Problem with mask and EPR

[sheepless]

those recovery breath events would probably be considered arousals but unless you have scores of them a night I'd be inclined not to worry about those for now & concentrate instead on figuring out what fully wakes you & what prevents you from rolling over & going back to sleep. have you looked closely in the charts for the 5 or 10 minutes preceding your awakenings? have you boned up on sleep hygiene?

[Sleeprider]

Putting on my satire hat....If ya can't roast a guy named Jomama for including a calendar, what is the world coming to?[ /hat]

Our information is limited to what we can get onto a chart, and your chart actually shows the progression to RERA from normal breathing through increasing FL and the recovery breathing/ arousal. I don't know what causes it, but it is a lot more like a limited hypopnea than chronic flow limitation. It's disruptive, and it's going to be there with or without CPAP. I have seen people that sleep with ergonomic pillows have far worse positional apnea clusters than a regular pillow, and I have seen impressive flow limits by people that sleep on their side and unconsciously tuck their chin and cut airflow. It may not be that, but I'll still point to the possibility.

If we really get into the weeds on the events you focused on, it is irapidly increasing airway restriction that at first limits the peak inspiration airflow, but progresses to an actual reduction as respiratory effort increases. You have decreasing airflow with longer inspiration time, and I think you know that reflects a struggle for air. Solving the problem, or at least learning what causes it, might be big help to you, whether you use CPAP or not. It might take some detective work or a video camera, but finding a workable collar solution might solve it too. Your sense of sleep disruption, in spite of low AHI makes some sense with these events.

[jomama]

those recovery breath events would probably be considered arousals but unless you have scores of them a night I'd be inclined not to worry about those for now & concentrate instead on figuring out what fully wakes you & what prevents you from rolling over & going back to sleep. have you looked closely in the charts for the 5 or 10 minutes preceding your awakenings? have you boned up on sleep hygiene?

I have really good sleep hygiene (I even started wearing blue light filtering glasses at night for a couple hours before bed), but I still feel tired/mainly unrefreshed in the morning, which is why I looked into apnea. But it seems like my case is effectively inconclusive. As for what fully wakes me up, well, PAP therapy. Seriously. Without CPAP, I don't normally experience insomnia, meaning, I don't normally have trouble falling asleep, and don't normally wake in the middle of the night unable to fall back asleep within a short period of time. And, normally, that happens later in the night/morning, maybe 5 or 6 am. For example, last night, since the insomnia with PAP has been wearing me down to nothing, I took a night off, took 25 mg of trazodone, and didn't fully wake up until 7am. I am sure that I was restless, but it was nothing like with CPAP. I feel mildly refreshed today, but not 100%. Though, at 47, I often wonder if I'm getting almost normal sleep sometimes (without PAP), but I'm expecting to feel like I did when I was younger (I seriously think that this is an interesting issue/topic). 

With CPAP, I have been waking up earlier in the morning, and having insomnia. My body kicks in wake up chemicals, and then I also find it hard to fall back asleep with the mask and machine. 

Also, I will notice what looks like an arousal on my charts, and then it looks like I'm struggling to fall asleep again (I may not remember it), and it takes a long time. I think that PAP therapy is making it hard for me to sleep. I have been telling myself that it just takes time, but the problem is that I simply cannot survive on the sleep I'm getting with PAP. I'm too worn out already to then pile insomnia, and the serious sleep deprivation it brings, on top of it. The idea of doing PAP for a solid month is basically unrealistic in my case, as I literally would not be able to live/function at all on only a scant few hours a night, night after night. I can't handle that at my age, and having suffered from often debilitating chronic fatigue for years now (again, potentially at least partly attributable to trauma/PTSD issues, and a couple recent years of prolonged, intense grief, which took a severe toll, no question). 

As to what arouses me (no puns intended), occasionally I'll see what looks like mildly FL breathing (meaning, it's not showing up on the FL chart, but the tops are flattened, or sunk in, a little bit), and then what looks like a mini-arousal. But then, I'll also just as often see something like in the image below, what looks like okay breathing, and an arousal out of nowhere. And then (especially with PAP) it's harder to fall back asleep, giving me even worse sleep than without PAP. Again, my case just seems so mysterious in many ways, and I keep wanting PAP to help, but I honestly wonder if it ever would.

[jomama]

Putting on my satire hat....If ya can't roast a guy named Jomama for including a calendar, what is the world coming to?[ /hat]

Our information is limited to what we can get onto a chart, and your chart actually shows the progression to RERA from normal breathing through increasing FL and the recovery breathing/ arousal.  I don't know what causes it, but it is a lot more like a limited hypopnea than chronic flow limitation. It's disruptive, and it's going to be there with or without CPAP.  I have seen people that sleep with ergonomic pillows have far worse positional apnea clusters than a regular pillow, and I have seen impressive flow limits by people that sleep on their side and unconsciously tuck their chin and cut airflow.  It may not be that, but I'll still point to the possibility.

If it's going to be there with or without CPAP, and I think we do have evidence of that, given that rising pressures don't prevent them, and my charts in general don't seem to indicate a need for higher pressures (unless I'm mistaken?), then why subject myself to CPAP?, is one of the basic questions in my case.

Re: chin tucking, I do see why you're suggesting it as a possibility, but here's why I think it's extremely unlikely in my case: when I am sitting here and breathing through my nose (like I normally do), and I tuck my chin down to almost touching my chest, I feel pretty much no flow restriction. Correct me if my logic is bad here, but that shouldn't be different when I am sleeping, right?

If we really get into the weeds on the events you focused on, it is irapidly increasing airway restriction that at first limits the peak inspiration airflow, but progresses to an actual reduction as respiratory effort increases.

Can you show me where there's evidence of an increase in respiratory effort? I can't see where that's indicated.

You have decreasing airflow with longer inspiration time, and I think you know that reflects a struggle for air.

Where are you seeing evidence of longer inspiration time? I also can't figure out where to look for/see that.

Your sense of sleep disruption, in spite of low AHI makes some sense with these events.

Yeah, I think so, too. The question that I'm trying to answer (with help from this forum), is: is there even a point of me subjecting myself to PAP therapy, if there's no hard evidence that it's actually going to address whatever's causing my bad sleep. Even if some of them are from occasional disordered breathing, I don't see evidence the pressure of PAP therapy is actually affecting it. And PAP is certainly making my sleep worse. Thus, the quandary.

[sheepless]

idk, it looks like your need / drive to breathe wanes occasionally & that may be why you have more ca than oa, if the last screenshot is representative. that's why I mentioned asv. bilevel's have setting options that seem to help with weak spontaneous effort but I don't think that's their intended use. if you have enough breathing lapses of some sufficient duration, you may be experiencing desats. I'm not saying it's likely in your case, but possible. otoh, so far it's sounding like what you surmise, that your current papping isn't working well for you. I don't have any experience with it but suggest you check out cbti or cognitive behavioral therapy for insomnia. it's the go to when optimizing settings isn't enough and people report success with it.

[Sleeprider]

Respiratory effort can be interpreted by the time of inspiration required to move a volume of air. Kind of liike if your milkshake is really good and think, it takes a longer draw to get a good taste, even with maximum effort/suction. We know the increased flow rate at the end of those limitations are arousals because you move in a way to free your airway and llow a large, rapid volume of air to pass. That's what we know. There is obstruction, and it has a physical source you are able to clear.

[jomama]

idk, it looks like your need / drive to breathe wanes occasionally & that may be why you have more ca than oa, if the last screenshot is representative. that's why I mentioned asv. bilevel's have setting options that seem to help with weak spontaneous effort but I don't think that's their intended use. if you have enough breathing lapses of some sufficient duration, you may be experiencing desats. I'm not saying it's likely in your case, but possible. otoh, so far it's sounding like what you surmise, that your current papping isn't working well for you. I don't have any experience with it but suggest you check out cbti or cognitive behavioral therapy for insomnia. it's the go to when optimizing settings isn't enough and people report success with it.

CBTi is, as you say, for insomnia, which I don't normally experience. I've certainly looked into CBTi (I've looked into pretty much everything, as far as I know), but since it's for insomnia (inability to fall and stay asleep--, and it could be argued that I have the latter problem, but I don't normally wake up fully and have trouble falling asleep again...which is what I think "sleep maintenance insomnia" is actually referring to... and I'm still not actually sure that my micro-arousals are that far off from normal for someone my age), so I don't really think CBTi applies to my particular situation.

As for CAs, I'm pretty sure that all my CAs happen while I'm awake and trying to fall back asleep. The charts seem to back this up. I will regularly take a breath and sigh, and then not feel the need to breath for 10-20 seconds or so. This is normal for me when I am resting/relaxing. Even the OAs I see, most of them don't actually seem to be obstructive events happening when I'm asleep. As for desats, I don't think that's happening to a dangerous degree, especially given  my home sleep test results.

I, too, have wondered about ASV for the fact that sometimes I just seem to slow my breathing. Not all the time, but occasionally. That said, thinking about ASV in my situation feels like grasping at straws, serious overkill. And bilevel, too, given that my Autoset has consistently so far, when on auto, not gone much above 10, which I can tolerate just fine with EPR 3, so I don't see what bilevel would do for me anyway. Because, again, higher pressures don't seem to make any difference to the majority of my sleep.

[sheepless]

despite the explanation, idk how Sleeprider knows it's obstructive, but that's the point: he knows way more than me. I demur.

[Osiris357]

Sheepless you can see it in the flow wave. One reason why a 2 min window is needed.

[jomama]

Respiratory effort can be interpreted by the time of inspiration required to move a volume of air. Kind of liike if your milkshake is really good and think, it takes a longer draw to get a good taste, even with maximum effort/suction.  We know the increased flow rate at the end of those limitations are arousals because you move in a way to free your airway and llow a large, rapid volume of air to pass.  That's what we know.  There is obstruction, and it has a physical source you are able to clear.

I understand the arousal, that's pretty evident on the chart. And it does look like an obstruction is happening before it, but that kind of thing has happened basically once a night. The rest of the night is more of an inconclusive mess. The point being that even if the event we're talking about is a legit RERA (and it certainly looks like one), I don't think it is/happens enough to explain my degree of unrefreshing sleep. Several RERAs a night maybe, but one? Even two? Doesn't make sense to me. Again, it's perfectly normal for people to have 20 micro-arousals a night, and they don't necessarily feel drained in the morning. And my charts don't seem to show the FL or apneas to explain it in my case. Thus, the mystery.

Not to be greedy, but would you also speak to the other things I mentioned in that reply above, like the chin tucking, and the issue of whether PAP therapy might actually be right for what's happening with me, given the logic I spell out, like the higher pressures not making any difference? I'm not expecting a definitive answer, of course, but I'd appreciate your take.