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+--- Thread: RERA? First time using Oscar Data (/Thread-RERA-First-time-using-Oscar-Data)
RERA? First time using Oscar Data - DTBetter - 05-05-2020
Hi,
Sorry to bother you all! I was diagnosed with moderate obstructive sleep apnea 2 years ago and was advised to purchase a mandibular advancement device to remedy this. This worked well for a year, however, despite adjustments to the device, for the last few months I've been really struggling to fall asleep; quite frequently, when I start to slip into a semi-conscious state, I seem to be awakened by a sharp inhale of breath and a raised heart rate.
I've been using a Dreamstation APAP to help try and overcome this with some success; however, I do still have these awakenings.
I tried to pinpoint one of these events last night (I held my breath soon after, which flagged an apnea so I could easily see it, but I didn't actually fall asleep during the first half of the night with the APAP):
[attachment=22614]
On the Zoomed in photo, under respiratory rate, there's a random spike at 23:09. There doesn't seem to be any disordered breathing before hand, but it's as I start to drift off, I'm awakened by a sharp inhale.
I appreciate this doesn't seem like a particularly big deal, and my AHIs are relatievly good overall (this was actually my worst night and I often score below 2), but this consistently stops me from falling asleep. The only time I seem to be able to reliably get good sleep is if I take a sleeping pill which I've been prescribed (I know these worsen apneas, but it seems they sedate my body enough that it doesn't have these random arousals).
I was just wondering if anyone has any ideas what they could be and how to remedy them? They look like possibly a RERA based on what I've read, but as I say, there's no disordered breathing beforehand.
With regards to my machine, I've basically been using/setting this solo; there was a 6 month wait for a CPAP machine on the NHS here in England, and the day before my appointment, this was cancelled due to the Coronavirus outbreak, so I've been trying to adjust this myself.
I used the initial settings of 4 to 20 range with a ramp, but found as I was drifting off, I would actually snore/snort myself a wake. I since removed the ramp and put the minimum pressure up to 6.5, which seems to make it impossible for me to snore. My 90% pressure usually falls somewhere in the low to mid 7s and my AHIs are usually between 0 and 2, so from an apnea perspective, pretty good I think. I also wear my Somnowell MAD and a Somnifix to keep my mouth closed whilst using a nasal pillow.
I have my Flex setting at 2. It used to be at three, which I found led my breathing too much. Not sure if going lower would be better or not (?)
I do think I suffer from positional sleep apnea (my breathing is much more laboured and sounds like snoring when I tuck my chin, and if I lean back, it's impossible for me to snore) and have ordered a cervical collar to help, though I'm not sure if this would help remedy the potential RERA (if that is indeed what it is).
Apologies for the essay and sorry if my post is missing any key details or screenshots; I'm pretty sleep deprived right now and definitely not all with it, so any advice or help would be massively appreciated!
Kind regards,
DTBetter
RE: RERA? First time using Oscar Data - Sleeprider - 05-05-2020
You do have some pronounced flow limitation ahead of the recovery spike as shown by the downward sloping peak on the inspiratory wave, so that appears to be a legitimate RERA. That event may seem to come out of nowhere, but there is enough restriction ahead of it that you built up some CO2, which gave you a shot of adrenaline and a command to "breathe now". Your chart also shows some clusters of hypopnea that suggest your thought on positional apnea has merit. I think an increase in minimum pressure is probably needed and the use of a soft cervical collar should help. With upper airway flow restriction, pressure support is often helpful, but not something you can get from your Philips CPAP. I think you should find the CPAP is more effective than the MAD, and a bit more minimum pressure will help with this flow limitation that leads into the arousals.
On a full night view of your therapy, look for spikes of flow above your normal level, and that will give you a clue on how often you might be experiencing RERA. Without snores, your machine won't increase pressure, so you're going to have to do it manually in settings.
RE: RERA? First time using Oscar Data - DTBetter - 05-05-2020
(05-05-2020, 08:08 AM)Sleeprider Wrote: You do have some pronounced flow limitation ahead of the recovery spike as shown by the downward sloping peak on the inspiratory wave, so that appears to be a legitimate RERA. That event may seem to come out of nowhere, but there is enough restriction ahead of it that you built up some CO2, which gave you a shot of adrenaline and a command to "breathe now". Your chart also shows some clusters of hypopnea that suggest your thought on positional apnea has merit. I think an increase in minimum pressure is probably needed and the use of a soft cervical collar should help. With upper airway flow restriction, pressure support is often helpful, but not something you can get from your Philips CPAP. I think you should find the CPAP is more effective than the MAD, and a bit more minimum pressure will help with this flow limitation that leads into the arousals.
On a full night view of your therapy, look for spikes of flow above your normal level, and that will give you a clue on how often you might be experiencing RERA. Without snores, your machine won't increase pressure, so you're going to have to do it manually in settings.
Thank you ever so much for the detailed response! There did seem to be other spikes so it does seem it wasn't just a one off!
I'm currently at a minimum pressure of 6.5 and the 90% tends to go towards 7.5 on most nights - would this be a good minimum pressure to adjust to?
I've also been using the APAP in conjunction with the MAD - im presuming it's okay to combine the two?
Kind regards
DTBetter
RE: RERA? First time using Oscar Data - Sleeprider - 05-05-2020
I think increasing the minimum to 7.5 is a very good idea. Keep in mind the Philips auto CPAP is slow to increase pressure an is not sensitive to flow limitation like the Resmed Autoset, you therefore need to set the minimum higher. Give it a try and post another chart.
Combining MAD with CPAP is fine if you are comfortable and can avoid leaks. I think it might be interesting to do a period of therapy with and without the MAD and compare to see if it makes any difference. I'll be interested to hear your results.
RE: RERA? First time using Oscar Data - DTBetter - 05-05-2020
(05-05-2020, 09:09 AM)Sleeprider Wrote: I think increasing the minimum to 7.5 is a very good idea. Keep in mind the Philips auto CPAP is slow to increase pressure an is not sensitive to flow limitation like the Resmed Autoset, you therefore need to set the minimum higher. Give it a try and post another chart.Thank you so much! I'll give it a shot! Tbh, the MAD isn't particularly comfortable so would be happy to give it a trial and feedback on the results!
Combining MAD with CPAP is fine if you are comfortable and can avoid leaks. I think it might be interesting to do a period of therapy with and without the MAD and compare to see if it makes any difference. I'll be interested to hear your results.
RE: RERA? First time using Oscar Data - DTBetter - 05-06-2020
(05-05-2020, 09:09 AM)Sleeprider Wrote: I think increasing the minimum to 7.5 is a very good idea. Keep in mind the Philips auto CPAP is slow to increase pressure an is not sensitive to flow limitation like the Resmed Autoset, you therefore need to set the minimum higher. Give it a try and post another chart.
Combining MAD with CPAP is fine if you are comfortable and can avoid leaks. I think it might be interesting to do a period of therapy with and without the MAD and compare to see if it makes any difference. I'll be interested to hear your results.
Thanks again for your support. I upped the pressure which resulted in a slightly lower AHI. Interestingly, I awoke without my MAD (not sure when I took it out), so this does act like a trial run without it, I guess.
That being said, it looks like I'm still having some arousals (22:52 and 23:09). I've added two photos from early in the night before I fell asleep and before I took my MAD out too, and an overview of the night as a whole:
[attachment=22637]
[attachment=22638]
[attachment=22639]
Do you think it would be worth increasing the pressure further? The 90% average was 8.5 yesterday, so higher than it has been (though I appreciate this will be impacted by the fact I had a lower minimum.
Kind regards,
DTBetter
RE: RERA? First time using Oscar Data - Sleeprider - 05-06-2020
If you're comfortable, go to a minimum pressure of 8.0. If we were working with a Resmed, I'd get you to EPR 3, but with Philips stick with your current flex setting. That little blurb at 22:52:30 is a sniff and a swallow. The other one looks more like arousal. Don't expect that CPAP is going to eliminate an occasional sleep arousal, they are normal. We just want to ease the flow limitation as much as possible to make your breathing comfortable with less effort so they are less frequent.
RE: RERA? First time using Oscar Data - DTBetter - 05-06-2020
(05-06-2020, 09:58 AM)Sleeprider Wrote: If you're comfortable, go to a minimum pressure of 8.0. If we were working with a Resmed, I'd get you to EPR 3, but with Philips stick with your current flex setting. That little blurb at 22:52:30 is a sniff and a swallow. The other one looks more like arousal. Don't expect that CPAP is going to eliminate an occasional sleep arousal, they are normal. We just want to ease the flow limitation as much as possible to make your breathing comfortable with less effort so they are less frequent.
Thank you! As an aside, do you think I would benefit from a different style mask?
I have slight turbinate hypertrophy due to dust mite allergy. I breath through my nose fine (I think - though I guess I have nothing to compare it to) during the day and don't suffer from anything like runny or blocked nose, but wondered if its possible slight hypertrophy might be limiting my flow?
RE: RERA? First time using Oscar Data - Sleeprider - 05-06-2020
I have always found that using nasal pillows allows me to breathe through my nose better. Even during the day, I often find myself mouth breathing due to congestion, deviated septum and whatever, however in the 12 years I have used nasal pillows, I have used nothing else. A full face mask that fits over the bridge of your nose will increase any nasal congestion you feel. You can pursue this therapy in any way you feel best, but for me, nasal pillows makes it most tolerable.
RE: RERA? First time using Oscar Data - DTBetter - 05-06-2020
(05-06-2020, 12:11 PM)Sleeprider Wrote: I have always found that using nasal pillows allows me to breathe through my nose better. Even during the day, I often find myself mouth breathing due to congestion, deviated septum and whatever, however in the 12 years I have used nasal pillows, I have used nothing else. A full face mask that fits over the bridge of your nose will increase any nasal congestion you feel. You can pursue this therapy in any way you feel best, but for me, nasal pillows makes it most tolerable.
Thabk you - really appreciate it! I much prefer nasal breathing so just wanted to be sure I wasn't being dense!