a sleep dentist to expand it later. If you want more space, you can either make the furniture smaller, or make the room bigger. I can make the furniture smaller."

In my case, he is referring to enlarged adenoids, which take up space in the pharynx directly behind the soft palate. Being an engineer in the rubber and sealing industry, I can tell you that expanding the hard palate to modify the behavior of a soft palate which is flapping around where it shouldn't sounds like a legitimate approach. Increasing the distance across its anchor line to the hard palate will induce some tension in the material, which should both make it firmer and pull it away from the back of the pharynx.