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(02-02-2020, 01:27 PM)bonjour Wrote: Document flow limitation in your charts, both inspiratory and expiratory, this is best done with a 2-minute view, both are visible in the 4-minute view. Add a zero line to clearly define inhale vs exhale on the flow rate chart. Ask your doctor what charts and what detail he would need to prove UARS.
Also, What does it mean when the flow rates go up and down very rapidly like so?
(02-02-2020, 02:14 PM)Geer1 Wrote: You require a prescription for a bilevel machine (so doctor would have to agree) and they aren't cheap (Resmed Vauto is the preferred model and I believe retail is ~$1730 and if like Canada some suppliers charge more). In order for the machine to be covered by insurance they require proof that a bilevel is required and as you know you don't even have proof APAP is needed in their eyes. Assuming the doctor or insurance route fails your only way to get one would be to purchase used either privately or through secondwindcpap (can find their website in supplier list).
Based on sleep study results part of your problem isn't the arousals but rather the amount of sleep time lost after arousal. I imagine you have looked into CBTi and sleep hygiene principals but if not it would be worth doing.
One thing with Melatonin is that many find that smaller doses (0.3-0.5 mg) seems to be more effective in some people as it raises levels to around what a person would normally see (assuming you have a melatonin shortage), 10 mg increases levels much higher and doesn't seem to always be advantageous. I tried 10 mg for a while myself but never felt like it was helping that much, haven't tried a low dose yet though.
You mention waking up and feeling like you are hyperventilating. Do you feel like you are kind of in that state before you even fall asleep (when breathing seems similar to your morning awakening)? It might be that you struggle to breath out against pressure. The reason a Resmed Autoset is a little bit better than dreamstation is two fold, 1) They respond to flow limitations and increase pressure to try to deal with them and 2) Exhale relief on Autoset is 3 cm whereas I believe dreamstation is only around 2.4 (when flex is set on 3) so you get a little more pressure support which helps deal with flow limitations. One thing I do recommend especially if you do find it difficult to breath out is increasing your minimum pressure to 7. This will give you the full advantage of flex all night (flex can only drop pressure as low as 4 cm and I believe these machines aren't as effective when trying to operate at minimum pressure and have noticed I feel exhale relief is more effective when min pressure is maintained around 5).
I would recommend reading up on flow limitations (SleepRider signature has a link) and reviewing your OSCAR data to see if that appears to be an issue. One thing you need to be aware of is that your breathing can and probably will show flow limitations during rem sleep and also post arousal (if you are awake). If your breathing seems uneven and strange then you might be in one of these situations. That is something I noticed in your zoomed in examples that you posted, I believe you are in rem sleep or post arousal (sleep wake junk is another name for this breathing) in most of them.
Rem sleep is notorious for worse breathing and it is something that I was and am still wondering about being the issue with yourself. The late onset I believe ties into your lack of sleep so body spending more time to recover/repair itself (hence also your high percentage of deep sleep). My theory was that you might only be in rem for a short period the first stage or two (if your sleep study has a graph of sleep stages that would help confirm) then after 4-6 hours your body is recovered and trying to get rem sleep but something happens in rem sleep (either breathing related or something else) that causes your morning awakening. Your time in rem sleep wasn't bad which might not support this theory but it was shorter than average (believe it is 25%).
Part of me wonders if maybe bruxism is an issue and if it is playing any role. You mentioned TMJ, do you know if clenching and bruxism is an issue?
Have you ever tried anxiety medication or other sleep aids? For bruxism they have found clonazepam can be helpful and it is also a treatment for anxiety as well as a few other sleep disorders. The problem being that it it is a benzodiazepine which can cause reliance and addiction in some people so it isn't preferred unless it is required. Depending on what your doctor thinks it might be something worth considering as a quick trial for a few nights to see if it causes any improvement. If you sleep better and longer it may indicate sleep disordered breathing isn't the primary issue. I used clonazepam for a couple trials (anxiety and trying to determine if facial sensation was due to anxiety/tmj) and it did help me sleep especially on a couple nights when anxiety was bad. I have since got anxiety under control and don't believe facial sensation is due to tmj so haven't used it in a while.
I follow pretty good sleep therapy. I don't eat before bed, I've quit drinking, avoid blue light before bed, only use my bed for sleep or sex, keep the same sleep schedule, and try relaxation breathing before bed. Falling asleep isn't the problem and my breathing is normal before I go to sleep. When I wake up I have a headache, heart racing, breathing heavy, clinching my teeth.
I'm seeing a dentist who specialises in TMJ and Sleep Breathing. He took a cbct of my head and said the following of my clinching. My tongue tie is extremely tight and causes a lot of tension in my jaw and throat. My jaw is underdeveloped because of the tongue tie and mouth breathing as a child. My jaw is compressed because of my maxilla being so small and my mandible not going into an underbite. My airway is narrow even before my tongue falls back at night, and he thinks the issue is that I have a sleep breathing issue and then clinch to breath better. Then I relax again and go through a cycle of small events, but the events cause a lot of clinching and waking.
I took anti-anxiety medication for a few weeks but I found it made my sleep and LPR worse. Exercise and deep breathing seem to make my tension and LPR worse which could be from my bite / tongue tie restriction.
Doesn't seem like REM sleep is the issue based on that sleep study(one night data is often skewed especially when hooked up to all the instruments etc, part of the reason they usually start with a home sleep study). I wouldn't even say your rem sleep was that delayed, you only slept briefly then woke up and had trouble falling back asleep.
Do you remember if you woke up with same issue(clenching etc) during that PSG or was that a good night/sleep affected just by strange setting/equipment?
Your RERA's did occur in clumps and maybe that is related to jaw positioning etc (like what we call positional apnea). In positional apnea many people find a cervical collar helps and I believe the right chin strap can as well. Not sure if either of those would necessarily help your chin/jaw stay in position but might be worth a look into/consideration if you think that might help if you believe movement of chin/jaw is creating the problem.
(02-02-2020, 02:14 PM)smokehouse502 Wrote: Also, What does it mean when the flow rates go up and down very rapidly like so?
The first example (3:34) shows normal breathing.
Second example shows what is most likely an arousal(or sleep wake junk if was already awake) occurring just before 4:30, possibly because of some sort of short obstruction at 4:29:55, at 4:29:35 you can see a later breath with a bit of flow limitation so this might have been a RERA(a view of breathing a bit prior to that event would help understand if there was more disordered breathing leading up to that arousal).
Third example is probably sleep wake junk, rem or a combination. A wider view of flow rate showing more breathing prior and and bit after (or images prior/after) would help better interpret.
Sleep pattern for the most part is usually what you posted in the first example. Rem sleep is an exception in which breathing can look very jagged and strange and bad which is normal. Usually when you see spiking/large breaths and especially unevenness like short apnea like periods between that is often arousal/post arousal/sleep wake junk breathing.
02-02-2020, 06:09 PM (This post was last modified: 02-02-2020, 06:31 PM by Gideon.)
RE: Help with reading Oscar Results.
I am reading these 3 charts out of context. Any time you are presenting zoomed views you should also include a whole night chart to provide context.
The 3:34 chart is what you want to see because that is as good as it gets. The Flow rate chart shows how much flow you are having in which direction at any point in time. If the magnitude of the rise and fall indicates the volume of breath, irregularities indicate resistance in breathing, on the top it shows inhale resistance, on the bottom exhale resistance. When we say OSCAR let's us see what is happening on a breath by breath level, this is what we are talking about.
You have IMHO established that you have a number of upper airway issues, Get them together in a list. That list goes with you whenever you are going to talk to a doctor about apnea or UARS.
These issues state that you have a "small" airway. This has strong implications for UARS. You need to document these non-flagged events, the best way is to scan each night looking at 2-minute segments for these irregularities. Each day should have the full night for context, and segments of issues, flow limited areas to illustrate what is happening.
The goal is to get you a better machine for your apnea
Gideon - Project Manager Emeritus for OSCAR - Open Source CPAP Analysis Reporter
(02-02-2020, 06:09 PM)bonjour Wrote: I am reading these 3 charts out of context. Any time you are presenting zoomed views you should also include a whole night chart to provide context.
The 3:34 chart is what you want to see because that is as good as it gets. The Flow rate chart shows how much flow you are having in which direction at any point in time. If the magnitude of the rise and fall indicates the volume of breath, irregularities indicate resistance in breathing, on the top it shows inhale resistance, on the bottom exhale resistance. When we say OSCAR let's us see what is happening on a breath by breath level, this is what we are talking about.
You have IMHO established that you have a number of upper airway issues, Get them together in a list. That list goes with you whenever you are going to talk to a doctor about apnea or UARS.
These issues state that you have a "small" airway. This has strong implications for UARS. You need to document these non-flagged events, the best way is to scan each night looking at 2-minute segments for these irregularities. Each day should have the full night for context, and segments of issues, flow limited areas to illustrate what is happening.
The goal is to get you a better machine for your apnea
Here is a google drive where I'm Going to upload my nights. I did one night in 2-minute increments. Can you help me make sense of this? It looks like i have some sort of flow limitation in every 2 minute increment. It also seems like I have more problems with exhaling flow limitation.
I'd be interested to know how accurate this watchpat is for determining RDI, there must be a little bit of black magic going on for it to be able to determine that respiratory effort is what is causing an arousal. I also don't get how it can say you had 25 arousals (I calculated this using the data) during rem sleep while the sleep stage graph does not appear to show these arousals.
Your PSG didn't show RDI like this and you did spend time in rem which makes me question things further as PSG is more accurate. The one thing about the home test is that you clearly slept better (longer duration, no long periods awake etc) so the poor sleep the night of PSG may have influenced things and there are different levels of rem sleep so maybe you never reached the trouble state due to the strange environment, probes etc.
The OSCAR images you uploaded do show a few arousals during/around the rem sleep period so I wouldn't write it off and if your sleep doctor is as good as he sounds he might be I would ask him to review your CPAP data specifically looking for flow limitations and RERA's/arousals. You can research that stuff a bit and try to find them yourself and could show some examples to doctor as well to help get ball rolling. The problem with rem sleep is like I said earlier your breathing is going to look bad anyways so is rarely clear that disordered breathing is causing the arousal, you would need better information like effort belts or esophageal pressure monitor to truly know that your respiratory effort is increasing which is then causing the arousal.
In rem sleep your muscles do relax and I have seen my chin drop down during rem sleep when I recorded myself sleep. This may be your problem and you might be able to confirm by recording yourself sleep and then comparing video data to your cpap data(with some practice is usually possible to know when you are in rem sleep as the flow rate waveforms get uglier and respiration rate usually increases). A cervical collar or chin strap might help avoid this if it is the problem.
If you are prone to arousals I might be tempted to run the machine in cpap mode. You don't have that many apneas so the machine's pressure doesn't change that much but when it does that might affect you. If you wanted to try that I would probably pressure at 8 cm. As mentioned a Resmed autoset would provide a bit more exhale relief and would also graph flow limitations (and increase pressure based on them) which could provide some minor improvement, you could ask about trialing one to see if it makes a difference. Next step would be bilevel as has already been discussed.
02-04-2020, 05:08 AM (This post was last modified: 02-04-2020, 05:12 AM by smokehouse502.)
RE: Help with reading Oscar Results.
(02-03-2020, 11:00 PM)Geer1 Wrote: I'd be interested to know how accurate this watchpat is for determining RDI, there must be a little bit of black magic going on for it to be able to determine that respiratory effort is what is causing an arousal. I also don't get how it can say you had 25 arousals (I calculated this using the data) during rem sleep while the sleep stage graph does not appear to show these arousals.
Your PSG didn't show RDI like this and you did spend time in rem which makes me question things further as PSG is more accurate. The one thing about the home test is that you clearly slept better (longer duration, no long periods awake etc) so the poor sleep the night of PSG may have influenced things and there are different levels of rem sleep so maybe you never reached the trouble state due to the strange environment, probes etc.
The OSCAR images you uploaded do show a few arousals during/around the rem sleep period so I wouldn't write it off and if your sleep doctor is as good as he sounds he might be I would ask him to review your CPAP data specifically looking for flow limitations and RERA's/arousals. You can research that stuff a bit and try to find them yourself and could show some examples to doctor as well to help get ball rolling. The problem with rem sleep is like I said earlier your breathing is going to look bad anyways so is rarely clear that disordered breathing is causing the arousal, you would need better information like effort belts or esophageal pressure monitor to truly know that your respiratory effort is increasing which is then causing the arousal.
In rem sleep your muscles do relax and I have seen my chin drop down during rem sleep when I recorded myself sleep. This may be your problem and you might be able to confirm by recording yourself sleep and then comparing video data to your cpap data(with some practice is usually possible to know when you are in rem sleep as the flow rate waveforms get uglier and respiration rate usually increases). A cervical collar or chin strap might help avoid this if it is the problem.
If you are prone to arousals I might be tempted to run the machine in cpap mode. You don't have that many apneas so the machine's pressure doesn't change that much but when it does that might affect you. If you wanted to try that I would probably pressure at 8 cm. As mentioned a Resmed autoset would provide a bit more exhale relief and would also graph flow limitations (and increase pressure based on them) which could provide some minor improvement, you could ask about trialing one to see if it makes a difference. Next step would be bilevel as has already been discussed.
I didn't sleep well in the in lab study because it was not my normal place of sleep and I had anxiety about what the test would or would not show. I was also probably mouth breathing during the study. I'm taping my lips to keep my mouth shut and breath through my nose because my mouth breathing ( jaw falling back and clinching) have caused me compression in my tmj. I've tried chin straps and cervical collar but the problem seems to be my tongue falls back and pulls my jaw back, then I have problems breathing, then I clinch extremely hard. I'm wondering if my breathing doesn't look bad because I'm clinching to open up my airway but the clinching means I can never go to a long relaxed state.
