New CPAP User seeking input – suspect UARS

[mikemctx]

A little background.  Several years ago, after having a severe sinus infection I developed ongoing trouble breathing through my nose.  I then had a septoplasty & turbinate reduction.  At the time my ENT told me that the turbinate reduction is a permanent fix.  But other sources say that turbinate tissue can regrow over time, meaning the procedure may need to be repeated if symptoms return.  Following the surgery my nose breathing was noticeably improved but not perfect.  I’m used to manually inhaling at night over the years as I try to go to sleep.
 
Over the last 6 months I’ve experienced significant daytime sleepiness and I consistently wake up about 3 times every night.  My sleep scores on my Garmin watch have been terrible for a long time.  Working with my Primary Care Doctor I had a home sleep study last month that showed an AHI of 5.8 (mild), longest apnea duration was 84 seconds, and lowest oxygen saturation nadir was 88.7%.  As a result of the study I was prescribed an auto CPAP.
 
Since starting on the CPAP my AHI has generally less than 0.2 events per hour.  I continue to be extremely sleepy, I still wake up 3 times a night and my Garmin Sleep Scores continue to be terrible.  One thing that does show up using Oscar is that I regularly have flow limitations, and the shape of my inhalation flow rate looks pretty crummy.  Oscar occasionally shows a RERA, but I can visually identify other RERAs shortly before I wake up.

I’ve attached 3 images:
1)      A full night’s Oscar screen
2)      A zoom into some crummy flow rate images followed by an apparent RERA
3)      A Glasgow Index image of one of my sleep sessions last night
 
My questions are:
1)      When I meet with my Primary Care Doctor next month should I push to re-engage with my ENT to explore having an additional turbinate reduction?
2)      Is there anything else I should be doing?
 
Thanks!

[DaveSkvn]

Hi mikemctx,

Welcome to the board!

It certainly looks like sleep apnea is not your main problem. Your flow rate graphs does not appear to have the regular curved-tops that you want. The Overall index of 3.38 is higher than anything I've ever had (but in a clearly different way). As the intro to the Index says its not a medical product and not meant to diagnose anything but there are clear signs that your breathing is not what you want it to be and that the problems are broadly constant through the night.

One question to address is whether your nose is the source of the problem. Given you are using a nasal mask, it is possible these results are caused by a nasal restriction. In your pre-CPAP life, I suspect if there was a nasal restriction you would end up mouth-breathing, bypassing any nose issue. There is a small possibility the issue is a result of your CPAP treatment. Given you had issues before CPAP, I suspect the problem is lower down. If you wanted to get a handle on what is going on, you might want to consider a DISE (https://www.youtube.com/watch?v=r9R_IwafDMo) by someone who knows what they are doing (i.e. does not film you breathing whilst still anaesthetised).
 
What can you do about it? (A) have you tried a soft foam surgical collar (about $10 worth)? It keeps the chin up and the neck a bit straighter. It made a big difference to me and it seems many others on the board were also helped. (B) I can't see from your screenshots but EPR can make a difference to flow limitations. If you haven't already, set it to 3 and for "Full Time". Do a test: a few nights with EPR 0 and a few nights with EPR 3. The 95% flow limits number on Oscar and the Glasgow Index should both reduce. If its of significant benefit, you can move to a bi level machine where the pressure difference can increase further to 5 or so.
 
As far a dealing with doctors on the topic of UARS, things get a bit vague. Your breathing does not stop and typically flow limitations do not cause SpO2 to drop so there is no clinical sign for them to hang a diagnosis off. Having a lumpy or erratic flow rate graph will not be taken by an insurer as proof of an ailment. Its just that people feel better when it ceases to be lumpy and erratic. Try the soft foam collar and the EPR tests. If the flow limit numbers reduce you can ask for "more of this please".

Good luck

[mikemctx]

Thanks, Dave.

For what its worth I've been a nose breather all my life - so it really bothers me when breathing through my nose is restricted.

I'll keep the DISE in mind if the opportunity arises to try that.

In terms of a soft foam surgical collar, does it matter if I sleep on my side or on my back?  I normally sleep on my side unless my shoulder is bothering me.

In terms of EPR I am already at 3 full time.  Would it be helpful to do a 0 to see if the flow numbers and Glasgow Index get worse?

In terms of experimentation, would it be of any value to try a higher fixed pressure (of course keeping the EPR of 3)?  I'm not sure I can get insurance to spring for a Bipap since they already paid for a CPAP.

Thanks again for your help!

[DaveSkvn]

"soft foam surgical collar": I would say its worth trying anyway - I have positional OSA and use a "positional device" to keep off my back and still seem to get significant benefits. You should be able to get one for $10 or so on ebay/amazon.

"Would it be helpful to do a 0 to see if the flow numbers and Glasgow Index get worse". Very much so. I would make it a few nights of each. That will give you a clear indication of whether an "EPR 5" (bi level) is worth the hassle for you. You can try different pressures. I would expect them (based on my testing) to make minimal difference but you may be different.

There is a canonical post from @Sleeprider & @Deborah K about the issue of bi level & insurance

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