Noobie UARS, pls help me fix my breathing :/

[jcoleman]

Hi There Newuser,

I think Sleeeprider has some good advice, as usual.

If it were me, I would still try and find a set of more fixed pressures. That is, to answer your question, how to get your machine to be more aggressive about managing flow limitations, is that you set your pressure(s) higher (so that it doesn't have to adjust). Looking at your data, it seems like ~ 6EPAP 9IPAP (PS3) might be a place to start. If you want to try and find a range that doesn't require auto-adjusting, through experimentation, you can find the IPAP that seems to knock out Hypopneas/FLs and the EPAP that seems to knock out OAs/Snores (not down to zero for FLs, snores, but to a point where you feel they are not disruptive).

I recommend this because it has been my experience that auto-adjusting is disruptive to my sleep, especially on the downslope of a pressure raise. I think auto mode is handy to see what sorts of ranges seem to manage events and give me the best flow rate graph (thick/fat, not grassy, with minimal spikes). That is, what pressures seem to give me the most restful/uninterrupted sleep.

As far as data goes, in my opinion, everyone is individual. Some people ride with an AHI of 2-3 and feel totally treated. My typical AHI is 0. Some people feel great with 95% FLs < .1, I find my best nights are 99.5% < .1. (although, I key into the spikes in FLs, especially the ones over .2 more than the 99.5% number).

One question that I would have for you is how are your leaks? Are you seeing leaks creep in/up when the pressure gets over a certain threshold? Seems like they are very well managed by your leak 99.5% number, but just figured I would ask. For me, even short bursts of mild leaks can be disturbing.

Again, the important thing is to key into how you feel, and through slow/deliberate experimentation, key into what certain changes tend to feel like (the next day) for you, as well as what certain data tends to feel like. Do FLs feel a certain way? How about leaks? How does duration affect the way you feel? What settings, or combination of settings make sleeping feel easier to you (fewer wakeups, easier to sleep longer, fewer bathroom trips, easier getting back to sleep, etc.)? Are there circadian issues at play (do you feel better when you go to bed earlier/later and wake up earlier or later)? Also, are you doing shift work? One of the Oscar images I looked at shows a bedtime of 6:30 and a wakeup of 12:30.

One thing with the inhale/exhale ratio, I have seen the exact same thing with both by data and another UARS person. It *seems* to correlate with much better therapy effectiveness (and/or lower stress while sleeping), but I am not 100% sure about that.

Anyhow, at least in my experience, this stuff takes a bit to figure out, and I hope you are able to find some relief. In my opinion, for what it's worth, you are on the right track.

[newuser1002]

I actually think you need to increase EPAP min higher to address the OS and some flow limitation.  I think you may need EPAP min at 7.0. You may want to delay increasing the PS until you have tried this.

Thanks for the response! I will try increasing my EPAP min to address the OAs. Sorry I had already increased my PS before I saw your comment.

There's quite a few random vertical spikes in my flow rate graph. Do you know if those are, in general, undetected OAs? 

Your flow limitation is nearly nonexistent, but the machine is raising pressure very quickly every time it is detected.

Hmm, I'm not sure if this is true. Scrolling through the flow rate graph during my REM breathing, I see a lot of weird looking breathing, a lot of which seems like flow limitation and/or RERAs. Almost none was detected by the machine, and my pressure didn't increase at all. Please correct me if I'm wrong though. Here's what I mean: https://imgur.com/a/CPAT70b
(sorry for the poor video quality...)

[newuser1002]

If it were me, I would still try and find a set of more fixed pressures. That is, to answer your question, how to get your machine to be more aggressive about managing flow limitations, is that you set your pressure(s) higher (so that it doesn't have to adjust). Looking at your data, it seems like ~ 6EPAP 9IPAP (PS3) might be a place to start. If you want to try and find a range that doesn't require auto-adjusting, through experimentation, you can find the IPAP that seems to knock out Hypopneas/FLs and the EPAP that seems to knock out OAs/Snores (not down to zero for FLs, snores, but to a point where you feel they are not disruptive).

__

One question that I would have for you is how are your leaks? Are you seeing leaks creep in/up when the pressure gets over a certain threshold? Seems like they are very well managed by your leak 99.5% number, but just figured I would ask. For me, even short bursts of mild leaks can be disturbing.

Again, the important thing is to key into how you feel, and through slow/deliberate experimentation, key into what certain changes tend to feel like (the next day) for you, as well as what certain data tends to feel like. Do FLs feel a certain way? How about leaks? How does duration affect the way you feel? What settings, or combination of settings make sleeping feel easier to you (fewer wakeups, easier to sleep longer, fewer bathroom trips, easier getting back to sleep, etc.)? Are there circadian issues at play (do you feel better when you go to bed earlier/later and wake up earlier or later)? Also, are you doing shift work? One of the Oscar images I looked at shows a bedtime of 6:30 and a wakeup of 12:30.

Thanks for the response, as always. Doing a quick scan, I didn't see any increases/decreases in pressure creating arousals (usually I saw the other way around, seemed like the pressures were changing fast enough) so I think I'm okay with a variable pressure for now. I think once I find a more optimal pressure range for me, I can try further narrowing that range. Does that sound reasonable? 

My leaks seem minimal from what I can tell (almost no green throughout the night). I know that my FLs highly correlate with how I feel the next day. Sorry my timezone settings were preset incorrectly, I generally sleep at like 2-3 am and wake up at 9-10 am (not good, I know... it's been a perpetual struggle to sleep earlier and longer :/)

[newuser1002]

Day 3-6 post (Friday 2/17/23 - Monday 2/20/23). 

Day 3: Increased PS by 0.6. Day 5: removed humidity. Day 6: Increased max IPAP to 16

Overall,
6 min EPAP - 16 max IPAP, 3.6 PS.
0 humidity
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

OSCAR: https://imgur.com/a/4w0itNB

On day 6, I actually did hit past my old IPAP maximum, peaking at 14. Though it also seems I had more intense flow limitation that day than usual, not sure why. Any thoughts there? I don't see any patterns in the data and don't feel notably different, but I might be missing out on some signal though with my untrained eyes, so would appreciate your thoughts.

To me, it doesn't seem like increasing my PS by 0.6 did much. I believe that supports my overall hypothesis, that I won't feel much different until I hit the IPAP range of like ~16 ish, since that is the pressure I need to actually be able to breathe through my nose with my enlarged turbinates.

One note of interest - after starting the Bipap for the past 6 days, I now sometimes randomly wake up after ~7 hours of sleep at roughly 10 am (possibly correlating with events? Unsure about this). I can think of two explanations. 1. Maybe I always have been waking up, often, (e.g RERAs) but just am not conscious of the awakenings since I was so sleep deprived. Now I'm slightly less sleep deprived, so I am more sensitive to awakenings. 2. It's also possible that my circadian rhythm has just been more regular this week. Occam's Razer perhaps suggests explanation 2.

[jcoleman]

Yeah, it's funny, I think to most people, they would say there's not a lot here. But, if you feel like you still aren't sleeping well (and/or still feeling like crap the next day) then there are still things to work on.

As far as flow limitations go, one thing I would do is change the scale of this graph to be 0-.5 (vs 0-1). This can make these limitations easier to read, and it also makes it easier to count the spikes. Personally, I find spikes over .2 to be disruptive to sleep (and too many, e.g. > 10, spikes over .1 to be disruptive as well).

One thing I cannot see from you graph, are you getting any snores? Also, what does your respiration rate look like throughout the night? Often I can find this graph makes arousals a little easier to spot.

If it were me, I would think the pressure is too low. I would look at this and think that an EPAP of ~ 7.5-8 seems to knock out your OAs, and an IPAP of ~ 11-12 seems to knock out your Hypopneas. On the second night, that pressure spike (and couple of hypopneas and big FLs) @ 8:15AM on 2/20 is weird to me. That is, I cannot tell if these FLs (and thus Hypopneas) were caused by pressure or not (the cluster of two Hypopneas comes on the downslope of a pressure increase). This is one of the reasons why I like a tight pressure range (and for me, I prefer no auto-adjusting pressure) because the added pressure can sometimes exacerbate the issue.

I think that it is good that you are working yourself up slowly pressure-wise, but I am kind of curious how you would be at settings of 8-12 PS4. Now, that's a ways away from your current settings, and what can often happen from making big/sweeping changes is that it can be hard to really know what works and what doesn't. For me, I find that making changes of .4 max to be the most helpful, and I also let my settings stick for at least a 3-4 days (unless I clearly feel way worse, then I'll let them sit for two days, just to confirm). Also, it's been my experience that pressure is not a linear thing, especially with nasal passages and sinuses. There is a golden range, and too much can be just as bad as too little. As such, I've found it helpful to try and find the minimal effective dose to manage my events (including snores and FL spikes) AND that leads to be most restful sleep.

The 7AM wakeups could be part of your natural sleep cycle, it could be a circadian thing, or it could be that therapy is not quite optimized. When I was first starting to dial in my pressure settings, I would wake up between 2:30 and 3:00 AM every day, like clockwork (after going to bed at ten), and then have to go to the bathroom, and lie there for an hour or more to get back to sleep. When I finally found more ideal pressure settings, I routinely made it to between 6-7AM, and if I did wake up earlier than that, I could go back to sleep pretty easily. I've since chalked these 2-3AM wakeups as REM sleep breathing issues, which then created not only a wakeup but also a mild anxiety response.

I hope that helps. It seems like you are on the right track.

[newuser1002]

As far as flow limitations go, one thing I would do is change the scale of this graph to be 0-.5 (vs 0-1). This can make these limitations easier to read, and it also makes it easier to count the spikes. Personally, I find spikes over .2 to be disruptive to sleep (and too many, e.g. > 10, spikes over .1 to be disruptive as well).

Ah great idea, that scale makes it much clearer. I'll keep that .2 and .1 rule of thumb in mind. Very impressed how in-tune you are with how you feel based on different statistics.

One thing I cannot see from you graph, are you getting any snores? Also, what does your respiration rate look like throughout the night? Often I can find this graph makes arousals a little easier to spot.

Hmm, I'm think I'm snoring but I'm not sure - I did a Watchpat a month ago with my Airsense 10 on, and that shows a lot of snoring, yet my OSCAR shows 0 snoring ever (even on the night of the watchpat, lol). I'm guessing my OSCAR just isn't scoring snores correctly. Here's that watchpat for reference: https://imgur.com/a/yNGslqF. Actually, this is probably worth diving into a bit more. 1. Overall, it seems like to me that the spikes in the flow rate graph seems to correlate with the watchpat respiratory events better compared to flow limitation. In that case, perhaps I should be using that as my primary metric to optimize? 2. Any comments about my heart rate graph? I'm thinking that's an even better metric of my sleep disruption compared to the respiratory events, since I feel like big heart rate spikes/dips must imply some disturbance, and there's more scored heart rate spikes/dips compared to scored respiratory events. 3. How do I read my respiratory rate graph in OSCAR? Should I be looking at big increases, decreases, or spikes in general?

If it were me, I would think the pressure is too low. I would look at this and think that an EPAP of ~ 7.5-8 seems to knock out your OAs, and an IPAP of ~ 11-12 seems to knock out your Hypopneas. On the second night, that pressure spike (and couple of hypopneas and big FLs) @ 8:15AM on 2/20 is weird to me. That is, I cannot tell if these FLs (and thus Hypopneas) were caused by pressure or not (the cluster of two Hypopneas comes on the downslope of a pressure increase). This is one of the reasons why I like a tight pressure range (and for me, I prefer no auto-adjusting pressure) because the added pressure can sometimes exacerbate the issue.

I zoomed in and I think it's vice versa - I was having some really flow limited stuff that prompted the pressure rise afterwards. I don't think I've seen examples of pressure rising causing FLs/Hypopneas, but I'm also not sure.

[TexasDon]

I see a full face mask and no leaks.   Any suggestions for this forum to achieve this?    My leaks are a marvel and I sleep on my back.   No tossing that I am aware of and I do pretty good hose management, clipping the hose to my PJs a couple of diff places.

Thanks!

Don

[newuser1002]

Hey TexasDon, sorry I don't really have any tips; I just adjusted the tightness of my velcro straps until it was tight enough to not have leaks even if I move my head around, but not any tighter than that. I use a dreamwear full face mask that goes blows air from under the nose. I don't do anything with the hose, I just have my CPAP on a table next to my bed (roughly the same height).

[newuser1002]

Day 7 - 24 Post (2/21 - 3/10)

Really sorry for the delay! TLDR: My sleep got much worse, now having ~5 AHI instead of < 1 with tons of OAs and very weird flow rate curves, but I don't think it's because of increased pressure or increased PS. I feel slightly, but certainly noticeably, more brain-fogged and fatigued. More details below.

Initial settings:
6 min EPAP - 16 max IPAP, 3.6 PS.
Humidity "Off"
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

Final Settings:
8 min EPAP - 16 max IPAP, 4.4 PS.
Humidity "Off"
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

Changelog

• 2/21 Increased min EPAP from 6 to 7 and changed humidity from "Off" to 4. 
  
• 2/24 Removed humidity - from 4 to "Off".
  
• 2/26 Increased min EPAP from 7 to 8.
  
• 2/28 Increased PS from 3.6 to 4.4.
  
• 3/2 Started using plastic bottom retainer. 
  
• 3/3 Increased PS from 4.4 to 5.0
  
• 3/6 Decreased PS from 5.0 to 4.4 (felt a bit scared having such high PS. Figured since I wasn't seeing many benefits, I'll just bring it back down for now). Also, finally washed my bedding and vacuumed, for the first time in 3 weeks (not good, I know).
  
• 3/7 Put my breathe right strips higher than before, from middle of nose now to upper nose pretty close to my eyes. 
  
• 3/8 Started using Dymista instead of Nasacort + Azelastine.
  

OSCAR: https://imgur.com/a/xqkL5pr

Note: I made my FL scale to 0-0.5 instead of 0-1.0. Also, feel free to ignore the user flags. I was experimenting to see if I can find a better metric than FL since I believe my FLs are being undereported by OSCAR, but I couldn't find a suitable metric. I now believe the number of spikes in the flow rate graph now most closely approximates RERAs and am using that. Though all of this feels irrelevant compared to my more glaring problem of increased OAs right now..

1. What is causing the stark increase in OAs and new weird breathing? I started having lots of mostly clustered OAs beginning on 3/2 and happening every day since then. I'm very confused on what caused it. Although it seems like a stretch, notably the one change that happened on 3/2 is that I got a plastic bottom retainer (instead of a "permanent retainer", which is a thin metal strip behind my bottom teeth, which I had previously). I'm guessing the plastic bottom retainer is now forcing my tongue further back, causing OAs that I've never had before. Does this sound right to you, or do you have an alternative explanation? Other possibly relevant detail: On this day, I also replaced my plastic top retainer for the past 6 years with a new plastic top retainer from a different brand.

• I don't think it's the increase in pressure or increase in PS, since 2/28 and 3/1 are totally normal. Specifically the issues start on 3/2.
  
• I think it's positional apnea/FL, but I don't think it's random. It's been happening consistently ever since 3/2. It has never happened before then. There is definitely a root cause that can be identified.
  
• However one piece of counterevidence - to test my hypothesis, I took off my retainers last night (3/10). Yet, it did not solve my issue - AHI of 6.8... Perhaps my tongue got used to the new position...? That would be very sad.. how do I reverse this? 
  

2. Analysis of the the new OAs and weird breathing close ups: What does my flow rate now going down to -40 instead of -20 for a significant portion of the night mean? Does the flow rate graph suggest this new issue is positional-related?

3. Overall - besides this stark increase in OAs weirdness, which I'm guessing is independent of my initial issue of flow limitations, this increase in pressure and PS doesn't seem to have helped my flow limitations / presumed RERAs (spikes in flow rate graph) much. This aligns with my initial hypothesis - that my nasal congestion from my increased turbinates requires a very high IPAP of 16-17 at its worst to actually open up. Since I haven't reached that level yet, I have not seen much benefits, since when my nose is completely blocked, my 12.4 or 13 IPAP (8 + 4.4 or 5) is insufficient.

Other secondary observations:

• On 2/24, I used Afrin on my left nostril, making it completely clear in the morning. It was still pretty blocked at night right before sleeping though. More than ever before. Yet my FLs didn't seem to be reduced. I'd imagine that even if my right nostril was blocked, my left nostril being open should be sufficient to not have FLs. Since I still had FLs, maybe my ultimate hypothesis of my enlarged turbinates -> FL is wrong... Seems unbelievable though, since I have so much other evidence supporting the hypothesis. Maybe my left nose wasn't actually fully cleared throughout the night from Afrin. It's possible that since turbinates swell during REM, just because they are clear upon awakening doesn't necessarily imply it's not swollen during REM.
  
• On 2/26-2/28 and 3/7-3/9, I can breathe clearly through my PAP mask upon first awakening in the morning now (previously, one or both of my nostrils would be congested to some degree.) Presumably, this is from the increased pressure. Also, my allergy and humidification optimization may be contributing as well. Though exactly like above, it is possible that since turbinates swell during REM, just because they are clear upon awakening doesn't necessarily imply it's not swollen during REM. Indeed, I still have some flow limitation in OSCAR.
  
• On 3/4, drank lots of alcohol but somehow had way more dreams. This is surprising, since alcohol is supposed to suppress REM sleep to some extent. And, it should act as a vasodilator, making my turbinate nasal congestion worse. Maybe alcohol -> increased fragmentedness of sleep -> remember dreams more. Alternate hypothesis (though seems unlikely): alcohol acting as a depressant -> less PLMD -> better sleep? I had RLS as a kid (and still have it now to a lesser extent), so this is theoretically a possibility. 
  

Impending changes:

• Going to try some more nights without the retainers. Maybe some different pillow heights. Maybe a bolster to encourage side sleeping more. Maybe a soft cervical collar (not sure if this would help with tongue positioning though). I need to fix my OAs...
  
• Going to try an alaxo airway nasal stent to guarantee my nose stays open.
  
• Interested in trying to literally video record my night to have this information to cross reference with my OSCAR data. This would be useful to see my sleeping position, matching RERAs to flow rate patterns, movements, snoring, nasal vs mouth breathing. I really should have done this a long time ago - there's so much useful data to be gained here. Any recommendations on how to best do this?
  

Would love your thoughts on these points and any other observations you may have!

[fishfinderG]

For recording yourself, a cheap home smart camera like the Eufy C24 or Wyze Cam work well. I’ve found them to be useful for checking positional issues, and also for confirming arousals that I see in my flow rate but don’t remember. The one word of caution I’d share is that it’s normal to move around and briefly wake up.  I got too focused on every little arousal or jerk when I had the camera footage.

Why did you turn humidity off? Your flow looks better with it on to my eyes. Humidity can keep turbinates happy and prevent some flow limitations from nasal issues.