Oscar Data. No events flagged but weird flow rate pattern during REM

[Ynot]

Did you ever go see that ENT? I had AHI 5.8 overall with nREM=0 and REM=25.8 at my sleep study, mostly hypopnea (longest over 50s) but plenty of apnea in there as well. After three years of struggling with various stuff I went to see an ENT and it turns out that 50-70% of the open space in my nasopharynx was occupied by adenoid tissue. Bye-bye. He fixed the deviation of my septum, trimmed and outfractured my turbinates while he was mucking around in there, and I feel worlds better already after just over a week.

If you don't get scoped, you have no idea what's causing your problem and you'll be shooting in the dark trying to fix it.

I see, I'll get on it, it's just that it is really hard to get a Dr here in Canada. Thanks for sharing you situation really interesting. Are you still suffering from sleep apnea? How much did it improved? Also do you notice the same flow limitation pattern as I do, where it spikes every 1.5h

[Ynot]

I think if you're still feeling sleepy and tired during the day, it's time to do two things.  One is to talk with a sleep specialist about REM-specific problems.  Another is to talk with your regular doctor about other possible causes of your daytime problems.  He or she would be wise to test for problems in these areas:  iron, thyroid, testosterone, Covid, Lyme disease, auto-immune disease, especially connective-tissue disease, deficiencies of vitamins B6, B12, and D.

I'll try to talk to an ENT. What about the flow limitations. Isn't that a bit high? Given that it improved with epr 3, would bilevel be appropriate?

Thanks

[Ynot]

It looks like to me that the flow limits may be causing the breathing.  I would move the min up 1 and make sure the EPR is 3 full time (it looks like it is but the left column does not go down far enough to see the setting).

Unfortunately, I do not notice an improvement in flow limitation with an increase in pressure, and I get aerophagia that wakes me up if I increase it further than what I have. Epr 3 did improve my flow limitations. Do you think bilevel would be appropriate? Also, flow limitation spikes at rem which can be deduced as it is spaced apart by 1.5h, is this a common pattern or most people just have constant flow limitation?

Thanks

[Dormeo]

I don’t know whether the FLs are the cause or the effect of a REM issue, and even if we knew that, it’d be hard to know whether greater pressure support would help. In the US, most insurance companies wouldn’t cover a bi-level machine for someone with numbers as good as yours. Could you pay for a machine yourself?

[SarcasticDave94]

If the FL are still bothering, and it appears EPR 3 is active, with the AutoSet I think the only tool you've got left is more pressure, specific to minimum as the base. Whatever your Min pressure is now, turn it up .2 and try it. If it's comfortable next determine if this addressed FL in even a small amount. Caution though, there will be a place where you take pressure up to reduce events and diminish comfort. As you reach that, you'll likely want to pursue how to get the bilevel VAuto.

[Ynot]

I don’t know whether the FLs are the cause or the effect of a REM issue, and even if we knew that, it’d be hard to know whether greater pressure support would help. In the US, most insurance companies wouldn’t cover a bi-level machine for someone with numbers as good as yours. Could you pay for a machine yourself?

I believe they are definitely associated with the cause. During my study, RDI and AHI was only a significant issue during Rem sleep, and the flow limitation pattern appears to correspond rem sleep. Also, the flow limitations reduced greatly with epr which suggests that it is somewhat treatable.

[Ynot]

If the FL are still bothering, and it appears EPR 3 is active, with the AutoSet I think the only tool you've got left is more pressure, specific to minimum as the base. Whatever your Min pressure is now, turn it up .2 and try it. If it's comfortable next determine if this addressed FL in even a small amount. Caution though, there will be a place where you take pressure up to reduce events and diminish comfort. As you reach that, you'll likely want to pursue how to get the bilevel VAuto.

I feel very tired during the day. I frequently suffer from insomnia but I believe my tiredness is likely associated with UARS because some days, when I wake up, I feel tired in an unnatural way: Dizzy, pressured head, dry mouth sometimes, disoriented. And those symptoms are worse when I do not use the Cpap.

I think I found the limit of how much I should increase the pressure sadly because if i increase it more, I get aerophagia, and I feel it hurts my sleep more than it helps it. Bilevel would be interesting though because epr improved my flow limitations quite a bit. 

However, as Dormeo mentioned, it'll be difficult to make my case with a low ahi with the doctor and therapist, I think they only or mostly look at ahi. 

How should I approach this, should I show the improvements of epr in flow limitations, connect the patterns with the study results with regard to rem sleep, and express how tired I feel?

I attached side by side comparisons with epr and without. This difference holds regardless of pressure.

[SarcasticDave94]

Honestly I'm not certain how to approach the doctor with the need to go VAuto. Here in the US, some doctors will listen to the complaint that the CPAP therapy isn't enough or is uncomfortable and that BPAP would help. There may be a component to the complaint about not feeling much better for usage, running higher pressures to treat events aggravates your aerophagia, it feels uncomfortable, something like that maybe if they'll listen.

[Ynot]

Honestly I'm not certain how to approach the doctor with the need to go VAuto. Here in the US, some doctors will listen to the complaint that the CPAP therapy isn't enough or is uncomfortable and that BPAP would help. There may be a component to the complaint about not feeling much better for usage, running higher pressures to treat events aggravates your aerophagia, it feels uncomfortable, something like that maybe if they'll listen.

Do you think it is normal to have such an irregular rem flow rate considering the FLs?

[PeaceLoveAndPizza]

Please do not zoom into specific areas without someone asking to see it. Always show the entire evening. Initially, the graphs we need to see are:  Events, Pressure, Flow Rate, Flow Limitation and the Leak Rate Graph.  Always include the entire left side bar, minus the calendar and pie graph.  

Set your display to the Standard view.  
(View > Reset Graphs > Standard)
Take a screenshot of your Daily screen.
   * For Windows or Linux: Use the F12 key
   * For a Mac: Use Fn+F12 or cmd-space-3


I would also like to see the respiration rate graph as that should show the arousals as well. When you pair it with the flow rate graph, it should be fairly easy to show how it is affecting your nights sleep. If you have a smartwatch that tracks sleep quality, that will help as well.

Based on the charts so far, you need more pressure support to manage the flow limitations. There are just not enough nerd knobs and geek gadgets on the Autoset to tweak much further. 

You have quite a few inspiratory flow limitations as you can see in the flattened peaks on your inhale. With the AS10 limited to pressure support of 3 and no trigger/cycle settings, all you have is pressure to deal with it. You can possibly reduce them with pressure, but that has its own challenges.

Read the following thread for more ideas. The entire motley crew pitched in to help DebK get the requisite information to justify a bilevel.

https://www.apneaboard.com/forums/Thread...to-Bilevel