UARS

[Sleeprider]

Some pretty bad flow limits leading to arousal in those results. Do you want to try more PS? I got pretty good results from Flonase when I was having nasal congestion from allergies. It might work for you, but it takes several days to get the full effect.

[tarah]

I scheduled the nasal surgery for 2 weeks from now.  Without being able to get through my nose, I don't think I can get good BiPAP results.  I don't know why it was so bad last night at the beginning of the night.  Maybe I was trying to sleep on my side and I cannot breathe through my nose at all when I'm on my side.  At the same time as moving forward with surgery, my ENT wants to aggressively treat every allergy that shows up.  I already had allergy testing done once, but she's going to redo.  I was having a reaction to every tree, weed, etc that grows around here.  I've already tried nasal steroids twice.  Both times, by the third night, I was up, unable to go back to sleep, totally wired.  As soon as I stopped the steroids, that went away.  So I'm doubtful trying the same thing a third time will help.

What do you think about reducing the IPAPmax?  The pressure ramping up and down was really bothering me last night.  Why is it that when the pressure ramps up, the flow rate doesn't improve?

Anyone with experience with nasal surgery and UARS that wants to share??

[mper6794]

Hi,
I empathize with you on this.
I have grabbed this from above:
…” I went to the ENT yesterday and she had a camera up my nose for a long time.  She said my nostrils are collapsing with each sharp inhale, the turbinates are swollen and she couldn't get the smallest camera past the septum to take a look at my adenoids……as per Sleeprider observations above, it looks this would be indicating need for surgery….  As a trial of what needs to likely happen with nasal surgery, she wants me to use Afrin for 3 nights and report back as to whether the congestion was controlled and how my sleep goes.  She doesn't believe allergies are the culprit because I do not have any other symptoms of allergies, like sneezing, watery eyes, etc, it's only severe nasal congestion.  My nasal passages were extremely sore and swollen after all the camera'ing around up there.”……. I just couldn't tolerate the EPAP with my nose being so congested……this looks to be an aspect, which surgery could help on back and use the BPAP….. I was again able to sleep on my back for the first half of the night (with a soft cervical collar) and my nose works much better in this position……does anybody know whether cervical collar would prevent tongue from collapsing (when her sleeping on back), if this would exist?.....

Yet still I have some doubts on your charts and your situation (whether or not there would be airways restrictions beyond nasal issues), I think there would be room for some more improvements with the BPAP currently (in the way I have suggested above, on posts 63, 70, 72).
Particularly, on increasing a little further PS (4.4..most likely to be your fine-tuned number, then eventually try….4.6…4.8). And also, not at same time of PS, increasing EPAPmin progressively. But, please remember here, as mentioned above, we still would need to know what would be your normal RR (hands on stomach counting x 0.89…lab studies, ….etc). That because the normal RR is the anchor while trying get quickly your fine-tuned parameters (Max EPAPmin and PS), because it increases with increasing EPAPmin, whereas at same time, it decreases with increasing PS (see graphs elsewhere).

Furthermore, surgery wise, I would strongly recommend you go for this nine Dr. Steven Park’s videos…...a great deal of things are here, from afrin, saline solution, vicious cycles on respiratory issues x fisiologic issues, and much more
https://www.youtube.com/watch?v=2HPaE7-k...ex=29&t=0s
https://www.youtube.com/watch?v=TYRIiiXD...ex=53&t=0s
https://www.youtube.com/watch?v=TYRIiiXD...z&index=52
https://www.youtube.com/watch?v=EL_8jyO7...z&index=53
https://www.youtube.com/watch?v=OMbH7tZ2...z&index=54

As well for this seminal Dr. Guilliminaut’s interview to Steven Park.
https://hwcdn.libsyn.com/p/8/0/2/802d335...94b06cab78

all the best

[mper6794]

I scheduled the nasal surgery for 2 weeks from now.  Without being able to get through my nose, I don't think I can get good BiPAP results.  I don't know why it was so bad last night at the beginning of the night.  Maybe I was trying to sleep on my side and I cannot breathe through my nose at all when I'm on my side.  At the same time as moving forward with surgery, my ENT wants to aggressively treat every allergy that shows up.  I already had allergy testing done once, but she's going to redo.  I was having a reaction to every tree, weed, etc that grows around here.  I've already tried nasal steroids twice.  Both times, by the third night, I was up, unable to go back to sleep, totally wired.  As soon as I stopped the steroids, that went away.  So I'm doubtful trying the same thing a third time will help.

What do you think about reducing the IPAPmax?  The pressure ramping up and down was really bothering me last night.  Why is it that when the pressure ramps up, the flow rate doesn't improve?

Anyone with experience with nasal surgery and UARS that wants to share??

... if were  me, no doubt I would keep IPAPmax: EPAPmin+PS, no bit more; all the way through. I did this; very happy with the results, particularly when you approach your fine-tuned EPAPmin and PS. Following awakenings, very often come some false OA, and even false FL; machine starts bumping bring difficult to go back to sleep.
For us, UARS-people, those autobumps pressure punchs does not pay off; moreover, quite often, unflagged RERA's are more important than the flagged ones (which triggers the machine).

good luck

[Sleeprider]

Surgery is a big step, and it will involve considerable discomfort for a few weeks. Hopefully it will pay-back with a significant improvement in your upper airway nasal restriction.  I assume your ENT is experienced and has discussed her expectations for your recovery and benefits based on patient outcomes she has worked with.  I wish you the best, and think you have carefully considered alternatives.  I usually see surgery as a last resort, but your comfort has not improved sufficiently with what we have tried here. 

Your question on max IPAP pressure and the example you provided are really interesting.  I usually prefer to avoid pressure that cause discomfort or sleep disruption, and that would be my inclination for you as well.  The image you submitted shows pressure increasing from about 12 to 15 in response to flow limiation.  We can see the flow limitation graph responds to the increase in pressure by dropping back as the pressure approaches 15.  Flow limitation appears to increase later in the example, but pressure is already near the maximum.  There is no right or wrong answer here.  I would suggest moving your maximum IPAP back to 12 cm and see if that improves your comfort.  Make your decision based on results.

Correct me if I'm wrong, I think I recall you once had a very high PS on your machine and experienced a lot of CA as a result, however you commented that you felt pretty good. You could try PS 5.0 and see what happens. You have no centrals at this point and the added PS may be all you need.

[tarah]

Changed PS to 4.4, limited IPAPmax to 12.  The first half of the night on my back, no pillows, cervical collar.  Slept soundly, very few wakeups.  Early morning I switched to my side, flow limitations became apparent and I woke much more, changing positions, trying to get air.  Feel like a million bucks today from large chunks of uninterrupted sleep.

I did try PS of 6 and yes, alot of CAs.  But there is plenty of room between 4.4 and 6.

Last resort, I am also trying the gauntlet of oral antihistamines at night in addition to the nasal azelastine I already use nightly, each for 3-4 days at a time, to see if any give me some relief.  Xylal last night, seem just as congested by early morning.  But we'll see how that goes.

Yes, surgery is a big step.  It's not one I take lightly.  I have been on APAP for 2 years, with varying results, always related to how congested that I am.  I already eat a paleo diet (no dairy, grains, low sugar), exercise daily, use a HEPA vacuum on my bedroom and replaced everything with allergy covers, use Neti pot 2-3 times a day, nasal antihistamines, none of it is enough to resolve the nasal congestion.  I feel like I've exhausted the lifestyle factors.  Even if I could tolerate nasal steroids, I'm not sure that's a reasonable solution long term.

[mper6794]

Changed PS to 4.4, limited IPAPmax to 12.  The first half of the night on my back, no pillows, cervical collar.  Slept soundly, very few wakeups.  Early morning I switched to my side, flow limitations became apparent and I woke much more, changing positions, trying to get air.  Feel like a million bucks today from large chunks of uninterrupted sleep.

I did try PS of 6 and yes, alot of CAs.  But there is plenty of room between 4.4 and 6.

Last resort, I am also trying the gauntlet of oral antihistamines at night in addition to the nasal azelastine I already use nightly, each for 3-4 days at a time, to see if any give me some relief.  Xylal last night, seem just as congested by early morning.  But we'll see how that goes.

Yes, surgery is a big step.  It's not one I take lightly.  I have been on APAP for 2 years, with varying results, always related to how congested that I am.  I already eat a paleo diet (no dairy, grains, low sugar), exercise daily, use a HEPA vacuum on my bedroom and replaced everything with allergy covers, use Neti pot 2-3 times a day, nasal antihistamines, none of it is enough to resolve the nasal congestion.  I feel like I've exhausted the lifestyle factors.  Even if I could tolerate nasal steroids, I'm not sure that's a reasonable solution long term.

Great, tarah
It looks your are heading to some more room on your therapy. Please, refers to your ongoing graphs attached.
gl

[tarah]

Looks like RR is around 14, pretty much the same as the machine is recording.  I am going to try to increase PS to 4.6 tonight.  Last night was a tough one.  My body is on some sort of 'sleep decent one night', 'sleep horrible the next', cycle.  Blech.  I have to keep reminding myself what it was like 2 years ago before APAP.  Sleep at most a few hours each night, wake gasping all night long.  It's better than that.

mper6794, I would like to begin manual counting of events, but I don't even know where to begin when I have long chunks of time that look like this.  Am I even asleep?  I don't know.  So many flow restrictions and obvious issues but I don't know that I can pinpoint how many arousals.

I'm feeling very settled and good about my decision to do nasal surgery.  I have a bunch of questions I will be asking the surgeon next week.  I want to push for her to do a drug induced endoscopy at the same time so that we are clear the areas that are involved in collapse.  Also try moving the jaw forward to see if a MAD might be of use for me.

[mper6794]

Looks like RR is around 14, pretty much the same as the machine is recording....ok, you could add check counting with hand on your stomach x 0,89.  I am going to try to increase PS to 4.6 tonight....it looks ok. But, also, I would suggest you increase EPAPmin to 6.4; there would a better balance aiming at a more stable RR, and eventually postpone any CA, and, of course, try to improve flow. Last night was a tough one.  My body is on some sort of 'sleep decent one night', 'sleep horrible the next', cycle.  Blech.  I have to keep reminding myself what it was like 2 years ago before APAP.  Sleep at most a few hours each night, wake gasping all night long.  It's better than that.

mper6794, I would like to begin manual counting of events, but I don't even know where to begin when I have long chunks of time that look like this.  Am I even asleep?  I don't know....it appears you was sleeping in that 10min-stretch, pretty much sure; however with arousal at 4:16:30 (look at FR and leak)....4:22 (idem)...4:25 (FR, TV, and leak); 3 arousals/10min = 18/hr, if followed like this all night; too much, indeed.   So many flow restrictions and obvious issues but I don't know that I can pinpoint how many arousals. It appears, indeed, stuffy nose is serious issue for you; however, independently, you could benefit from better adjusted EPAPmin and PS. Let us try and see; nothing to loose, maybe….

I'm feeling very settled and good about my decision to do nasal surgery.  I have a bunch of questions I will be asking the surgeon next week.  I want to push for her to do a drug induced endoscopy at the same time so that we are clear the areas that are involved in collapse.  Also try moving the jaw forward to see if a MAD might be of use for me.

 good luck

[Sleeprider]

Looks like RR is around 14, pretty much the same as the machine is recording.  I am going to try to increase PS to 4.6 tonight.  Last night was a tough one.  My body is on some sort of 'sleep decent one night', 'sleep horrible the next', cycle.  Blech.  I have to keep reminding myself what it was like 2 years ago before APAP.  Sleep at most a few hours each night, wake gasping all night long.  It's better than that.

mper6794, I would like to begin manual counting of events, but I don't even know where to begin when I have long chunks of time that look like this.  Am I even asleep?  I don't know.  So many flow restrictions and obvious issues but I don't know that I can pinpoint how many arousals.

I'm feeling very settled and good about my decision to do nasal surgery.  I have a bunch of questions I will be asking the surgeon next week.  I want to push for her to do a drug induced endoscopy at the same time so that we are clear the areas that are involved in collapse.  Also try moving the jaw forward to see if a MAD might be of use for me.

Tarah, focus on the nasal and upper airway soft tissue issues, and don't worry about the MAD or jaw advacement.  From your description, these are not your problems, and would be a separate procedure, usually by an oral surgeon, anyway.  You need to get through the proposed surgery, recover and then see where you stand.  Less is more.