Hello Guest, Welcome to Apnea Board !
As a guest, you are limited to certain areas of the board and there are some features you can't use.
To post a message, you must create a free account using a valid email address.

or Create an Account


New Posts   Today's Posts

Fine tune APAP for possible UARS
#11
RE: Fine tune APAP for possible UARS
Hi Dave, thanks for the reply. I think I can move my jaw forward something like 1.5-2cm, but hard to tell exactly. I actually had a device similar to a MAD that held my jaw forward when I was a young teenager (well before my apnea problems) to treat a receded chin, it's one of the reasons my doctor thought it was a factor, and I didn't find it too uncomfortable. So maybe it might help me. Although it I'm not sure how much sense it makes to think a MAD would work when APAP didn't. I'm willing to try anyway.

I've attached two OSCAR screenshots with the respiratory rate graph pinned. One is from December when I was mouth taping but before I used the collar, and the other is from last night, with the collar. Hopefully it can tell you something. I had my suspicions about UARS because I had a deviated septum that I've had a septoplasty for and my sleep study gave me an AHI around 6 but an RDI around 22.

And I haven't had my tonsils out, but I remember my doctor mentioned it as something to try if APAP didn't work. Do you think it's something I should look into?

Hi Chad, thanks for the tip. I figured out a way of taping my mouth so it didn't come off, but it didn't seem to make me feel better. Although I haven't combined it with the collar, so I might try that tonight. And your two suggestions look good, thank you.


Attached Files Thumbnail(s)
       
Post Reply Post Reply
#12
RE: Fine tune APAP for possible UARS
This might be a long one so buckle Up...

I don't know how much you know about UARS. Most of what I know comes from this guy - from what you've said above you might get a bit of a jolt at 2:05 - I did (daytime sleepiness hit in my mid 20s, 6ft 2in, 75kg / 165lb). 

https://www.youtube.com/watch?v=sa9zNYpTWlM

So UARS, by his definition, is not about complete blockages. Its about trying to breathe through a narrow opening - "breathing through a straw". A single UARS "incident" can go on for several minutes or even an hour. Your breathing will be in steady state - same one breath to the next - doesn't have to be increasing or decreasing like apnea/hypopnea - its just restricted enough to cause some light to be flashing in the brain to stop you getting into a proper sleep state.

The following is from my flow rate graphs. Top two from last night. Bottom one from early December before I discovered Oscar.

   

The top trace is what you want. Regular breathing. The inspiration section above the mid-line should be like half an egg (or sine wave if you prefer) with a nice curved top. The middle trace is when some kind of minor obstruction is in the way. The inspiration flow gets to some level and can't get any higher so it continues about that level for longer than normal before dropping off - "flattening of the inspiration curve". There is a whole zoo of such flow limitations (see https://www.apneaboard.com/forums/Thread...#pid461525). The third graph is when the brain starts to panic and starts gasping / panting. Broadly each time the line goes from below to above the mid-line is counted as a breath so the higher your respiratory rate is recorded the more likely you are having issues with UARS-style flow limitations.

Note that the flow is not settling near zero in any of these situations - so no OA or H events will be recorded. Your body is getting enough oxygen so it will not show up in SpO2 traces (and it didn't in mine). But your brain may have some warning light flashing in scenarios 2 & 3 which means you wake up unrested.

Bluntly IMO CPAP machines are not designed / set up with the intention of dealing with this kind of issue. They will be regulated to focus on OSA. From my rooting around in the last few weeks the flow limitations score you see on OSCAR is heavily weighted towards OA / H like events. You can get periods of significant "not great" form which only get 0.1 flow limitation score.

Here is your respiratory rate graph from last night.

   

From my experience the restriction is cleared by shifting in your sleep (I video myself) but as you start to drift deeper into sleep in a new position it tends to re-emerge.

Zoom in to the detail of your Flow Rate graph at the times highlighted by the red line. Look at 60 seconds of data and fix the Y-axis so that you look at the same height each time (right click to the left of the graph on "Flow Rate" - Y-Axis -> "scaling mode" = override, min = -40, max = 40). Compare it to the Desired From & "Not Great" above.

Mr Veer has another video titled "Why Doctors Don't Understand UARS" from Nov 2023 outlining why it is so difficult to detect. There doesn't seem to be a real practical test for UARS. Sleep clinics have a process set up for OSA and will declare you treated with AHI < 5. So if, like me, you have UARS-like issues and OSA (supine positional), you'll be declared treated any time you raise ongoing daytime sleepiness and sent on your way.

As far as treatment goes, its the same as OSA. CPAP/APAP/BiLevel if it works for the individual. The word on the street here is that having a large difference between inhalation and exhalation (BiLevel) is good but try telling that to a sleep specialist. A MAD may be helpful. There is also the option of surgery. In the last couple of weeks I've found a soft foam surgical collar transformational.

Upload your flow rate detail (during the worst of the red line areas) and we'll see if they look like any of the "zoo".
Post Reply Post Reply
#13
RE: Fine tune APAP for possible UARS
Hey Dave, thanks for all the detail! Sounds like we might be in kind of the same boat so I really appreciate it.

The video definitely sounds like me, you were right about the jolt at 2:05 (mid 20s, 6ft, 80kg). I've attached an image with 4 samples from the parts you underlined and they don't have that rounded shape like normal breaths. Maybe look like Class 2s and Class 7s from the link you sent? It says they are to do with collapse of airway so would correlate with UARS.

I might look into MAD and see if I can get an opinion on my tonsils while I'm at it, if they're enlarged or not. Did you have them removed? Did it help you at all? I'm on the cervical collar as well like you mentioned you are, I definitely noticed some improvements, just would like to get it consistent and reliable.


Attached Files Thumbnail(s)
   
Post Reply Post Reply
#14
RE: Fine tune APAP for possible UARS
They certainly don’t look like the “Desired Form”. An annotated version...

   

In the first line there seems to be two groups of breaths at different levels (red lines). In the first group with the higher flow levels, there is the typical exhale behaviour (sharp downward trace from the mid-line then a leisurely return to the mid-line) followed by a pause (lurking at the mid-line – green circles) and then the inspiration (with flat tops – not great). In the second set with the lower flow peaks, there appears to be no pause between exhale and inhale. That seems a bit odd – a bit more panicked. On the second line the same story. A few breaths with pauses then faster breaths without pauses. And again on the fourth line. On the fifth line, groups at different flow levels and breaths with and without pauses.

I have no evidence or proof that these cause daytime sleepiness but they don’t seem ideal steady-state breathing.

If these are causing you an issue due to some kind of blockage, I very much doubt the CPAP machine has been designed to detect and react to them. The flow limitation score seems to be defined to give the highest values to things that look like hypopneas. These don’t look like hypopneas so won’t get a high score or trigger a response.

If it was me, I would increase the min pressure upwards every few days. Once I started waking up with an almighty belch due to air being pumped into the stomach I’d have hit the aerophagia limit and its time to stop. I hit it at 13 which is quite low. If we have much the same body type then you’ll probably be much the same. You then have to make the judgement if your symptoms are better with or without the CPAP. There is no guarantee that CPAP will handle your particular issue (I have positional OSA on my back and CPAP is of little use).

There is Apnea Board folk wisdom that flow limitations are better handled with a higher difference between inhale and exhale pressures than a standard CPAP machine is set up to permit. It requires a BiLevel machine which costs 4 times as much. Here is a thread with the before (CPAP) and after images (BiLevel). Getting access to a BiLevel machine to give this a try might be challenging.

https://www.apneaboard.com/forums/Thread...#pid497142

The big problem in all this is there is no measure of your/my problem beyond eyeballing the flow rate graph (and respiration rate). The AHI is irrelevant and there is no equivalent. We can’t approach a doctor and say “my Scooby Coefficient is over 12”! There is no standard process like there is for OSA.

Trying a MAD is one thing. It seems a key diagnostic if you are considering surgery is a “Drug Induced Sleep Endoscopy”. Mr Veer has a video on it and here is one from a Californian surgeon that shows examples of the four main locations of issues.

https://www.youtube.com/watch?v=r9R_IwafDMo

Without some kind of diagnostic or clear issue, doing random surgery is probably unwise. I had my tonsils out when I was 6 and the original Veer video mentioned littoral tonsils that are left behind can be an issue with UARS – there is no specific reason to consider a tonsilectomy above any other operation.

I’ve got an appointment to see Mr Veer in March privately (there seems to be very few “sleep experienced” ENT surgeons in the UK and zero chance of seeing one on the NHS). I’ll see what he has to say and will probably ask for a BiLevel prescription to give it a shot.
Post Reply Post Reply
#15
RE: Fine tune APAP for possible UARS
Yeah going back over my data it looks like my steady sleep respiratory rate is around 14 breaths per minute but I'm getting these elevated periods where it spikes sometimes even over 30. I guess it must be the reduced airflow causing some hyperventilation. Can't be good for rest.

I've experimented with raising pressures before but nothing had the same effect as the soft collar, so I wonder if my issue is primarily positional in nature. Reading around on the forum it seems like PAP machines often aren't sufficient to overcome positional blockages, which makes intuitive sense, it would take a lot of pressure to dislodge your jaw or tongue from blocking your airway. I bought a tennis ball today to use for the trick for stopping back sleeping and I'll see what that effect has, in the meantime before I can try a MAD. Although what you said about shifting sleeping position seems to clear a progressive blockage building up is interesting. Maybe I can just switch from side to side rather than onto my back.

I've tolerated high pressures though so I'll experiment with that. I have got aerophagia before, around 13 or so I think, haven't gone higher than that. Switching to EPR definitely helped with flow limitations as well, so I believe that about the BiPAP. I'm still in touch with Resmed about my machine so maybe I can have a chat to them about switching if the other options don't pan out.

I have to see prosthodontist anyway about getting a fitting for a MAD, so I might ask them how my tonsils look while they're at it. I'm sure they could tell me right off if they look enlarged or not, but yes I agree you'd need a doctor to determine a medical need for the procedure before you get them removed. Good luck with your appointment with Mr. Veer, he seems sympathetic to people who say are taking an active interest in their treatment and looking at their own data, so maybe you can have a franker discussion with him about what your suspicions are. I'm just glad I have a few things I can experiment with going forward. Thanks for all your help!
Post Reply Post Reply


Possibly Related Threads...
Thread Author Replies Views Last Post
  [CPAP] Experimented with CPAP Pressures, Minimal Improvement (Possible UARS) Alark 53 2,487 1 hour ago
Last Post: Sleeprider
  New Apple watch software update, Fine Print. "Sleep Apnea Notification" UnicornRider 0 83 02-14-2025, 02:37 PM
Last Post: UnicornRider
  APAP to relieve aerophagia Ferloft 4 142 02-14-2025, 09:34 AM
Last Post: Sleeprider
  [Diagnosis] introduction, long story of OSA/UARS diagnosis GreenAvocado 13 372 02-13-2025, 11:33 AM
Last Post: Jay51
  Effect of mask type setting in ResMed APAP GuyScharf 7 403 02-13-2025, 08:05 AM
Last Post: ejbpesca
  Uars/need help please Jlcdsc 4 392 02-11-2025, 11:28 AM
Last Post: DaveSkvn
  UARS Diagnosis - Seeking Advice on Path Forward ayyzee23 8 395 02-10-2025, 08:15 PM
Last Post: ayyzee23


New Posts   Today's Posts


About Apnea Board

Apnea Board is an educational web site designed to empower Sleep Apnea patients.