[Treatment] Help - OSA + UARS

[MikeR20]

Hello all, 

After 1.5 years of doing every medical test in existence, 5 months ago I received my initial OSA Diagnostic ( AHI = 25.8, RDI = 26.4). I was 23, leaner than I am now and I never snore

I have been on CPAP ever since with apparent great success, with low AHI and leaks. I suspect that I'm having some RERAs with CPAP.

I have ERP=3 due to flow limitations, I mouth tape, use a nasal spray, and use a soft cervical collar. Additionally, I started to sleep on my side. I also tested sleep on a wedge pillow.

The thing is I'm still exhausted, with trouble concentrating, staying alert, and overall well-being. So, it's not much different from the starting point. It doesn't matter how long I sleep, I can't feel normal again.

All the blood markers are great and I had no previous illness or symptoms like this. I sleep with a Fitbit, which from what I have seen is not bad at detecting sleep stages, and I always get little REM Sleep.

Recently tried to reduce the IPAP from 12.6 to 11, due to aerophagia,  and the AHI decreased a bit.

Is there anything I can do to improve therapy? 
Try to move to Bipap or ASV?
Should I explore surgery options? 

Thank you very much

PS: This night I slept some time without the mask, which is not very common.

[BoxcarPete]

If you want to talk REM, please reformat your charts to include at least tidal volume at the bottom. The squiggliness of the lines can frequently help us find where you are dropping in and out of the REM cycle. It's no substitute for PSG, but in my opinion on most charts it is easier to tell from breathing patterns than what fitbit is able to track. Your symptoms do correlate to REM problems, but there are many things that go into sleep architecture. The easiest to rule out are alcohol use and medications, especially those used for anxiety and depression.

You're a bigger guy, around 190cm and 90kg? I'm guessing this based on what I see in your chart's respiration statistics. Between your stated age, use of nasal spray, and inspiration time greater than expiration time, I suspect you may have a firm airway obstruction/restriction that does not respond to pressure. I don't know what kind of options you have within your health system and you may be able to manage it with a bilevel machine, but I would try to get my airway scoped if I were you. I did that when CPAP seemed to help some but not enough, and I was told that I had deviated septum in both directions, enlarged turbinates on both sides, and adenoids that occupied 50-70% of my nasopharynx. Once that was all cleaned up, I got a few really nice looking charts before deciding that I would try sleeping without it to see how I did (not good enough).

[MikeR20]

Thank you very much for your response. 
Tidal Volume is attached, as well as the Fitbit report.

I'm 25M, 1,83cm, 86kg. Was 77kg before all of this. I still workout 4/5 times a week and ocasonaly run.
The only medication I'm on is TRT, which I was diagnosed with when I started having these shythoms, at the time with no apparent cause. Helped a bit.
I carefully watch my blood work, and now all of my values are within range, they are not over the top. 

I have no problem falling asleep. I don't feel anxious or nervous, just lethargic. Take Magnesium before bed and normally have a better sleep schedule than this day.

I had septosplasty and turbinate reduction canceled last minute, and was sent to Neurology, because the Dr. changed his mind after seeing for 2nd time the Low AHI.

I'm waiting on a PSG with CPAP, to prove that this is still a respiratory problem.
I plan to have a DISE after and see which surgeries make sense. 

Would you say that you feel normal again after surgery, with CPAP?

[CPAPfriend]

Do you mean you reduced the max pressure? In the screenshot you shared, your pressure wasn't going up that high to begin with, so I wouldn't expect any change.

What user flags are you using?

There is a chance, as mentioned, that bilevel could provide the additional pressure support you need to adequately open up your airway, and I second getting a physical evaluation of your airway. Many others and myself have gone way down the surgical-inquiry route, and I advise you to get involved in some communities where such topics are thoroughly discussed before proceeding with any recommendations by local providers. I would personally not permit 98% (random almost all-inclusive number for effect) of sleep surgeons to do surgery on me, as it really requires finesse, and the hard part is doing the right movements on the right people. A lot of sleep surgeons too loosely prescribe general surgeries to too wide a demographic. Many can execute the surgery well, but they get the plan wrong. I suggest getting many opinions and many charts, scans, scopes, etc. before proceeding with anything, and I wouldn't go through with a surgeon unless they hyperspecialize in treating sleep-disordered breathing patients. Others may have a different view, but that's where I come down.

[MikeR20]

Apologies for the mistake.

I recently reduced the pressure from 12.6-13.6 to 11-12.6. I always keep the min and max close.
I feel comfortable falling asleep at min 12.6, but get some aerophagia and need to tape my mouth really well, so I don't get a continuous flow of air out of my mouth.
Additionally, I took off the mask one of these days, and the Fitbit sleep graph appeared way better. So I'm trialing with lower pressure, but I don't believe I can sleep with lower than this. Not the most flawless logic behind this, but the best my sleep-deprived mind can do. I guess it can't hurt to try it, AHI seems unchanged.

The user flags are the standards on Oscar.

My ENT is the Head of the Service so I'm hoping he's better than average. Even though I will get more opinions then.

The flow limits appear to be small, and I'm not sure if I can get an Bipap. Will see.

[MikeR20]

I have done a new PSG with CPAP. It shows a very shallow sleep, with an AHI different from the CPAP machine (1.6 vs 5.1) and several awakenings caused by bruxism which I suspect is mouth puffing, i sleep with mouth tape.

Looking at the original sleep study I'm doubtful of the OSA diagnosis, seems more Central, gonna push for ASV and maybe a DISE.

OA: 1.3/h
CA: 4.2/h
Mixed: 2.6/h
Hypoapneas (Unclassified): 16.8/h


I have been trying to lower the pressure and the EPR, to try to reduce possible awakenings and central events.
It appears that when I'm going into REM sleep, something happens ( some collapse?). What could this be?

[MikeR20]

Some screenshots from last night. Apparently took off the mask in the middle of the night. 
Normally have a better sleep schedule.
EPR=1 in this night, very small increment in flow limitations

[CPAPfriend]

It's common for sleep-disordered breathing patients to struggle to get into REM, where collapsibility is greater because of muscle paralysis, so this could be what is happening.

What would be interesting to review would be your data from the sleep study to see how many of your 'spontaneous' or other arousals coincide with flow limitation of some sort. I suspect that smaller, more subtle breathing disturbances are still playing their part in disrupting your sleep, but I of course cannot say for sure.

[BoxcarPete]

If we assume that there is a settings tweak session or something earlier in the night that we are meant to ignore, and that initial sleep onset is 02:05, the sleep architecture looks pretty normal aside from the occasional sighs or spontaneous arousals. REM1 is 25 minutes long at 80-85 minutes, and REM2 is 20 more following 55 minutes later. The problem here looks to me like the deep sleep looks is fragmented.