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[Treatment] Seeking treatment guidance
#1
Seeking treatment guidance
Hello,
I am new to this site and this is my first post.  I've learned a lot already by reading various threads over the last 2 weeks.  I'm at the point where I am finally using my CPAP AutoSense 10 but am still not feeling better.  I'm extremely sleepy most of the day and have a lot of dizziness/brain fog/disorientation, especially in the morning.  I am waking frequently overnight and rarely have a continuous block of sleep more than 1 - 1.5 hrs.

Here is a brief overview of the last year.
- Since July 2020, started not being able to sleep thru the night, waking up frequently
- Developed anxiety about this resulting in insomnia and worse sleep
- Tried some sleep meds which didn't help much (haven't used these for a while now)
- Home sleep test in January 2021 showed mild apnea using AHI, moderate using RDI
- Got CPAP machine but had an extremely difficult time trying to use it
- Got my anxiety under control from April thru the summer, including going for CBT for insomnia
- Now I still get very fragmented sleep but am not anxious about it and not staying awake in the middle of the night like before
- Conditioned myself to get used to the CPAP mask by using during the day for an hour/day (went thru various masks before I found one I liked)
- Started using the CPAP at night for the last 3 weeks, now using it thru the night
- Still waking frequently and not getting restful sleep
- Installed and started looking at Oscar data in last week
- Frustrated with sleep doctor who was not interested in looking at Oscar data and talking about RERAs, UARs, flow limits, ...  Only looked at AHI and compliance.
- Advised to stay with current settings for 3-4 months and then come back to possibly do a titration study
- Additional notes - I sleep on my side and used to sleep on my stomach but it's hard to do that with the mask.  Rarely sleep on my back even though I did partly during the sleep study (that was a tough, weird night).  I am 50 years old and about 6 feet, 175 lbs.  No other major health issues.

I basically would love some advice on how to proceed with trying to improve my sleep using Oscar and advice on this forum (which seems like has helped a lot of people in similar situations).

From the limited knowledge that I've gained from this site over the last two weeks, here is a summary of my issues:
- Home sleep test - AHI was only 7 and RDI was 23.  There were a low level of centrals as well (1.2 AHI).  But it seems like my main issue is RERAs.  Maybe UARS.
- Using my machine with min 4, max 8, EPR 3 (settings I started with set up by sleep tech), my AHI is usually very low - under 2 and often under 1 or close to 0.  From what I understand though, the machines are not great at capturing RERAs so it's unclear how many I might be having that are not flagged.  I also see consistently see flow limits that are not super high but may be a problem.
- With the settings just listed, I was mostly getting centrals flagged, specifically in the later part of the morning.  I would also sometimes feel a little better in the morning and then I would go back to sleep and feel worse when I woke up again (after some centrals).  So I changed my settings first to CPAP only at 6 and then to a 4-5 range and these centrals went away.  And I didn't see much of an increase in anything else.  So it seems like any obstructions, hypopneas are treated well at low pressure (I've only seen 1 obstructive event ever since using CPAP).  But after these changes I wasn't feeling any better.
- So I changed my settings back to min 5, max 9, EPR 3.  Some centrals came back.  Still not feeling better.

This is basically where I am now.  I essentially need some guidance.  The sleep doctor said that the centrals I was getting wasn't anything to worry about but I'm not sure.  My sleep study had a few as well.  Should I worry about the centrals?  Should I focus more on the RERAs/flow limits which I feel might be my main issue?  The 95% number is not high but there is a fair amount of time with the mask on where I am not sleeping so this probably averages the numbers down.  There are also sometimes leaks around the same time as some of the flow limits, but not always.  Should I be thinking about bipap or ASV for more pressure support (and pay out of pocket).  I'm curious too if maybe a cervical collar can help as I've seen others have had success with those on this site but I can't tell if that's appropriate based on my charts.

I understand my AHI is super low but I feel terrible all of the time.  I would really appreciate some feedback on my data and guidance on how to proceed, etc...  I'm sure people here will be able to see way more than me as I'm kind of winging it and not really sure how to proceed.

I'm attaching a few Oscar charts:

- one with pressure 4-8
   

- one with pressure 4-5

   

- latest session with pressure 5-9

   

Please let me know if there is anything else I can provide.

Again, thanks for any help in advance.  And sorry for the long post.  Just wanted to provide as much info as possible up front.
Thanks!
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#2
RE: Seeking treatment guidance
Here is my sleep study.

   

   

And here are a few zoomed in views of events:

central
   

flow limit
   

unidentified
   


Thanks!!!
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#3
RE: Seeking treatment guidance
Welcome!  You gave us a lot of information.  Let me explain a few things that might help.

First how the setting work -

Min pressure is the inhale pressure
EPR is exhale pressure relief - It is subtracted from the min pressure to get the exhale pressure
Max pressure is the highest the machine will go when it detects obstructions. (O, H, FL)

Types of Apnea
Central - can not be controlled with the machine you have - you need a much more expensive machine.  But you do not have that many centrals so that should not be a problem.

Obstructive Apnea is the largest apnea (see my signature for percentage of blockage) and they must last for at least 10 seconds to be recorded.

Hypopnea Apnea - Just like obstructive but less percentage of blockage and also must be 10 sec

Flow Limits - They are also obstructive but they are the smallest percent of blockage and are not timed.

We use EPR to help with Hypopnea and Flow Limits.

The problem you have is that the min is to low.  All pap machines have the lowest setting possible of 4cm.  And that setting is used for children - same machine is used.

Your settings are Min 4, Max 8 and EPR 3 -  EPR is doing nothing because the min you have set is as low as the machine can go.  So what we need to do is raise the min and keep the EPR at 3 to help with the H events and flow limits.  Flow limits are small but for most people they interfere with sleep by not allowing you to get into deep sleep and sometimes waking you up.  Also the machine reacts to the flow limits by raising the pressure (max) to stop them from becoming larger events (H and O).

So the EPR is important and I think it is a reason you are not sleeping well.

Try the following settings for tonight and post tomorrow.

Min 7
EPR 3
Max 10

I think you will breath easier and sleep better tonight.
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
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#4
RE: Seeking treatment guidance
Yep, try min 7 for a while to take advantage of EPR.

I don't like watchpat in situations like this because it isn't a true measure of respiratory arousal. It measures arterial tone which can be affected by other issues.

Unfortunately the only way to get good data for uars is an in clinic sleep study with eeg data but that often doesn't give great results either. If it is something available to you then you could do it to try to confirm if these are actually respiratory related arousals or if they are spontaneous arousals.

My recommendation is to try the increased min pressure for a while and to start looking for signs of any other health issues that could be at play. For example I have found that a dairy intolerance and bruxism are two significant factors in my sleep quality and even my apnea/breathing (I had huge nasal congestion issues before removing dairy from dirt that I believe was cause of my "sleep apnea". I made significant improvement with dairy removal but still trying to figure out bruxism.
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#5
RE: Seeking treatment guidance
Thanks staceyburke and Geer1!!!

I will change my machine to the suggested settings and report back.

Geer1, thanks for the info regarding the WatchPat study.  Right now, an in clinic study is not an option as my sleep doctor said it won't do anything but tell us the same thing as the home study.  They also want me to use the CPAP for 3-4 months before making any adjustments.  Sad

As far as other health issues, I've been trying to figure out what other things could be causing these frequent arousals for about a year now.  My anxiety is now under control which was a possibility but after that, I've gotten workups by my regular doctor and a functional medicine doctor to check on thyroid and a whole bunch of other things.  My diet has been gluten and dairy free for years and very healthy.  I will certainly be on the lookout for other things though.  I am hoping the right adjustments to my machine will improve things.
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#6
RE: Seeking treatment guidance
That's distinctly BS about "not showing anything different. And having a sleep study done with a decent therapist who actually understands that there's more sleep disorders than OSA means there are a LOT of things that could be diagnosed during a sleep study OTHER than apneas. I get so frustrated with the "try the thing that isn't working for x months and then maybe we'll do our jobs". So annoying.

But agreed with the others, try the settings changes, and also, I know you've done CBT, but there is an app that helps with specifically CBT for insomnia, versus generalised CBT: Although it says "Veterans" on it, anyone can get and use the app. https://mobile.va.gov/app/cbt-i-coach


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#7
RE: Seeking treatment guidance
PSG could definitely tell more of the picture but is expensive and they rarely want to do it. Sometimes it isn't super helpful like in my situation where all it really showed is that I have disturbed sleep but not due to sleep apnea/uars unlike my initial home study that said I had sleep apnea.

Sleep apnea is one of if not the most common sleep issue and it is the easiest to diagnose and treat which is why it is always the first thing investigated/tried. You should give it a good fair trial to see if you start having improvement. The big thing to note is that the basic stats (AHI) given by CPAP machine do not indicate if it is helping UARS, you need to interpret the actual data to look for RERA's and see if the prevalence of them appears to decrease over time as you adapt to CPAP and also when changing settings.

Your OSCAR data shows some potential signs of UARS which could backup the watchpat findings, for example the couple RERA's flagged and a couple other periods where flow rate saw slow decline followed by spike. For the most part your OSCAR data shows disturbed sleep quality with numerous flow rate spikes (usually arousal breathing) and that is what you are looking to minimize.

UARS is usually due to a smaller restricted airway or oversensitive nervous system. Unlike in apnea pressure rarely helps this because the issue most likely is not a collapsing airway (if it was would be more signs of obstructive apnea). Assistance in breathing rather than pressure stinting airway open is more helpful in UARS and this is accomplished by machines providing a pressure increase while inhaling and decrease during exhale. On a bilevel or ventilator this is called pressure support but on your machine they call it EPR (because they have limited its range and mostly it helps with exhalation). As Stacey pointed out any minimum pressure below 7 will not take advantage of 3 EPR because the machine can only drop pressure as low as 4. In order to get the most pressure support these machines have to offer to see if it helps your UARS you need min pressure at least 7 and EPR of 3.

Give it a try and do try it for weeks/months as you will continue to adapt. Even though I supposedly don't have sleep apnea I do sleep better with cpap machine and continue to use mine.
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#8
RE: Seeking treatment guidance
Ratchick, it's definitely a bunch of BS and very frustrating.  Thanks for the CBT-i link.  I've actually had CBT but also CBT for insomnia as well which has definitely helped a lot.  I am still waking frequently but I can now calmly just try to fall back asleep instead of stressing and waking myself up more.  Meditating and focusing on my breathing in bed helps me fall back asleep.

Geer1, thanks for the explanation on pressure support/EPR.  I tried the new settings last night (min 7, max 10, EPR 3) and was able to fall asleep initially but later in the night after waking and trying to go back to sleep I had a hard time getting used to the min 7 pressure.  On inhale, I would breathe in and then when trying to exhale, it felt like the inhale pressure would continue and push more air than I wanted into my lungs, making it hard to exhale.  Eventually I lowered the minimum to 6 to get back to sleep with a 10 minute 5.4 ramp.

Looking at Oscar, my first segment of sleep has lowered flow limits (with min pressure 7).  Later after changing to min pressure 6, there are more flow limits.  And also a bunch of centrals later in the morning.  In terms, of how I feel, it's pretty much the same.  Last night's chart is attached.

I know 7 is a low pressure but it's higher than I'm used to so I will have to get used to it.  Hopefully I will do that over the next couple of days.  I wish the machine would allow a pressure lower than 4 so I could use a pressure of 6 with EPR 3 resulting in exhale pressure of 3.  I've seen a bunch of people say that a pressure of 4 is uncomfortable and too low but I find it comfortable.  I will work to get my min pressure to 7 over the next few days.

I have two questions:
- I've seen that soft cervical collars have helped some people.  Based on my Oscar charts, does that look like something that could help me?  Not sure how to tell from the charts.  Let me know if a different view is needed or how to determine this.
- It seems like my centrals are treatment emergent since they went away when I previously lowered my pressure.  I've seen the term sleep wake junk.  How do you determine if that's what these are?

Thanks.
   
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#9
RE: Seeking treatment guidance
There is no indication you would benefit from a soft cervical collar. Ii is used to prevent positional apnea which is indicated by clusters of obstructive events.
Download OSCAR

Organize Charts
Attaching Charts

Mask Primer
Soft Cervical Collar

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.

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#10
RE: Seeking treatment guidance
I can’t and won’t say you did not feel what you felt with your pressure. But a min of 7 and a EPR of 3 gives you an exhale pressure of 4 that is the same exhale pressure as min 6 and EPR 3, they are the SAME exhale pressure. 

The inhale pressure would be 1 more more however.
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
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