Flow Limitation/UARS and BiPAP

[RonWessels]

True or False:

1) SpO2 % is the source of truth for whether or not there are sleep disordered breathing problems of any kind present, including UARS.

2) A good, healthy SpO2 % that stays consistent throughout the night is the best single indicator for sleep quality and non-fragmented sleep architecture.

Standard disclaimers, this is only my understanding.

1) False, I believe. I can imagine situations where a UARS patient is still getting enough air to fully oxygenate their blood, but is under sufficient stress doing so that their sleep quality is compromised. However, dips in the SpO2 are good indicators that there is _something_ going on.

2) This one I'm pretty sure is also false. There are many sleep disorders other than Sleep Apnea that cause poor sleep quality. And again, there's the point I made in (1) above.

I'm pretty sure that the best single indicator of sleep quality is an EEG, which can determine the various stages of sleep.

[WakeUpTime]

I just read this thread for the first time. Wow, it's a complicated read but may help others (like me) who have found complications that weren't addressed properly during sleep and titration studies. I still haven't grasped all the ideas so I'm going back to read it a fifth time.

[car54]

This is my 1st time posting on any cpap site. I have been on treatment for over 6 months, my apnea and hypopnea rates are under control but I still get a large amount of rera's. To me , this means that I am having sleep disturbances. I read this article and made the necessary adjustment on my machine and my rera's are almost zero.

Last night, just for the heck of it, I set my machine back to apap with the lowest amount of pressure and I had about 200 occurrences of breathing problems. Obviously I will switch the machine back.

Thanks for the info!!!!!!!!!!!!!

[trish6hundred]

This is my 1st time posting on any cpap site. I have been on treatment for over 6 months, my apnea and hypopnea rates are under control but I still get a large amount of rera's. To me , this means that I am having sleep disturbances. I read this article and made the necessary adjustment on my machine and my rera's are almost zero.

Last night, just for the heck of it, I set my machine back to apap with the lowest amount of pressure and I had about 200 occurrences of breathing problems. Obviously I will switch the machine back.

Thanks for the info!!!!!!!!!!!!!

Hi car54,
WELCOME! to the forum.!
It's great to hear that you have discovered what works best for you with your CPAP therapy.

[Sleepster]

Last night, just for the heck of it, I set my machine back to apap with the lowest amount of pressure and I had about 200 occurrences of breathing problems. Obviously I will switch the machine back.

Set it back to what?

[robysue]

In MY case:

Yes, a lot of the UARS symptomatology fits me better than OSA symptomatology does. But O2 desats were never part of my problem; on my diagnostic sleep test there were no clinically significant O2 desats scored and all my hypopneas were scored under Rule 4B as "hypopneas with arousal".

But Krakow's proposed fix for UARS (Titrate until all flow limitations are gone) leads to a DRASTIC increase in my (IPAP) pressure and that in turn leads to a DRASTIC increase in aerophagia, which in turn leads to a DRASTIC increase in both night time and daytime misery. Sometimes you just have to compromise. And in my case, that means having the pressure high enough to eliminate the "hyponeas with arousal", but low enough to not trigger the aerophagia misery.

On my PR System One, Flow limitations are scored as discrete events, which is very different from how the S9 scores Flow Limitations. But you get a Flow Limitation Index, and my Flow Limitation Index is consistently in the 2.0-3.0 range. (My AHI is almost always below 2.5 and is usually below 2.0) I've learned that compromises sometimes have to be made, and in my case, compromising on having more FL than I'd like in exchange for a tolerable amount of aerophagia so that I can actually sleep is a necessary compromise.

[Sleepster]

Sometimes you just have to compromise. And in my case, that means having the pressure high enough to eliminate the "hyponeas with arousal", but low enough to not trigger the aerophagia misery.

I wonder if in cases like this a dental appliance, along with (bi-level) CPAP therapy, is worth considering.

I'm in a situation that's somewhat similar. Bi-level auto CPAP therapy treats the majority of flow limitations, hypopneas, and apneas and has reduced the aerophagia so that it's now only mild and occasional. But I wonder if the higher pressures are inducing the mouth-leaking I experience. It's not severe enough to compromise therapy, but it appears to be waking me up.

The issue for me is cost versus benefit. I doubt my insurance will cover the cost of the dental appliance and I wonder what the chances are of it being successful.

[robysue]

Sometimes you just have to compromise. And in my case, that means having the pressure high enough to eliminate the "hyponeas with arousal", but low enough to not trigger the aerophagia misery.

I wonder if in cases like this a dental appliance, along with (bi-level) CPAP therapy, is worth considering.

I have severe TMJ and wear a custom made guard at night (and even wear the guard during the daytime when needed). My TMJ dentist is also a sleep dentist who makes OSA appliances. He believes that an OSA appliance would aggravate my TMJ problems. The TMJ appliance does help the OSA in the sense that the 90% EPAP has decreased from the 5.5-6.0 range to the 4.0-5.0 range on most nights, which helps my stomach a lot.

[PaytonA]

With my vast lack of knowledge regarding dental appliances, whether of the TMJ or OSA variety, what I have read here by some other posters makes me wonder if it would not just add an extra complication for those who are mouth leakers or breathers.

Robysue,

It sounds like you have done some serious "needle threading" in order to arrive at the sweet spot that you have found. Impressive!

Best REgards,

PaytonA

[robysue]

Robysue,

It sounds like you have done some serious "needle threading" in order to arrive at the sweet spot that you have found. Impressive!

It has required a lot of hard work and support from a quality medical team that includes:

• A PA in the first sleep doc's office who was great with managing my initial CBT for Insomnia, but not so good on managing serious aerophagia and other adjustment issues with PAP. Which lead the supervising doc into firing me as a patient for not getting better soon enough. I do wish I could still see this PA when it comes to managing the insomnia, but they burned the bridges and I ain't going back.
  
• A fantastic PA in my (second) headache doc's office who has been good at thinking outside the box about treating my chronic migraines and chronic tension headaches. She also has a good understanding of how the insomnia, OSA/PAP, TMJ, and headaches are all tied together and affect each other.
  
• A great TMJ specialist who also understands how the OSA/PAP and insomnia and other headaches affect the TMJ and how the TMJ affects those issues.
  
• A high quality sleep doc (sleep doc #4) who actually communicates with me by email when I have questions. He understands the full suite of my sleep problems, which include ongoing issues with too many arousals and wakes during the night, a circadian rhythm problem, and some continuing (minor) problems with aerophagia from the PAP needed to manage my moderate OSA. He has been very supportive in my experimenting with my PAP settings. (Though last fall he did tell me before the last round of experiments: "I don't think you're going to find something that's any better than what you've already arrived at with previous experimentation." He was right; after two weeks of experimenting with allowing the IPAP to go higher in an effort to reduce the Flow Limitations, I went back to my previous "best" settings.)
  
• A very good psychiatrist who doesn't push meds and who has done some serious genetic testing that helps explain many of my bizarre reactions to the medicines that have previously been prescribed by a headache/vertigo doc whom I dislike intensely for a number of reasons, the main one being that this doc kept pushing me to take a med that I had a very bad reaction to and telling me that my sleep problem wasn't OSA at all, but rather bipolar disorder. The psych has told me that I am neither bipolar nor depressed, and that with all the genetic anomalies and previous reactions to mood stabilizing drugs prescribed for the chronic migraines, I need to be super careful with any kind of medication that is intended to affect my mood.
  
• A very good PCP recommended by the psychiatrist after my previous PCP kept pushing me to take an antidepressant or anti-anxiety med because I was unwilling to take Fosamax after my first bone scan. The new PCP really listens and has no problem with "prudent waiting" in regards to any potential osteoporosis problem. And he also understands that the particular set of problems that I'm facing are thickly tied together.

In other words, I've learned the hard way that bad sleep not always just about untreated OSA and that PAP by itself won't fix other problems that directly affect the quality of your sleep.

And as for the overall quality of my sleep? Well it's not as good as any of us would LIKE it to be, but it's slowly getting better from where it was about 1 1/2 years ago when for some unexplained reason, everything (except treated AHI) went down hill real fast in about a six to twelve week period. And these days I sometimes do feel pretty good during the day and wake up feeling almost refreshed and almost rested.