Your thoughts on my sleep data?

[Sleeprider]

We can probably attribute much of your flow limitation to chronic rhinitis and your deviated septum. Your zoomed view shows what I expected to see which is a classic flow limitation that triggers an arousal (RERA) and it even looks like this one woke you up. I don't know what you have attempted to do with the chronic rhinitis, but Flonase (fluticasone propionate) is a good long-term therapy to reduce inflammation and improve airflow. Nasal therapy, nasal pillows in particular will apply pressure directly to your nasal passages. This inflates and opens them, combined with an anti-inflammatory it is often possible to enjoy good nasal airflow and more normal sleep that goes with it. Don't knock it until you've tried it. You are already using EPR 3, so if you want more help to overcome the flow limits you would need to go to a bilevel machine like the Aircurve 10 Vauto, and use more pressure support. Pressure support off-loads the respiratory effort if inspiration from your chest muscles to the machine. As you inhale, the pressure increases and avoids that slower peak flow which is the flattened inspiratory flow peak. There are solutions, but it takes some effort, and sometimes money to try them out. I have worked with many members with similar flow limits, and they have gotten better sleep and comfort by taking steps like I have described above.

Flow limitation is your airway collapsing from the resistance of air entering the airway, relative to the vacuum created by the inspiratory effort. Flow limitation can progress to hypopnea and apnea, or just be increased resistance to flow resulting in higher respiratory effort to pull in a breath. Your flow limitation shows a classic double-peak, and some multiple peaks in the airflow. Class 2 flow limitation has 2-peaks and indicates the upper airway reopens after initial collapse creating the secondary peak. Multiple peaks are class 3 flow limits and indicate soft tissue vibration (alternate opening and closing often with snore) during inspiration. Both can be resolved by either removing or overcoming the airflow resistance (congestion, restriction, inflammation, obstruction) with increased air pressure, decreased inflammation, or tissue reduction (surgery). The tool you use to beat this problem is your choice, but to me the surgical solution is the last resort. Good article here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688581

I've asked both sleep specialists I've seen in the past about the issue and they seem to know less about flow limits than the people on this board. I'm at my wits end with all of it.

I'd rather not be compared to the sleep specialists you have seen in the past. I believe we are way ahead of them on this subject, and our only concern is to see you succeed, rather than keep you from the best possible therapy and solutions.

[Geer1]

A bilevel allows you to use higher PS (called EPR on your machine) which creates a larger pressure difference between inhale and exhale. This pressure difference provides ventilatory assistance which can reduce effort and RERAs by forcing more air through the restriction rather than trying to prevent the restriction from happening (primary method CPAP works). It is a somewhat off label use of a bilevel in that mainstream medicine hasn't fully adopted bilevels to treat flow limitations (slowly starting to get evidence to support it though) but we have seen enough cases to know it can help. Unfortunately it is tough to convince most doctors that a bilevel can be needed to treat their flow restrictions so most people end up having to try doing so out of pocket by buying a used machine for which prescription is not required.

Do you take nasal spray to help with the nasal congestion or considered surgery (septoplasty with turbinate reduction)? I too had bad nasal congestion and still have the odd bit now, it is also the reason I switched to a FFM. Doctors had me on multiple sprays and rinses of which only Dymista helped slightly (decongestants helped too but you can't use them regularly or rely on them). I had surgery and that helped a bit but didn't fix the issue, I still think it was worthwhile though. What I found through a series of food elimination diets was that the bulk of my nasal congestion was related to a dairy intolerance and that I also get some nasal congestion from gluten. In my research food intolerances (and most commonly dairy but I think any can cause it) seem to be fairly common cause of chronic rhinitis when there aren't other known causes (allergy etc). Since making diet changes I no longer require any sprays and only have the odd night that congestion bothers me.

[17WRX]

Thank you for the information on my flow limitations. Nobody has ever been able to explain them as well as you just did. I really appreciate it. Regarding my nose problems, I've been on on all the meds that you listed and then some. I'm currently on Montelukast, Xyzal and nasacort x2 per day. I've also recently started using the navage machine twice per day. I've seen two ENT doctors about my nose problems. They all say I have a deviated septum, enlarged turbinates and chronic rhinitis. One of them said I needed the surgery for it and the other said I didn't. So I went with the one who said the surgery wasn't needed and instead earlier this year I got the vivaer procedure in hopes of reducing my turbinates. That helped slightly but honestly it wasn't worth the misery and many sleepless nights I endured from the month long recovery. I'm also being treated by an allergist for bad hay fever allergies which is the cherry on top of the physical obstructions I have. I plan on starting immunotherapy shots for hay fever this year. 

I'm still up in the air about going back to the surgical ENT for the turbinate reduction and septum repair. It will be a big stretch to be out of work for a month recovering from it. I had co-worker get the septum surgery last year and he said the recovery was quite unpleasant and prolonged. And I've read the surgery doesn't work for some people. But if nothing else works I'll pretty much have no other choice. I cannot go on living with terrible sleep quality.

I'm hooking up my Aircurve 10 machine now. What settings do you suggest I use?

[Ron Poelstra]

I have problems with nose breathing during the day, but the nasal pillows seem to keep at least one nostril open.  I typically plug whatever side I am sleeping on.  Do you use any kind of steroid spray or saline?

[Geer1]

Yeah the surgery recovery isn't super pleasant but if I remember correctly was only really unpleasant for a week or two but I guess it depends on what you do for a job (I have a mostly desk job). Being that this obviously creates symptoms and issues for you I am kind of surprised one of the ENT's didn't recommend surgery, if his opinion was that it was probably a good thing but isn't necessary then that would be enough in my books to support getting it done. If he had reasons to not get it done then that would make me a little more uncertain. It does sound like you have other allergy issues etc that are being working on and maybe he was waiting to see if those would improve things before considering surgery?

As for the bilevel I would say EPAPmin of 8 cm, PS of 4, max IPAP of 18. Try that for a bit and see how it compares to previous autoset data and if the PS of 4 seems to be helping.

[17WRX]

Last night wasn't that bad. Still woke up with a bit of head fog but better than many nights. I used my Aircurve 10 last night. I set the MAX IPAP to 18 MIN EPAP to 12 and PS to 4. I have the trigger set to very high and the cycle to MED. 

No RERA data given on my Aircurve machine. Anyway to turn that on?

[Sleeprider]

Flow limits are significantly reduced with the pressure support with a 95% limitation index of 0.10. This compares to FL of 0.57 on your 12/20 chart. Your respiratory tidal volume and rate are unchanged, but inspiration time has dropped from 2.38 seconds to 1.7 seconds, so you are meeting your tidal demand faster and with less effort. As you become more accustomed to this easier breathing, your sleep should become more refreshing as you work less, and sense of feeling better should improve with time. This are exactly the changes we were looking for. I would keep the same settings, and increase PS by 0.2 or 0.4 increments to find that spot where the 95% flow limit falls to about 0.05. Give a PS of 4.4 a try, and hold that for a few days.

On your charts, try dragging the left pane to be smaller to give more room to the charts.

[Geer1]

On a side note the settings you used actually made two changes. You increased PS from 3 to 4 and you also increased EPAPmin from 9 to 12. Your average EPAP didn't increase a whole lot (12.3 vs 11.5) but it is possible the higher EPAP was part of what helped. I assume you used EPAP 12 thinking it would be the same as 12 pressure from autoset (which is actually IPAP and EPAP = IPAP - EPR so was previously 9).

If you are comfortable at these pressures then I would stick with them and fine tune PS as sleeprider says. Then once you find good comfortable settings you could try lowering EPAPmin slowly as you may not need it this high. If the high pressures are an issue you could try reducing EPAPmin first to see what effect that has and then fine tune PS once you find an effective EPAPmin.

[17WRX]

Flow limits are significantly reduced with the pressure support with a 95% limitation index of 0.10.  This compares to FL of 0.57 on your 12/20 chart. Your respiratory tidal volume and rate are unchanged, but inspiration time has dropped from 2.38 seconds to 1.7 seconds, so you are meeting your tidal demand faster and with less effort.  As you become more accustomed to this easier breathing, your sleep should become more refreshing as you work less, and sense of feeling better should improve with time.  This are exactly the changes we were looking for.   I would keep the same settings, and increase PS by 0.2 or 0.4 increments to find that spot where the 95% flow limit falls to about 0.05.  Give a PS of 4.4 a try, and hold that for a few days.  

On your charts, try dragging the left pane to be smaller to give more room to the charts.

Are my flow limitations better for me, or good for anyone? I still woke up with the brain fog. I guess what I'm asking is, if you were in my shoes, would you still consider the surgery?

[Geer1]

We can't answer that after one night of data. What you need to do is continue to refine settings and see if data stays good. If data stays good and less than adequate PAP treatment was the cause of symptoms you should start to see a slow improvement in those symptoms (they won't all just go away after one good night). This could take weeks if not months to see all of the differences.

To me the decision as to whether or not to get nasal surgery would not be driven by my PAP data. It would be based on doctors opinions, any imaging you have (they did a CT scan of my sinuses and I could see the large turbinates, deviated septum etc) supporting the issue, and the effects of having to live with the congestion of which CPAP is only one of many factors (medications, nasal rinses, congestion during day or night etc). If on the fence a 3rd ENT opinion to act as the tiebreaker may be worthwhile.