OSCAR flow rate assessment -- mouth leaks, palatal prolapse?

[manders513]

Hi folks,

I have UARS and have been using a ResMed Aircurve 10 VAuto since sometime last year. I'd also tried the AutoSet 11 before that. When using a nasal mask, I had seen a lot of what I thought were mouth leaks in my flow rate (expiration at the 0 line), though not really marked in my leak graph. I then added a chin strap and mouth tape along with my nasal mask and was still noticing the issue, assuming I was still somehow mouth leaking through the tape. Eventually, I got really tired of the strap/tape and switched to a FFM in November of 2023. However, I still see the same "leaks" with the FFM, so I'm thinking they weren't leaks at all (unless marked Large Leak, which is exceedingly rare for me but actually happened once last night). The 0 line exhales happen pretty often, usually causing an arousal. The same kind of thing happens on my inhalations, probably more often, also causing arousals. Lately I've been waking up many times in the night, often every hour or so, sometimes not able to fall back easily or at all. 

I'm wondering if the 0 flow rate exhalation events that I thought were leaks are actually palatal prolapses? Here are 2 examples that led to arousals (first is last night with a FFM, second is months ago with a nasal mask):
   
   

I also notice 0 flow rate inhales--what are these? Brief airway obstructions (indicative of my UARS)?
   

Two reasons for posting this...1. My insomnia is back and I'm feeling pretty awful. 2. If I'm having PP I want to get that evaluated. And if I'm not actually having mouth leaks with a nasal mask, I may switch back as it was more comfortable.

Thanks in advance for any help you can provide! I can post more examples and/or the full night screenshots as needed.

[apnea505]

The breathe event just looks like OA that is less than 10 seconds and therefore not flagged. from my understanding of UARS, which I may also have, its laboured breathing where obstructive apnea is a full blockage.

As far as leakage, is it possible that a fitting is slightly leaking, or even the humidifier tank? Full face masks leak more than nasal pillows, either way leaks look minimal. 

How did the airsense 11 treat your UARS compared to the Aircurve 10? Im contemplating buying a used Aircurve 10 (since its not covered), though the Airsense 11 is a newer model with more modern features so not sure I want to do that unless i find im not properly treated on the newer 11.

[manders513]

Thanks!

I haven't really noticed much difference, to be honest. I don't believe I'm properly treated or ever have been. The 11 was nice, though I think having the ability to increase pressure support with bi-level has made a difference in my comfort levels as I'm able to exhale more fully with the bi-level machine.

Quick edit: I highly recommend renting a machine first! I used RespShop and rented both models before I made a decision to purchase.

[BoxcarPete]

Your charts do not show any sign of palatal prolapse, because you have approximately equal area above and below with each breath. The fact that flow goes to zero before your next inhale is a completely normal pause before you take your next breath. PP usually occurs in long chains, for minutes at a time where every breath is in only and there's no exhale shown at all; this pattern is effectively exclusive to nasal masks. In the two instances where it goes to zero after inhaling and then showing inhale again, that's all it is. You can try this while awake: breathing normally, don't exhale at all when you have taken a breath, instead hold your breath once you are done. Then inhale again sharply, like a sigh. That's what's happening; the odd flow rate is a result of the arousal, not a cause of it.

[apnea505]

Well im already stuck with the 11, though it was paid for by insurance. Your flow rates look very similar to mine actually though I dont think they indicate UARS (untreated anyways) but im hoping someone with more experience will comment on this. How do you know you are not treated properly? Still symptoms? I just bought a device approved by health Canada that measures O2 levels and heart rate throughout the night to hopefully see if things have improved, I figure I can also use for my daughters asthma when she is sick. I no longer feel or hear my heat beat when I wakeup and try to go back to sleep, so thats a positive. Unfortunately my Apple Watch's heart rate monitoring did not even pickup the 109 BPM spikes that my sleep study did. Sadly my sleep study did not measure RERA's. Apparently the wabtchpat does though, you could try that to see if you are effectively treated. Or maybe just a device that measures heart rate continuously, smart watches are not capable of this.

[manders513]

Your charts do not show any sign of palatal prolapse, because you have approximately equal area above and below with each breath. The fact that flow goes to zero before your next inhale is a completely normal pause before you take your next breath. PP usually occurs in long chains, for minutes at a time where every breath is in only and there's no exhale shown at all; this pattern is effectively exclusive to nasal masks. In the two instances where it goes to zero after inhaling and then showing inhale again, that's all it is. You can try this while awake: breathing normally, don't exhale at all when you have taken a breath, instead hold your breath once you are done. Then inhale again sharply, like a sigh. That's what's happening; the odd flow rate is a result of the arousal, not a cause of it.

Thanks for responding! I'm still a little confused about it, if you don't mind indulging a question or two...

I see what you're saying about PP being persistent vs a one-off here and there. I guess I'm still just not sure of this being a normal breath hold. I tried holding my breath like you suggested and then breathing in again, but why would I do that? It feels wrong. When I inhale and hold, what I really want to do is exhale that air, not inhale again. But that's me awake, so I'm not sure what my sleeping brain would do. The spots I highlighted (first attachment at 4:49:50 and second at 6:41:00) seem to show what you said, an inhale, a hold, and another inhale/arousal. It seemed to me that the hold caused the arousals (spike/sigh around 4:50:00 and just before 6:41:15)?


When you say it's a result of arousal, do you see any reason for there to be an arousal in the first place? I usually don't. Is that just our old friend UARS being difficult?

Thanks again!

[manders513]

Well im already stuck with the 11, though it was paid for by insurance. Your flow rates look very similar to mine actually though I dont think they indicate UARS (untreated anyways) but im hoping someone with more experience will comment on this. How do you know you are not treated properly? Still symptoms? I just bought a device approved by health Canada that measures O2 levels and heart rate throughout the night to hopefully see if things have improved, I figure I can also use for my daughters asthma when she is sick. I no longer feel or hear my heat beat when I wakeup and try to go back to sleep, so thats a positive. Unfortunately my Apple Watch's heart rate monitoring did not even pickup the 109 BPM spikes that my sleep study did. Sadly my sleep study did not measure RERA's. Apparently the wabtchpat does though, you could try that to see if you are effectively treated. Or maybe just a device that measures heart rate continuously, smart watches are not capable of this.

Regarding feeling that I'm not treated properly:
Yes, symptoms. Once I got used to the machine/mask, I was sleeping mostly through the night for months, but still waking groggy and feeling like I needed to rest first thing upon waking (like sleeping is a workout, that's the only way I can explain it). That said, that was still a massive improvement over waking gasping with my heart pounding and having terrible insomnia. Fast forward to late January though, and while I'm still not back at zero, I've never woken feeling rested/not exhausted and now I'm having insomnia again. Though the insomnia is different this time. Waking way more often, fully aware. Sometimes able to fall back quickly, sometimes it takes a awhile, sometimes I'm up for hours. Not sure what that's about yet.

I had thought about doing a Watchpat before but then forgot, thanks for the reminder! And yes, my watch doesn't quite capture my heart rate either, unless I get up to go to the bathroom I don't see any massive spikes like in my sleep study.

[apnea505]

Yeah I would suggest a device that measures heart rate and O2 continuously, im waiting for mine to show up. I didn't want to spring for watchpat just yet because they are disposable, im hoping the heart rate/o2 device will rule it out for me. Insomnia can be caused by lots of things as you are likely aware, stress/depression being one of them. I still wakeup 4-5 times a night for no reason despite starting to not feel like im dying anymore, trying to rule out breathing issues aswell. It takes effort to fall back to sleep though, especially if it's within 2 hours of when I get out of bed. I remember when sleep would come easy, but now it's conscious effort to all back to sleep every time. Maybe try Ashwagnada twice a day and see if that helps? The experts say your graph looks good, Do you get congestion at night? If so might want to visit an ENT, im planning to do that also.

[BoxcarPete]

Nope, I don't see any reason for the arousal. Unfortunately, that's often the case with these; if the breaths leading up to them are normal, then we don't have any clue from your data why it's happening. Did you ever have micro-sleeps before you started treatment? I would do that sometimes, fall asleep for a handful of seconds and often wake up with a bit of a gasp. Same thing happening here, you are partially waking up and a sharp intake of breath is just part of the deal. Sorry I can't be of more help, if it's not happening many times per night the juice probably isn't worth the squeeze to dig into it and do anything for them.

[BigWing]

PP usually occurs in long chains, for minutes at a time where every breath is in only and there's no exhale shown at all; this pattern is effectively exclusive to nasal masks.

Is there something else that causes that same pattern? If not, have you any idea why I might have suddenly had lots of those typical PP patterns last night even though I was wearing a FFM?? Here's an example: