Therapy Help - Possible UARS - REM

[jkossis]

Hi all!

I've read through so many of the conversations and threads here, and I can't say enough about the advice provided. You all are fantastic, and it's amazing that a community like this exists.

In terms of me, I've been working on trying to maximize my therapy for a while now, and appear to be at a relatively important crossroads. I currently have an AirSense 11, but am starting to wonder whether I may need to upgrade to an AirCurve 10 or 11. As you can see in my attachments, my non-REM sleeps looks pretty smooth, and thus I am happy with it. Where things get a little murky is when I enter REM.

What I'm hoping to get a feel for from some of the experts here is, does my flow rate look like "normal" REM breathing, as I know REM can be more volatile/erratic, or is there still a lot of disordered-breathing occurring? And if so, how can one distinguish that (what's normal for REM vs. non-normal)? I still feel pretty exhausted and foggy most days, and it seems to be correlated with the amount of REM sleep I got the previous night. In terms of how I am validating REM vs. non-REM, I'm using a combination of the respiration rate, tidal volume, and the sleep staging algorithm on my Apple Watch.

The reason I am considering the jump to bi-level is, I can eliminate my obstructive events around 7-8 cm/h20, and would like to avoid unnecessarily increasing my EPAP for the sake of more IPAP. I currently run 11 IPAP/8 EPAP (EPR of 3), but am trying to decide whether my REM breathing could benefit from greater pressure support. While my flow limits look pretty good, they used to be a mess without EPR, so it does look like my airway responds appropriately to pressure differential.

Some info to note, that chunk that of missing therapy is when I go to sleep on my side. For whatever reason, I get terrible aerophagia when I'm not on my back. So I have grown accustomed to taking the mask off when I need to side-sleep (roughly only an hour per night). I understand that this isn't ideal, but I prefer to sleep on my back anyways, so it's a compromise I am willing to make (at least for now).

I truly appreciate any help, info, and expertise from the community.

[BoxcarPete]

From what you've shown, I don't see any issue. Do you have a night where you slept through instead of multiple breaks in machine usage? If you're talking about sleep architecture, awakenings mess with the evaluation of what's normal. If you don't have any such nights, I'd focus on that as the source of your trouble.

[jkossis]

Most of my nights do only have 2 wake-ups (usually to switch from back to side, and then side to back), but outside of that, that's usually it.

I'm attaching a few more snapshots of REM, so just to confirm, these new flow rates looks normal to you as well? To me, it seems quite erratic, and along with the added data point of "I feel much worse the more REM I get", it just has me questioning things. I have seen/felt this correlation for a while now, which has led me to believe there is something going awry with my REM sleep.

[jkossis]

As another data point, I'm attaching a night of the settings (9 IPAP/8 EPAP) I used to run for a while, before I was motivated to chase down the REM-related issues and flow limitations.

[Sleeprider]

Your zoomed shots are about 30 to 45 minutes in duration and don't provide enough resolution to really interpret the flow wave. I can see some respiration volume variation and what might be some irregularity in the inspiration peaks, but you need to get this back to 3-4 minutes for it to be useful. As far as moving to an Aircurve Vauto device, It's clearly got more options to work with and most people find the therapy more comfortable, even when they have good results like you do on CPAP. Basically, I agree with BoxcarPete that your therapy is effective, and appears to meet all the objectives of CPAP therapy, however if you have the means to transition to VPAP, I'm not going to argue against it. Maybe with a closer look something may stand out.

[jkossis]

Sleeprider, I appreciate you providing your insight. I wanted to take the approach of providing a zoomed-out perspective, to highlight the periodic/rem-related flow limitations (and how they began improving when going from 9 IPAP/8 EPAP to 11 IPAP/8 EPAP). I'm attaching some screenshots of the smaller chunks that you were looking for.

Largely, I'm trying to figure out what is normal vs. flow-limited/problematic REM breathing.

[Sleeprider]

Now that makes more sense. You actually have both variable rate and volume in your breathing, and it is related to unresolved inspiratory flow limits. Both of these charts are 11/8 (EPR 3). What bilevel can do is to eliminate the residual flow limitation and use inspiration timing (Ti Min) to prevent a breath from concluding prematurely resulting in those half-breaths and result in a momentarily increased respiration rate. This might be one of those rare cases where a less sensitive cycle sensitivity might also help. Bilevel pressure support would certainly fix the "flutter" at peak inspiration where you have double peaks, or declining flow at peak inspiration. Respiratory timing issues are be bit more complex.

On charts, you may want to use the mask pressure chart rather than pressure. It shows how you CPAP times inspiratory trigger and expiratory cycle in relation to your breathing flow.

[jkossis]

I appreciate the suggestion with regards to elevating the mask pressure chart to a better position.

I’m gonna go ahead and secure an AirCurve. In terms of settings, I’ll start with 11/8 briefly, just to get a baseline in case it somehow behaves differently on the new machine (due to PS instead of EPR, EasyBreathe, etc). Then start bumping the IPAP, as well as dialing in the TiMin and Cycle settings.

[Sleeprider]

Be sure to check back, and use this thread to post results on the Aircurve. I do follow threads I participate in, and that will avoid the need to point me to a new thread. We also have what you have already posted as a history for comparison. Your plan is good, and I would leave any inspiratory timing or trigger/cycle sensitivity settings alone until you establish a base line with the higher PS.