Effort to improve treatment of OSA and IH

[QuietSign]

Hi all,

I was hoping to make some improvements to my sleep, so I thought I'd lay out my situation and what I've tried.

I'm a guy in my early 20's, fairly overweight. I'm tired pretty much all the time and barely had the energy to make it through college, taking multiple naps a day to get by. I had my sleep study done about a year ago. My initial sleep study showed an AHI of 10 overall, but roughly an AHI of 22 during REM sleep. The doctor considered this mild OSA and put me on APAP, a Philips Dreamstation with an Airfit P10 nasal pillow mask. We dialed around with the settings for a few months and settled on 13-17 pressure. My AHI varied, but would usually be around 3-6 AHI with CPAP. I didn't feel much better, and the doctor thought I also had Idiopathic Hypersomnia, so we've been experimenting with Armodafinil at various doses (150mg-250mg), but it frequently makes me feel jumpy without resolving the tiredness and makes it hard to nap.

Lately I've been trying to improve my APAP and overall sleep experience to try to get closer to 1 AHI. Here's what I've been trying:

I had a Radiofrequency treatment to reduce the size of my turbinates earlier this year which seemed to help my breathing, and my EN advised using Nasacort (with 12 drops of Afrin mixed into the bottle). He has claimed this low dose of Afrin can be done indefinitely without issue. This overall seems to improve the use of my nasal mask. I was hoping to get a second Radiofrequency treatment to increase the effect but it's on hold due to the pandemic.

I've been experimenting with the Swift FX mask as well, since I've heard the Airfit P10 can have a clogging issue with its vents. The Swift FX isn't as comfortable for me, and when I sleep on my side, it tends to get dislodged a bit and leak, but I'll still continue to try it out. Regarding cleaning, I soak my mask/hose in soapy water every ~10 days, and rinse. I haven't scrubbed with a brush in the past, but maybe I should?

I've realized that I mouthbreathe quite a bit (waking up with dry mouth), so I've been experimenting with mouth taping. I'm trying out the expensive Somnifix strips, but also have cheaper "X" shaped strips for naps. I also have generic micropore tape. I'm not sure if the goal with taping is to actually create a hermetic seal, or if it's just to prevent the jaw from falling too far away.

I've been using various types of chin straps. The generic velcro straps that cup the chin seem dumb because they have a backwards component of force. I've liked the "loopy" type straps that are better at providing an upwards force on the jaw, but lately I've been experimenting with the Knightsbridge dual strap. It was a little difficult getting used to it as I found the non-elastic strap to be kind of uncomfortable, but it's been working better lately. I think it might be a size too large though, as I wake up with it having shifted around and not feeling as snug. I suspect that the shifting of the straps is why the AHI gets worse as the night goes on.

This oscar data in the attached image was for last night, where I used the Airfit P10, Somnifix tape, and Knightsbridge chin strap. I also used the Nasacort/Afrin mix in the morning/afternoon/evening. I woke up with a very dry mouth, as always, so it appears that I still managed to mouthbreath despite all these counter-measures. Note that I woke up for about 20 minutes and adjusted the Knightsbridge, which is why there's a gap in the chart.

   

This OSCAR data was from a better than average night, but even then I still struggled with alertness and needed multiple naps the next day. I'm trying to come up with ideas for improvements, or see if there's something important I'm missing. One thing I'm curious about is UARS, as I have some predisposed factors (Asian, never had wisdom teeth). My doctor didn't have much to say about UARS since he thinks it'll just be APAP treatment anyways. I'm a little curious to see if BiPap would make a difference. I've noticed that since starting taping, I frequently "hiccup" so that air gets trapped in my mouth. I guess normally it would just escape during sleep, but I wonder if this means I'm struggling to breathe out against pressure? My RERA's are pretty low though so I feel I don't have a full understanding of the situation.

Any suggestions are appreciated, as I'm just trying to figure out how to make this situation more tolerable.

[staceyburke]

It really looks ok except from 8:30 until you got up.  There were more than 22 events.  That being said most of that is probably you moving around before fully waking up.  The V2 chart means nothing as far as your sleep quality. You can try moving the bottom up .5 and changing the ps from 3 to 2. That should make it more aggressive in attacking events.  But truthfully I don't think there is much to change.  I'm sure someone will see something I did not, anyway I hope so.

[Gideon]

On UARS, I don't see nearly enough RERAs to say UARS but UARS is mostly about flow limits. Your flow limits are higher than I like to see them, unfortunately Philips machines do a poor job of treating flow limits. Try a ResMed AutoSet with EPR=3 for a week and see what I mean. Look at the detailed view (5-minutes) and scroll through the flow rate chart looking for disturbances. Looking at your detailed flow rate will give a much better idea of how bad your flow limits really are. ResMed machines will be much better for you since they more aggressively attack flow limits.

[Sleeprider]

I bet if you zoom in on your charts from 04:10 to 04:35 before the first arousal, 07:10 to 08:00 and anytime from 09:00 to 10:40, you will see a very flattened inspiratory flow wave (Flow Rate chart zoomed in to a 2-3 minute length will show the flow wave). You have really bad flow limitation that Philips does not help with. If we had you on a Resmed Airsense 10 Autoset or a Vauto, your sleep would be transformed, because you need bilevel, not CPAP.

[QuietSign]

So here was yesterday's sleep from 8/27/20. It was probably the best sleep I've had in a while. This time I used a simple piece of 3m micropore tape to cover my entire mouth (although it wasn't quite a perfect hermetic seal) but still woke up with a bit of dry mouth.
   

It really looks ok except from 8:30 until you got up.  There were more than 22 events.  That being said most of that is probably you moving around before fully waking up.  The V2 chart means nothing as far as your sleep quality. You can try moving the bottom up .5 and changing the ps from 3 to 2. That should make it more aggressive in attacking events.  But truthfully I don't think there is much to change.  I'm sure someone will see something I did not, anyway I hope so.

What is ps - pressure set? I'm not really familiar with what this number means, and how to change from 3 to 2. I'll talk to my doctor about moving the bottom pressure up 0.5 though. From last night's sleep, It was pretty good for most of the night, but started having some more events close to wake up time. This seems to be a common pattern for me. Is it common for people to have the last 1-2 hours be full of events due to moving around? And what is a V2 chart?

On UARS, I don't see nearly enough RERAs to say UARS but UARS is mostly about flow limits. Your flow limits are higher than I like to see them, unfortunately Philips machines do a poor job of treating flow limits. Try a ResMed AutoSet with EPR=3 for a week and see what I mean.  Look at the detailed view (5-minutes) and scroll through the flow rate chart looking for disturbances.  Looking at your detailed flow rate will give a much better idea of how bad your flow limits really are.  ResMed machines will be much better for you since they more aggressively attack flow limits.

I was wondering how good these machines are at detecting RERAs and flow limits, and how good they are at distinguishing these from other events? For that matter, how bad is a flow limit compared to the other events? Looking back through my data it seems that on most nights I have roughly 5-8 or so flow limits, according to OSCAR. However, last night I had just 1 flow limit - qualitatively it feels like the best night of sleep I've had in a while, and I'm not sure if this is a causal relation. I wish it was easy to try out a different machine - I guess I'll try to learn as much as I can for now and try to make a decision later as to whether to take the plunge and purchase. Why do you suggest EPR=3? Are we trying to get a slight bipap functionality? What does this have to do with flow limitiation? Also see image below for a flow rate chart from 8/26/2020 (detailed view of the original post).

I bet if you zoom in on your charts from 04:10 to 04:35 before the first arousal, 07:10 to 08:00 and anytime from 09:00 to 10:40, you will see a very flattened inspiratory flow wave (Flow Rate chart zoomed in to a 2-3 minute length will show the flow wave).  You have really bad flow limitation that Philips does not help with.  If we had you on a Resmed Airsense 10 Autoset or a Vauto, your sleep would be transformed, because you need bilevel, not CPAP.

How bad are flow limitations compared to other events?Why do you suggest bilevel, and how does that relate to flow limitations? Can you explain why you recommend an Airsense 10 Autoset as an option - isn't that an APAP rather than a biPAP? The following image is from 8/26/2020, the same night of sleep as the original post. I zoomed in at around 04:11 to try to figure out if I could get an image of what you where talking about. Does this reveal anything to you?

   

[Gideon]

Flow limits and thus RERAs are poorly indicated by all devices. The number detected is but a fraction of what is indicated. Yes we are trying to achieve a BiLevel impact as Pressure Support, the difference between inhale and exhale, is the best treatment for flow limits, RERAs, hypopneas. We do this so that you get the most effective treatment possible for your apnea

[Sleeprider]

Your chart shows the characteristic flattened or downward sloping tops on the flow rate that I suspected would be present, especially in the second half of the segment below.  You may notice that this pattern of flow limits is closely tied to periods where snores occur.  The Philips Dreamstation Auto CPAP dies not really give us any tools to deal with that.  I notice you are using Cflex at 3, and when I used a Philips machine I found a setting of 2 worked better.  Everyone is different, but wondering if you have tried a lower setting in Flex.

[QuietSign]

Flow limits and thus RERAs are poorly indicated by all devices.  The number detected is but a fraction of what is indicated.  Yes we are trying to achieve a BiLevel impact as Pressure Support, the difference between inhale and exhale, is the best treatment for flow limits, RERAs, hypopneas.  We do this so that you get the most effective treatment possible for your apnea

Can I pick your mind a bit regarding why having a pressure difference between inhale and exhale is good for flow limits, RERAS, hypopneas? I read that article by Barry Krakow where he talks about Bilevel PAP being good for UARS but it seems mostly to be a guess regarding anxiety of breathing out, and it's not quite clear to me why UARS patients would particularly struggle with this. I've read other opinions that talk about how having this pressure differential makes the CPAP less effective because it could let your airway collapse, and there was a suggestion to get rid of the EPR setting.

Your chart shows the characteristic flattened or downward sloping tops on the flow rate that I suspected would be present, especially in the second half of the segment below.  You may notice that this pattern of flow limits is closely tied to periods where snores occur.  The Philips Dreamstation Auto CPAP dies not really give us any tools to deal with that.  I notice you are using Cflex at 3, and when I used a Philips machine I found a setting of 2 worked better.  Everyone is different, but wondering if you have tried a lower setting in Flex.

I can give this a shot. I had no clue that Cflex was even on. Cflex is basically Philips Dreamstation's version of having a pressure differential between inhale and exhale right? Can I ask what your rationale is for lowering the differential? Would you expect this to impact the flow limitation issue?

[Sleeprider]

Flex does provide a temporary pressure relief during exhale, but it tends to anticipate respiration rather than follow it.  The maximum pressure change for Flex is 2-cm regardless of whether it is set to 2 or 3, but the timing changes.  I personally found that my sync was off from the machine with Flex at 3, and we have often seen that in others.  Since Flex is actually flow based, it varies for individuals, so your experience may be different from mine.  Cflex only changes pressure on exhale, but Aflex changes the pressure on both inhale and exhale.  As long as we have brought it up, I'll give you my usual "too bad you didn't get a Resmed" talk.  The Resmed CPAP machines actually provide true bilevel pressure with up to 3-cm pressure difference between inhale and exhale pressure, and it is delivered in a very predictable and comfortable manner that actually follows your respiration. In the chart below notice how mask pressure produced by the Resmed Airsense 10 Autoset, follows the user's respiratory flow.  This is why the Resmed actually treats flow limits, snores and hypopnea and we frankly don't quite know what the Philips is doing, but it's different.  If you ever get a chance to try the Resmed, don't turn it down. It's better.

[QuietSign]

Flex does provide a temporary pressure relief during exhale, but it tends to anticipate respiration rather than follow it.  The maximum pressure change for Flex is 2-cm regardless of whether it is set to 2 or 3, but the timing changes.  I personally found that my sync was off from the machine with Flex at 3, and we have often seen that in others.  Since Flex is actually flow based, it varies for individuals, so your experience may be different from mine.  Cflex only changes pressure on exhale, but Aflex changes the pressure on both inhale and exhale.  As long as we have brought it up, I'll give you my usual "too bad you didn't get a Resmed" talk.  The Resmed CPAP machines actually provide true bilevel pressure with up to 3-cm pressure difference between inhale and exhale pressure, and it is delivered in a very predictable and comfortable manner that actually follows your respiration. In the chart below notice how mask pressure produced by the Resmed Airsense 10 Autoset, follows the user's respiratory flow.  This is why the Resmed actually treats flow limits, snores and hypopnea and we frankly don't quite know what the Philips is doing, but it's different.  If you ever get a chance to try the Resmed, don't turn it down. It's better.

I'll talk to my doctor to see if I can try out the Resmed. My understanding is that Resmed Airsense 10 Autoset is an APAP, it just has a limited (3-cm) bilevel functionality. This is different from the Aircurve, which is a true BiPAP. Should I ask to try out the Airsense APAP in this situation? Any advice for how I should make the case to the doctor? I'm basically thinking that I've experimented with so many different things on my end because sleep is not going well, that I'd like to try a different machine as well to see if there's a difference.

In the meantime I'll try out Flex at 2. Do you recommend Cflex over Aflex.