Suspected UARS - Question Re Next Steps

[theclient1437]

    Here is my OSCAR data from last night.  After doing a bit more reading, I suspect I need to lower the PS in order to lower the CAs. 

[UARS.DDS]

A bit of further background: I have a *gigantic* tongue, and large tonsils (Dr.'s frequently remark on them upon inspection).

Gigantic relative to the size of your jaws. I wouldn't be surprised if you have a "scalloped tongue" - could you check on that? I also wouldn't be surprised if you suffer from heartburn, which many hypothesize are a side effect from sleep-disordered breathing and which may increase the size of your tongue due to inflammation.

As a child, I had palatal expansion.  About 7 years ago, I had a turibnaplasty, sinuplasty, and septuplasty due to recurrent sinus issues.   While I stopped getting as many sinus infections, my sleep symptoms still worsened/persisted.

It's possible that the palate wasn't expanded enough, or the treatment wasn't done well. It's also possible that your palate width is good, but the positioning of your teeth gives no room for your tongue. And it's also possible that your lower jaw is too narrow. Only a thorough examination can tell. 

The recurring theme I see is that all these ENT procedures are done but sleep remains crappy. Could it be possible that the jaws are getting ignored here? Hmm...

Due to the parasomnias I experience, I have tried most commonly-prescribed sleep drugs, namely z-drugs, benzo's, etc.  None was a solution to my sleep issues, though klonopin helped somewhat (probably because it reduced my REM sleep during which I suffered flow limitations/RERAs).  

Typical medical system - throwing drugs at the symptoms without investigating and curing the underlying cause.

Recently, I saw another sleep doctor, who wanted me in for a lab sleep study.  However, because of COVID, the best I could do was the WatchPAT study.  When I asked this new sleep physician about UARS (before the WatchPAT study), he replied that he didn't believe in the diagnosis, insofar as the treatments for it are the same as those for apnea (CPAP, dental devices, surgery, etc.), which isn't exactly an encouraging sign.

I'm not sure how this sleep physician doesn't believe in the diagnosis but believes in treatment for it. How can you have a treatment without a diagnosis? Puzzling... 

My first unresolved issue is that the nasal pillow seemed to chafe the skin below my nose and above my upper lip.  Perhaps this was due to my roughly 3/4c facial hair.  I've trimmed my facial hair, and will see if this resolves things.  Also, has anyone used some sort of moisturizer (e.g., vaseline, etc.) to help avoid this chafing?  Does anyone have any other suggestions?

People like using Lansinoh around their nostrils - it worked for me when I used the P10 and I have a lot of facial. hair.

For lack of a better description, occasionally, when I would inhale, I would take in too much air to the point that I would feel that I was suffocating.  This seems to me (based on my highly naive opinion) that the max IPAP might be set too high.  What are your thoughts?  I will post OSCAR screenshots later in the day.  

I'm not sure either, but perhaps PS is too high? You have a pressure differential of 4.0 between inhale and exhale, and it also looks like it's causing CA's so I would suggest dropping PS. I will leave it to more knowledgeable people to suggest different pressure settings for you.


I couldn't figure out how best to place the tubing in order to be able to roll around freely in bed.  Does anyone have suggestions?

Unfortunately, you can't with the P10 ... that was my only issue with it. Switch to the "ResMed AirFit P30i Nasal Pillow." The starter pack comes with either a small or regular frame, and small/medium/large pillows that correspond to the size of the P10 pillow that you use. The hose connection on top allow you to roll around without the tubing strangling you, haha. The P10 is great but the P30i is even better for me!

[slowriter]

Here is my OSCAR data from last night.  After doing a bit more reading, I suspect I need to lower the PS in order to lower the CAs. 

Maybe, but that clustering near where you're obviously awake suggests it may just be SWJ. If you're awake during those periods, you can ignore them.

[theclient1437]

Here is my OSCAR data from last night.  After doing a bit more reading, I suspect I need to lower the PS in order to lower the CAs. 

Maybe, but that clustering near where you're obviously awake suggests it may just be SWJ. If you're awake during those periods, you can ignore them.

The clustering near the 3am awakening seems to pretty clearly be SWJ.  Not sure about 4-4:30.  I don't recall being awake from 5:30-6:30, but it's hard for me to remember.

[Illorum]

This is UARS - and the MDs behavior makes no sense. The AASM started using RDI to diagnose sleep apnea ages ago. Under current AASM rules, you have "mild sleep apnea" since your RDI is > 5 and < 15. He's violating AASM guidelines - is he AASM accredited?

http://www.aasm.org/resources/clinicalgu...ng-osa.pdf

The third edition of the International Classification of Sleep Disorders (ICSD-3) defines OSA as a PSG-determined obstructive respiratory disturbance index (RDI) ≥ 5 events/h associated with the typical symptoms of OSA (e.g., unrefreshing sleep, daytime sleepiness, fatigue or insomnia, awakening with a gasping or choking sensation, loud snoring, or witnessed apneas), or an obstructive RDI ≥ 15 events/h (even in the absence of symptoms).23 In addition to apneas and hypopneas that are included in the AHI, the RDI includes respiratory effort-related arousals (RERAs). The scoring of respiratory events is defined in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.3 (AASM Scoring Manual)

[theclient1437]

This is UARS - and the MDs behavior makes no sense. The AASM started using RDI to diagnose sleep apnea ages ago. Under current AASM rules, you have "mild sleep apnea" since your RDI is > 5 and < 15. He's violating AASM guidelines - is he AASM accredited?

aasm.org/resources/clinicalguidelines/diagnostic-testing-osa.pdf

The third edition of the International Classification of Sleep Disorders (ICSD-3) defines OSA as a PSG-determined obstructive respiratory disturbance index (RDI) ≥ 5 events/h associated with the typical symptoms of OSA (e.g., unrefreshing sleep, daytime sleepiness, fatigue or insomnia, awakening with a gasping or choking sensation, loud snoring, or witnessed apneas), or an obstructive RDI ≥ 15 events/h (even in the absence of symptoms).23 In addition to apneas and hypopneas that are included in the AHI, the RDI includes respiratory effort-related arousals (RERAs). The scoring of respiratory events is defined in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.3 (AASM Scoring Manual)

Thanks for your reply, Illorum, I'm familiar with the AASM guidelines, and agree that I have mild apnea according to their criteria. 

Unfortunately, I may not have been clear in my initial description of my sleep study. 

My at-home sleep study was reviewed by a remote physician, with whom I've never met.  He has no knowledge of my EDS, unrefreshing sleep, gasping or choking sensations, which according to my reading of the above, he would need to know of to diagnose me as having mild apnea. 

Your point is a good one - I'll write him and inform him that experience all of the symptoms listed above so that I can get a prescription that I can use to get masks, tubes, etc. 

My local sleep physician, who has not reviewed the in-home study and is essentially unreachable due to COVID, has not made a diagnosis one way or the other regarding sleep apnea. 

Thanks!

[theclient1437]

My wife informs me that I removed the nasal pillows every hour or so.  I'm going to trial a full face mask, as I'm a mouth breather. 

Last night's OSCAR data is here - will be bumping up the PS to 3.5ish tonight.  Also, bumping up the trigger seemed to aid in comfort.

https://i.imgur.com/2yMgUJ6.png

[theclient1437]

Some further updates, currently up to PS=3.8. with 4-20 as a pressure range. See the below screenshot from last night.  It looks to me like everything's pretty well-controlled, but please let me know if you have any suggestions for tweaks/improvement.  Of note: I didn't fall asleep until after 11pm, and did take the mask off once in the middle of the night.




I've been trying to figure out the best nasal pillow size for the P10 until the FFM arrives.  Last night, I used a large-sized nasal pillow, which resulted in a lower leak rate. Using a bandaid under my nose and lanolin in the nostrils has helped reduce irritation, though it's not perfect.  

I'm still awakening in the middle of the night due to nostril irritation, or taking too large of a breath and freaking out. But, I'm doing so less frequently, so everything is trending in the right direction.

[slowriter]

Looks pretty good, but you could bump min EPAP to 5 or 6.

[theclient1437]

Thanks for the reply. What might bumping min Ipap accomplish?