[Treatment] UARS Diagnosis - Need Assistance with Self Titration

[shanicher]

Heres a few zoomed in segments from last night that occured around flow limits and the CA event.

           

[Gideon]

Was that person on reddit beerdujour by any chance? ;-)

Generally a AutoSet range is preferred because we use that as a gauge to see where the algorithims try to take you. It often helps the optimizing process but in and of itself does not optimize the process. AutoSet will adjust for different sleep stages and different sleeping positions and an increase in pressure serves as a flag that something may, not is , be happening here.

The goal is to have a steady pressure over a small range.

All that said, comfort trumps all else as the goal is to get a good comfortable night's sleep.

[shanicher]

Well last night was a win and lose night. Was able to fall asleep on it without a sleep aid, but I woke after 1.5 hours and couldnt sleep, even with a sleep aid. Breathing on the 9 pressure felt perfectly fine, but I am beginning to really think it is a mask issue for me. I have a sore in my nose from the nasal pillows, so I switched to the small pillows, which were more comfortable, but Whenever I wake up it feels like theres too much upward pressure on the septum on my nose. I feel like I got punched in the nose with the heel of a hand, like in a self defense move haha. I tried loosening the straps, but it still ends up pushing upward. I ordered a nasal cushion from amazon, which should come tomorrow, and a new small cushion for my F30 FFM, which should come in a few days. I may take a night off from the machine while I wait for the new cushions to come, and give my nose a bit of a break. Slathering it in Lanolin over and over today lol

Thanks again for all your help everyone! Ill update in a few days. 

Heres last nights data, the overview I only zoomed in on the time I was sleeping. Also did a couple zooms on flow limit/event areas.

           

[shanicher]

Also it wasnt beerdujour haha but I have seen that username quite frequently in all my research on the various apnea reddits.

[SarcasticDave94]

Maybe a different mask is in order to preserve comfort. It does happen a lot that after some use the mask you thought would be great while trying it on becomes uncomfortable in actual use. And that one sounds like it tends to pull upward.

Things that are different sizes in masks give lots of fit combinations. Headgear, cushion, sometimes the frame, not to mention type. Maybe a different ResMed pillow, P10. Or a brand like my new fave Fisher and Paykel. Look for the F&P RollFit on some of the nasal and full face masks. It's a bellows that uses very light tension and leverages the air to reinforce fit. Back to the P10, several here like it a lot.

[Amerikiwi1]

Hi Shanicher.

Our issues are similar. Our graphs are similar.

Do you have Tinnitus?
Do you have sinus problems or  narrow airways that cause you to mouth breathe?
Do you find it hard to equalise (like when on a decending plane)?
Do your ears block easily?
Do you get a nasal drip sometimes in the mornings after waking?
Do you get allergies?

[sheepless]

stating the obvious, but if you're taking adhd stimulants, consider how much you take and more importantly when you take them (like not after noon). I took adderall for ~20 years plus modafinil for several years prior to and for a while after starting cpap, originally for adhd, but as the years went by, to compensate for severe sleep deprivation. probably not the same for everyone but I feel pretty strongly that sleep deprivation worsened if not caused my adhd beginning in childhood.

as you reduce apnea and improve sleep your adhd symptoms may decline and you'll need less stimulant. in the meantime, it may be working against improving your sleep. it took me too long to decide to cut out them out, but eventually figured out that while stimulants might help us get through the day, they simply mask fatigue and obviously are not conducive to sleep. as much as I wanted to continue using them to get through my days, I felt I couldn't give cpap a fair shake until I stopped, which I did for a couple years while sorting out my pap use. it was an adjustment but in the end it worked out better for me. I'm back to taking modafinil in the early morning but I'm not sure the benefit is worth the potential detriment to sleep. it helps with wakefulness but unlike adderall, I don't think it does much for my adhd, the symptoms of which, fortunately, have declined substantially with slowly improving sleep.

[2SleepBetta]

Here is another line of thought to consider as you think about your sleep and suggestions in this thread. Thank you for posting the 2-minute views. I focused on the one closest to what follows. It looks like your increase in pressure and EPR did help. Others are much better qualified than I am to guide you on those matters. 

I believe JoeyWallaby referred to what I suspected and think I now see as well: the continual deformations in the crest of your (inspiratory) flow rate (FR) curves in some, if not most of your sleep. To the extent your crests are not mostly smooth and rounded, like crests of a sine curve, it is a signal you are inhaling through and past restrictions somewhere in your airway. There is soft tissue or mucus somewhere near a narrower point in the airway and it "flops in the breeze" when your inhaled air is moving past it (at its greatest velocity of inflow). You have to do extra work inhaling because you have to create enough vacuum to draw air past the vibrating restriction. This often wakens us with mostly mini-arousals, which we do not remember but feel their effects later in fatigue.

Think of the 'raggedy" slurping sound of the airflow when you continue sucking on a straw after the remainder of the milkshake is just a few drops in the glass. You will hear and, possibly, feel the intermittent partial airflow blockage at the bottom of the straw. Now if the milkshake were more viscous, like honey, the effect would--I'm guessing--be more pronounced. A flag flutters in the wind, an open door on hinges slams shut (when wind can blow in through the doorway and cause airflow through and out of the house). All these instances, and wings that lift airplanes are effects of differing pressures and flow velocities on sides/surfaces of the milkshake drop, the flag, the door, the top and bottom of the wing.   Similarly, your have tissue that flags or stretches because of different pressures on the sides of a tissue flap or, maybe, due to slack in muscle tone somewhere along your airway that allows tissue to sag and stretch into the airway and reduce its cross sectional area because of the vacuum. Mucus in the airway could also be a factor. 

Our machines draw the irregular flow rate crests, but don't yet have an algorithm to score what underlies the regularly deformed crests. Scored flow limits, as shown by OSCAR, reflect changes in flow rate and volume over a large number of seconds, a number of breaths. When every breath is somewhat flow limited the algorithm sees no change in flow volume within the set time interval for a number of breaths, so  there is no flow limit flag. There aren't flags for every breath. 

In my case, higher EPAP pressure together with pressure support of my VAuto helps tremendously.

As others do, or will point out, sleep position, cervical collars, diet, prescriptions, alcoholic drinks are examples of things to consider changing, in addition to achieving your optimum titration and settings.  

Below there are links to my thread on the topic. A member posted, there, a link to an excellent site, too. Scan some of that material. A lot of work has been done on inspiratory flow limits (IFL). There are links in my thread to a lot of information.

AHI < 1.0 now, but still tired? Is it UARS, RERA, arousals or FL in your FR peaks? | Apnea Board       My thread on the topic.

Physiological consequences of prolonged periods of flow limitation in patients with sleep apnea hypopnea syndrome - Respiratory Medicine (resmedjournal.com) A link provided by another member.

Below, there is a sine wave clip and a clip from your 2-minute views. The rabbit- or Corgi-ear crested inspiratory flows, those "M" crests, are classic markers of the presence of IFL and there are a lot of other signals as are discussed in the thread. ResMed has a patent on a method for scoring the M's. Further, Apnea Board has a Wiki topic showing various flow rate curves: normal and irregular, but I failed to find it.

Only the roundedness of the sine wave is relevant and to be compared, along with crests of the waves in the OSCAR logo, to the irregular shapes of most of your crests in the clip.