[Treatment] Help with treatment, questions, approach, understanding

[UsuallyTired]

Hi all, 
I was diagnosed with sleep apnea ~2 years ago, and I've lurked here since then. This is my first post. I will try to put as much information and questions in 1 post as possible. 

Problem: 

• Despite CPAP and O2, on most days I continue experiencing completely debilitating fatigue and brain fog, dramatically curtailing work, study, and social life. 
  
• My sleep doc sees good CPAP AHI numbers and shrugs. 
  

Attachments: 

• 3 screenshots from last night, one of the best nights I've had, and I do feel better (but not great) today. 
  
• 1 screenshot is the whole night
  
• The 2nd zooms in at an unmarked area that had a leak
  
• The 3rd zooms in on a semi-random spot that is entirely unmarked but shows some odd waveforms
  

Background Information: 

• Male, mid-40s, 5'8", 205 pounds (was fit but steadily gained over past 4 years), short beard (which would affect some masks)
  
• I live in Colorado, USA at 5600 feet altitude
  
• Originally diagnosed with home test with mild to moderate OSA (depending on 3% or 4% criterion) and severe oxygen desaturation (145 min <= 88%) 
  
• Currently using ResMed AirSense 11 Autoset as CPAP 5 and EPR 3 with N30 Nasal Cushion. 
  
• Just started using EPR last week without any change in CA. I got the idea from the UARS pages and do find it more comfortable. 
  
• I use an O2 concentrator at 1lpm b/c my own O2 testing showed me dipping below 88% at times (however, official testing shows me getting near or to 88% but not below). 
  
• My AHI with CPAP is always below 5, usually in the 0.5 - 2.5 range. 
  
• I learned about UARS here, and I suspect it may be the primary source of my problems for a few reasons. I often have arousals throughout the night or too early. I am struggling with metabolic problems which point toward chronic stress, elevated cortisol, sympathetic nervous system activation. My HRV (measured by Oura and Apple Watch) is consistently low (even considering variations between individuals). One of my nostrils is nearly always congested. In my mouth, I have a high palate and narrow upper arch. 
  
• I have trouble with oral venting when above CPAP 5 or 6. I am not a mouth breather, so I don't think it's mouth breathing but CPAP air escaping through my mouth. This venting wakes me up. 
  
• I have started the process with my dentist and an orthodontist to look into maxillary expansion. This would fix a crossbite but also hopefully help the airway. 
  
• My ENT has said I do have enlarged turbinates and has me on Nasacort. She has said I qualify for and could do turbinate reduction, if the Nasacort isn't sufficient. I am concerned about Empty Nose Syndrome and would like to address the root cause with the maxillary expansion. 
  
• Via my dentist, I tried the SleepImage device which showed significant sleep fragmentation (40-60%). I don't know how well-known or reliable this device is. 
  
• Considering a Medibyte Jr test, which I believe is a home sleep test but particularly looks at flow rate waveforms to diagnose UARS. 
  
• I found out about soft cervical collars here, and I tried a makeshift one last night. I believe it is the cause for my improvement today! I have ordered a Releaf. 
  
• I do not snore much
  

Questions: 

1. How common is it to have abnormal flow rate waveforms for a healthy person? That is, does everyone have some breathing hiccups? How should I think about this and what should I consider as normal variation vs significant? 
   
2. My TV (280) seems low, respiration rate seems high (17) (to make up for low TV?), and Minute Vent (4.88) seems on the low end for my size. I suspect this points toward UARS. Are my observations and conclusion accurate? 
   
3. Do you recommend any specific settings for the Oscar Custom User Event Flagging to help me identify problem events?
   
4. What's the latest recommendation for an oximeter which I could import into OSCAR? I've looked at some of the posts here (including the supported oximeter page), but much of what I've found is 2-4 years old. 
   
5. Does anyone have recommendations or opinion regarding the difference between these ResMed nasal masks: N30 cushion vs P30 pillow? I've been using an N30 and wonder if P30 would be better for any reason. 
   
6. Should I attempt to increase my CPAP pressure to compensate for RERAs and/or UARs? What about my oral venting concerns? 
   
7. Am I going in the right direction pursuing UARS? 
   
8. Any comments or concerns about pursuing maxillary expansion vs turbinate reduction? (Turbinate reduction would be significantly faster, easier, and cheaper.) 
   
9. What am I missing? 
   

Lastly, I want to give my thanks and gratitude to all who built, maintain, and support this forum, wiki, and Oscar. As I've dug in, I've been astonished at the level of detail and insight. I also feel less alone to see others who advocate for their health just as much, if not more, than I do. 

Thank you.

-UsuallyTired

Full Night: 
   

Zoomed in on Leak: 
   

Zoomed in on semi-random section without any events: 
   

[G. Szabo]

Does anyone have recommendations or opinion regarding the difference between these ResMed nasal masks: N30 cushion vs P30 pillow? I've been using an N30 and wonder if P30 would be better for any reason. 

Should I attempt to increase my CPAP pressure to compensate for RERAs and/or UARs? What about my oral venting concerns? 
 
Any comments or concerns about pursuing maxillary expansion vs turbinate reduction? (Turbinate reduction would be significantly faster, easier, and cheaper.) 

You have many questions, and I am trying to address a few today.

I found P30 better because the N30 compressed my nose during the inhalation (higher pressure) period, although its size was selected according to the manufacturer's recommendation.

It would not hurt to try 7 cm minium pressure with EPR=3. Most importantly, use the AUTO mode instead of CPAP.

You will need an oxygen monitoring device.

Turbinate reduction: Before taking any drastic measures, try using an Alaxo nasal stent (the short one for sports). It expands your nasal airway and also helps with congestion. You can use two of them simultaneously. 

I might add some more comments later.      

[G. Szabo]

... try 7 cm minium pressure with EPR=3. Most importantly, use the AUTO mode instead of CPAP. ...      

Post your result with the above setting. We might need to fine-tune it.

[UsuallyTired]

Thanks G Szabo. I appreciate the comments. 

I had never heard of the Alaxo Stents before. What a surprise! Thank you. 

I'll give the APAP 7 a try and see what happens. I'll post the results. 

I do want to get an oximeter device. It's just a matter of choosing the best model available at this time and that is compatible with OSCAR.

[UsuallyTired]

@G Szabo, 
Looking at Alaxo Stents, I see there are a variety of lengths. I'm curious why you suggested the short sports one. I'd like to understand your reasoning. 

Is it b/c of my mention about turbinates? Or, something about my waveforms, UAR, or something else? 

Thanks again

[Phaleronic]

Hi UsuallyTired,

I would raise pressure to 8cm with EPR at 3 as it does need more pressure, and you were at such a low pressure that it wasn't functioning really at all

[G. Szabo]

@G Szabo, 
Looking at Alaxo Stents, I see there are a variety of lengths. I'm curious why you suggested the short sports one. ...

You wrote that you are considering turbine reduction. The short one (about 4") will cover its range. The longer, more expensive ones also cover and additionally help patients with palatal prolapses. However, your flow pattern does not indicate that you have such an issue, although some more samples would be beneficial to be sure. 

The short one benefits from being easy to insert and tolerate. Unfortunately, the more extended hybrid 5" and the original 6" version initiate gag reflexes, which might take a month or two to tolerate. You might want to read my experience with the hybrid stent.  

I do not know how enlarged your turbine is. In very extreme cases, the stent cannot help (it cannot be expanded), or you might not even be able to insert it. But be aware that a surgeon might push you toward a surgery you do not necessarily need. 

Unfortunately, the stent lead time is about three months. 

I trust you will progress even without a stent with the suggested Auto setting.

[G. Szabo]

Hi UsuallyTired,

I would raise pressure to 8cm with EPR at 3 as it does need more pressure, and you were at such a low pressure that it wasn't functioning really at all

Agree. UsuallyTired might want to upgrade from 7 cm to 8 cm and see. But at least seven and not the five he is using.

[UsuallyTired]

Good morning, Phaleronic & G Szabo. 

I set my machine to APAP 7.0 - 9.0.  EPR was 0.  
I didn't know what to use for my APAP upper range, so I just went with 9.0. 
(I believe EPR reset to 0 when I changed to APAP, and I overlooked that change. I had intended to keep EPR 3.) 
I used mouth tape. 

Subjectively, I remember waking up a few times to a very dry mouth and discomfort there. This is unusual for me. I used mouth tape, and the tape was intact in the morning, so I'm surprised at the dry mouth. I must have had some large leaks / oral venting into my mouth. 

My CAs were slightly elevated. 

I woke up clear-headed and alert but still very tired. Writing this, I already want to go back to sleep. 

Here's the whole night: 
   

I saw some of these oscillations, sometimes 2 or 3 ups & downs. 
   

What is this pattern? There are several of these. 
   

Thoughts? 

---------

G Szabo, besides discomfort, are there any disadvantages to the stents? Safety issues, hygiene issue, long-term concerns? My turbinates are not extreme. My sense is they're only mild to moderately enlarged, and that my ENT thought the Nasacort might be sufficient.

[G. Szabo]

G Szabo, besides discomfort, are there any disadvantages to the stents? Safety issues, hygiene issue, long-term concerns? 

To address your above question, I must first discuss it with the advisory members and comply with our policies. I might be able to respond later. 

You are having a new experience in the APAP mode, and it will take some time to settle down and hopefully lessen the CA occurrences. Because of these, you want to adjust the EPR more slowly. I recommend starting with EPR=1 and seeing its impact on the CAs.
 
You can see that the 9 cm max was not high enough because you were hitting it. So, it is better to increase it to 10 cm. I suggest these small incremental changes because your mask, which was okay for the lower-pressure CPAP regime, might have leaks at this higher regime. The AUTO mode demonstrated that you need higher pressure than 5 cm; hence, you might want to change your mask to suit these higher pressures if you cannot mitigate the leaks. 

Also, to reduce the pressure swings which disturb your sleep we want to narrow the pressure window by setting the minimum pressure to 8.

Try to mitigate the dry mouth by increasing the humidity setting.      

Your wave patterns are not particularly concerning, and your flow limitation figure is okay. Let's focus first on the APAP setup.