Noobie UARS, pls help me fix my breathing :/

[newuser1002]

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.

Got it, thanks for the camera recommendations, will check those out!

I tend to notice my nose being more congested when upon first awakening in the morning when I have humidity on rather than off, so I turned it off. I didn’t see any noticeable differences in the flow rate graphs, could you point me to what signals you saw that shows it was better with humidity on?

[fishfinderG]

To my eye, at a quick glance, there are fewer large spikes up or down on the days you had humidity on. In my graphs those are often snorts from congestion but I don’t know if that is what you are experiencing.  It’s another potential explanation if you don’t think the retainers are the issue.

[newuser1002]

Hmm looking back at the data, I don't think that the humidity is related to the drastic increase in OAs, since the timing isn't correct: 2/26 - 3/1 with humidity off is totally fine. But beyond that, it does seem like there's like less spikes overall with humidity. It seems I got misled by me waking up in the morning with my nose not completely blocked on 2/26 onwards because I increased pressure and removed humidity at the same time. Seems like it was the increased pressure that pushed me past the threshold - not the humidity. Will be transitioning back to humidity 4 and doing some more testing on that. Thanks for the flag!

[jcoleman]

Boy, there's a lot here, and I am sure this is pretty maddening.

I agree about the humidity setting, especially if you feel like the main issue is nose congestion. Also, I think you are on the right track looking at positional stuff for the clusters of OAs.

Also, the tube temp is really only there to prevent rainout. It does not heat the air to the temp set, it heats the exterior of the air tube to prevent condensation. As such, with a humidity of 4, you might find a tube temp of ~80 degrees (depending on how cold your bedroom is) to control rainout better. I mention this because, personally, I find rainout to be really disruptive (especially when my hose gurgles). I also find a tube cover to be really helpful, especially in the winter, with controlling condensation (my bedroom is ~ 65 all night and my tube temp is 82, my humidity is 5, and I use a humidifier to keep the room humidity at 50%).

What I would do, if I were you, is really focus on the subjective aspects of your therapy. I think it is good to use oscar data as a baseline, but the most important thing is how you feel. Also, these were some pretty big pressure changes, and you might find more luck going more slowly (e.g. adjusting .2 at a time).

The notes function in Oscar is really helpful, as is looking for nights that seem more quiet in Oscar (fewer FLs, fewer FL spikes, lower FL 99.5%, less grassy and more "full" flow rate curve, etc.). I am also, still, a big advocate of fixed pressure settings, especially for UARS, but that is my opinion. That is, it could be something to look at, subjectively, how rested you feel as compared to what the pressure changes were doing all night.

You can also look back over the summary screen and see what correlation you can make with regard to settings. For me, I look at the usage, wakeup time (later is better), total time in apnea, snores, leaks, and FLs.

Most importantly, though, and I know I am repeating myself, what matters is actually feeling better. As such, as you are gathering data, see if you can find a set of settings where you feel better/good/energized the next day. You can start with a baseline of settings that seems like it is the most "quiet" and slowly adjust from there. From your screenshots, it seems like the boost of EPAP to 7 helped you, but I am not so convinced that higher PS is necessary. Also, it seems like going to EPAP 8 from there might have been a step backwards (more FLs, grassier flow curve). To me, the night of 2/22 seems pretty quiet.

I kind of wonder with you if your pressure range is really sensitive, and if more pressure past your golden range is causing issues. If it were me, I would start out with a quiet range (e.g. 7-11 PS 4) and see what happens. From there, I might want to see what less IPAP does (e.g. PS 3.8 and 3.6, adjusting Max IPAP down accordingly) as well as what more PS does (PS 4.2 and 4.4, adjusting Max IPAP up accordingly). Mostly, I'd just want to try and figure out what role IPAP is playing here, since it seems like the EPAP of 7 or so is pretty good for you. I kind of have a feeling that too much IPAP is congesting you (or not playing well with your turbinates), but that is just a guess/hunch.

On another note, do you feel like you have any sort of GERD going on? Do you frequently eat close to going to bed (and/or have really spicy food, or eat really big meals for dinner)? Do you notice varying degrees of face swelling and/or sinus tenderness in the morning? Do you notice that your sleep/numbers/tiredness goes haywire after certain sorts of dinner meals (and/or meal timing)?

Anyhow, lots to look at here, and you are definitely on the right track. For me, it took a long time to finally be able to make sense of things, but that did come. Keep going, go with how you feel, use what you learn/know works for you (e.g. feels the best, leads to the best days), and you will be able to dial this in.

[jcoleman]

Oh, one other thing, subjectively, I think it is really important to be aware of your UARS symptoms and key into what settings seem to manage these the best.

For me, it is:

1. Brain fog (slow thinking, fuzzy, difficult word recall, slow/garbled reading, etc.)
2. Cold hands/feet (and just colder in general)
3. Low mood
4. Apathetic/Unmotivated
5. Bigger appetite, especially in the morning and late afternoon

In addition to just checking into how I feel every day, I notice when these symptoms pop up and see if there is something that needs to change in my therapy (or if a previous therapy change resulted in fewer symptoms). There are a lot of variables here and sometimes (or often, especially when it is dialed-in) PAP has nothing to do with it, but a good thing to focus in on when looking for ideal settings nonetheless.

[newuser1002]

Thanks for the response as always. I agree with your suggested approach, I'm going to try taking a step back and will try 7-11 PS 4 tonight (and not eating anything after 7 pm). I think it is possible that at this point, I am past my point of optimality in terms of pressure. 

In fact, last night, I did three changes at once that led to my worse night in a while - bad idea, I know, will be hard to distinguish what specifically caused it. I increased min EPAP to 9, increased humidity back to 4, and also took 0.3 mg of melatonin 1 hour before bed (to be fair, the melatonin was necessary since my sleep schedule was super screwed up from the weekend). I also ate late night non-spicy indian food (chicken tandoori). I ended up taking off my mask in the middle of the night and falling asleep for the rest of the night without it. Was so tired the entire day, fell asleep while sitting at my computer for an hour, could not concentrate on anything, etc. Presumably, the humidity was a non-factor. Not sure whether the melatonin or increased pressure caused the worsened quality.

Now that you mention it, I have been eating more often at night in the past two weeks. Is it at all possible that the late night eating is causing the OA clusters? What would be the mechanism? Do you think that is more likely compared to the new retainers hypothesis?

[newuser1002]

To make it more concrete, here are four competing hypotheses for what is causing the stark increase in clustered OAs beginning on 3/2.

1. I started using a bottom retainer and replaced my top retainer on 3/2. Perhaps the presence of the new bottom retainer and/or replacement of my top retainer has changed my tongue positioning, causing OAs. Yet me stopping this for the past few nights has not reversed it. One way to consolidate that fact would be that maybe my tongue has already adapted and learned the new positioning. Or maybe my teeth have actually shifted from my retainers in a negative manner. I don't know though..

2. I have been eating late at night frequently for the past week or two. I was not measuring this, so I don't know if this was an every-day occurrence or just some days. Perhaps GERD or something could be causing events..? This is easily testable - I will not eat late at night for the next few days and see if anything changes.

3. The increased pressure is causing the increased OAs, somehow. The events tend correspond with an increased pressure, sometimes even to my max of 16 IPAP. The increased pressure tends to follow the events, so it is probably a symptom, not the cause. But perhaps it is a negatively reinforcing loop that is simply initialized by a minor change, such as the increased PS to 4.4 on 2/28. If this were true though, how come 2/28 and 3/1 were okay? And what would be the actual mechanism of increased PS causing obstructive apneas..?

4. Unbeknown to me, I have been sleeping in a new position that I have never done before that is causing the OAs. The OAs do look positional. But I highly doubt this since throughout my 7 months of PAP, I have never ran into this issue. What are the odds that my sleep position has never caused this in the past, and that some random change in sleep position beginning to cause this, consistently?

I am feeling quite sad since I really am not confident in any of my hypotheses... The most plausible to me would still be the dental retainer hypothesis since that is most consistent with the timeline. In my opinion, I really think the timing is of critical importance, and that any hypothesis must be consistent with the actual sequence of events. Do you have any thoughts on which hypothesis (or any other hypothesis) seems most promising to you?

[newuser1002]

Great news! Last night my sleep returned back to normal (pre 3/2, still UARS though). Did min EPAP 7 - max EPAP 11, PS 4 (i.e fixed range) with humidity 4. Also, did not eat anything past 7 pm. Wore my retainer. So it is almost certainly either hypothesis 1 (increased pressure) and/or 2 (GERD). Probably primarily hypothesis 1 since that's what you've been saying and you've got great intuition. Probably the increased pressure wasn't nice to my turbinates. 

Also another counterexample to hypothesis 2 is that I reported that I ate cookies/milk close to bedtime on 2/28 and that night was fine. Tonight I just treated myself to a massive meal of a burger, fries, and korean bbq at 10 pm to test out this hypothesis further, lol. One confounding variable to keep in mind is that I took 50 mg of Modafinil (for the first time ever) today at 11am since I am really behind at my workplace after being so tired for the past week.

One thing to note though is that I only tried increased pressure with humidity off (except for 3/12). I wonder, if I have increased pressure but with humidity on, if that would be nicer to my nose and actually see positive effects instead. Though on 3/12, I did turn humidity back on to 4 and that was the night that was so bad that I took off my mask in the middle of the night (note: I also increased my min EPAP to 9 that night). But even then, maybe one night is not enough to disprove this hypothesis - case in point, I'm still confused about how 2/28 and 3/1 were okay - without the clustered OAs - despite the increased pressure and lack of humidity. Only 3/2 did the clustered OAs start and were consistent for the next 11 days. So, I don't think that 2/28 and 3/1 could be explained by inter-night variance, since it shouldn't be so consistent afterwards in that case. The only explanation I can think of is that there must have been an additive negative effect from the increased pressure, which then crossed a "critical threshold" on 3/2. The critical threshold being the point in which the pressure raised far enough that it caused more events, causing more pressure increase, etc. until the ceiling. Not super confident on that explanation though - 3/1 doesn't look significantly worse than 2/28. And 2/28 doesn't look significantly worse than 2/27.

OSCAR of last night for reference: https://imgur.com/a/foljf9k

[fishfinderG]

I know that it’s hard to give it a few nights when you are tired at work, but any time I change my PS or significantly change my pressure it takes 2-3 days for my body to get used to it and for me to actually see if it was a good or bad change. And even then I still will have random bad or really good nights for unknown reasons.

I wish that sleep was one of those things where you could test a single variable change every night but it sometimes takes 2-3 nights to really know if a change is good or bad.