Help with reading Oscar Results.

[Geer1]

I am surprised he was even prescribed APAP based on the sleep study results. Practically 0 AHI and RDI under 4 wouldn't be considered OSA or UARS by most doctors (requirement is usually > 5 for both). Can ask about bilevel but I doubt doctor would consider it and have a hard time seeing what data would prove to insurance it is needed.

[smokehouse502]

Were you awake for a while(~13 mins) before you got up and turned the machine off? Your respiration looks like you were awake and breathing seems similar at the beginning of the night which would agree with that idea.

Regarding LPR I have just been reading into this as I believe I suffer from it as well (appointment this week to try and confirm). In reading about it LPR can be caused by gastroparesis (stomach not emptying so builds pressure which then passes esophagus), something to get the doctors to look into if they haven't already. Elevating your upper body/head when you sleep seems to be a strong recommendation if you don't already do that. If nothing is helping you may need surgery to remedy it as well, something to push for if nothing else is working.

Did your sleep study comment on your sleep architecture (time spent in each sleep stage, onset time for rem sleep etc)?

Two days isn't much data and CPAP takes a while to adjust to, I think that might be part of the story here.

Do you take any medications? Some cause early morning awakenings.


I have had a barium swallow and gastric emptying test done.  My gastric empyting was normal and my barium swallow showed a small sliding Hiatal Hernea and mild relux. I have the head of my bed raised, don't eat within 5 hours of bed and have worked on my diet.  Nothing has helped with the LPR and the gastro says that I shouldn't be having this much LPR with how normal my tests were.  It is probably related to my sleep. For the past 1.5 Years, I've only slept 3-5 hours a night and I wake up heart racing, hot, breathing heavy, and clinching my teeth.  

My sleep study said I had normal slepe onset at 15 min, Latency to REM was extremely long at 158 Minutes. Sleep efficency was poor at 66% and I had an arousal index of 5.6 p/hr.  I slept 4.1 hours in the study and had 5.2% N1, 35.3% N2, 41.1% N3, Rem 18.3%.

Its been 6 days on CPAP Now and it hasn't helped my symptoms and seems to be making them worse.  I now wake up more hyperventilating than I was without it.  The only prescribed medication I am taking is Zegerid for my LPR.  I am taking 10mg of melatonin to help me sleep.

[smokehouse502]

Smokehouse, you have a physical airway that is restricted, resulting in flow limitation and all the not-so-fun stuff that goes with it like sleep disturbance RERA and hypopnea.  I know you can be treated without resorting to a mouthpiece that will do nothing. I am yet to see the person come here and solve a problem with a mandibular advancement device. They are uncomfortable, mess up your bite and don't work with CPAP.  

Your answer is pressure support as in a bilevel machine.  Let's talk about flow limitation and why bilevel works. Flow limitation is a restriction on the maximum flow that can pass through your airway. Like a narrow straw, you can only suck so much air per second because the airway collapses as the vacuum builds. You can see it in your flow rate charts in OSCAR as flat-topped inspiration waves. That flattening or even diminishing flow during inhale is flow limitation at work. It takes a lot of respiratory effort to pull the air in when that is going on, and it results in arousals to get more air.  

Your doctor wants to try to open your airway, but if we use can just apply more pressure during inhale, and less pressure during exhale, the problem is easily and comfortably resolved  Unfortunately you have a Philips Dreamstation which cannot help us. If you had a Resmed Airsense 10 Autoset, we would have 3-cm of pressure to work with.  A bilevel like the Aircurve 10 Vauto would give us as much pressure support as you can use. We have seen lots worse problems with this than you have, and I could show you what pressure support can do, even with the limited 3-cm pressure support from a Resmed CPAP as in this Flow Limitation wiki http://www.apneaboard.com/wiki/index.php...limitation

Your answer is to get a machine with pressure support. You can buy one out of pocket or redirect your doctor to let you try bilevel. It solves a world of hurt.

Thank you for the information.  I bought the dreamstation out of pocket and I would have to buy everything else out of pocket because of my sleep study.  I am not talking about a mandibular advancement Device.  I have a mid-face deficiency, a really bad tongue tie, and tmj compression issues.  I have been recommended to get facial growth orthodontics or do MMA and get my tie revised and/or get a genioglossus advancement. According to a CBCT, My jaw is extremely small and I have a small airway without my tongue falling back.  How much does a Bi-level machine costs, because everything that has been recommended to me won't be covered by insurance.
Even if I don't use a bipap, why would a Resmed Airsense 10 autoset be better than the dreamstation Autoset?

[smokehouse502]

I am surprised he was even prescribed APAP based on the sleep study results. Practically 0 AHI and RDI under 4 wouldn't be considered OSA or UARS by most doctors (requirement is usually > 5 for both). Can ask about bilevel but I doubt doctor would consider it and have a hard time seeing what data would prove to insurance it is needed.

My doctor saw I had poor sleep efficiency and that all my symptoms point to UARS, even if It didn't show up on a test.  I would have to pay for everything out of pocket.  He is one of the only doctors who take me seriously when I describe what's happening.  Everyone else tells me it's anxiety but he said anxiety wouldn't be something that occurs every night for years.

[Gideon]

It sounds like you have a great doctor.  Medical necessity is a different than normal standard.  Ask your doctor about that.

Also we can help you find a good price on a BiLevel machine.  First could you really spell out your insurance situation.  We have a lot of experience here dealing with insurance and apnea.  Let's see if we can come up with something to help you out.

[smokehouse502]

It sounds like you have a great doctor.  Medical necessity is a different than normal standard.  Ask your doctor about that.

Also we can help you find a good price on a BiLevel machine.  First could you really spell out your insurance situation.  We have a lot of experience here dealing with insurance and apnea.  Let's see if we can come up with something to help you out.

I have Caresource Kentucky HSA Bronze.  I am on an individual High Deductible plan because I work in a family business of 2 people.  They Actually cover UARS, but it hasn't shown up on a test, so my doctor says they will not cover it.  I can see any specialist without a referral as long as they are in-network.  

They only thing that shows I could have a problem is my symptoms and a CBCT that shows how narrow of an airway I have.  An ENT who thinks this is just anxiety said he would do a sleep endoscopy to see what's actually happening.  I'm thinking about doing it.  I just took a WatchPat test and am hoping that shows something so I could get it covered.  All Medical equipment must get prior approval before being covered.  They do not do reimbursements after the fact.

[Gideon]

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.

[smokehouse502]

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.

Thank you for your help.  How do I add a Zero Line on the chart?

[harrywr2]

How do I add a Zero Line on the chart?

Right click on the left side of the chart to get the popup menu, then select dotted lines then check zero.

[Geer1]

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.