[Treatment] NightmaresOfTheBottom - Therapy Help Thread

[NightmaresOfTheBottom]

Thanks for the feedback on O2 and heart rate.  I will also try to edge up my min pressure settings to see if that helps.

Regarding sleeping longer, do you have suggestions on how to achieve that?  I typically wake up naturally each morning and don't cut my sleep "short".  I average 7h12min of sleep per night according to Apple Health and Oura.

[Dormeo]

It's possible your wake-up time is keyed to changes in the light or temperature in your bedroom. So my suggestion would be to go to bed a little earlier and see whether that gives you a bit more time asleep.

[NightmaresOfTheBottom]

At the suggestion of Lanky Lefty, who spotted many unscored arousals and breathing disturbances in my sleep data, I've been using CPAP mode and trying out higher pressures. My current settings are CPAP mode, pressure 10.0, EPR 3, no ramp, autotemp and humidity, still a full face mask F30i. No longer using Ambien for insomnia. Sleeping fairly well but still tired in the mornings sometimes. AHI <1.

He suggested higher pressures at 11, 12, and 13. However, going any higher than 10 results in swallowing air, which is quite uncomfortable and wakes me up, so I don't have any real data to share there.

My questions:
-How can I increase pressure while avoiding swallowing air?
-I've been experimenting with mouth taping (with full face mask) to encourage nose breathing and possibly reduce air swallowing. Any reason to think this will help/hurt my sleep quality?
-I have a chin strap I have not tried using yet. Could this help with air swallowing?
-I'm getting a CBCT scan (self-pay) tomorrow to find out more information about my airway, as I suspect it may be narrow (possible UARS). Any suggestions on where to get it analyzed online? I was thinking of using SeeThruReports.

I had a 8 month follow up appointment today with my sleep doctor. It had been 6 months since the previous one. She was quite irritated when she saw I had been adjusting the settings myself. Incredibly condescending, asking me what my medical training and background is. The lack of professionalism and open-mindedness from sleep doctors is astounding. My insurance and I are paying a combined $500 for a 15 minute Zoom call where she won't even look at my data, it's a joke.

She then informed me should would be having the DME remotely switch the settings back to APAP mode pressure range 10-12 or 10-15. Will this negatively impact my sleep or should I stick with my own settings? I only have about 4-5 more months until the rental is paid off through insurance and I don't have to deal with the DME or sleep doctor anymore.

Thanks

[jdougc]

Are you on any medications that may affect your breathing or your sleep?
Do you have any health issues that may affect your breathing?

Can you post new data, since you are on cpap mode?

I wouldn't let the DME make any changes to your settings, especially since your sleep doctor was so dismissive.
You can have your primary care physician take over and write scripts, mine does that as my sleep doctor was very bad also.

Consider the use of a SomNoSeal device,a soft, flexible mouthpiece that prevents mouth breathing and dry mouth during sleep.
https://www.youtube.com/watch?v=1u_S1ADwVmA

Nose breathing is better for you sleep, unless there are underlying conditions preventing this.
https://health.clevelandclinic.org/breathe-mouth-nose

If you use a chin strap, make sure that the strap fits under your chin and only pulls straight up, not back at all. Pulling the jaw back can make your apnea much worse.

[NightmaresOfTheBottom]

I'm not currently taking any medications aside from 1 mg melatonin. I used to have seasonal allergies and nasal inflammation, but it has majorly decreased since doing allergy shots for over a year. My nasal passages feel clear now.

I have uploaded new data to SleepHQ.

The past two nights I tried the APAP 10-12 3 EPR setting suggested by the sleep doctor. The first night my AHI was 1.64. The second night I tried using mouth tape and it decreased to 0.27. This matches my prior observations from past CPAP mode where mouth tape seems to help reduce AHI and make me feel more well rested.

I looked into the SomNoSeal device and think it will help and be a better option than mouth tape or chin strap, so I have ordered it.

I may still try experimenting with the chin strap and mouth tape in the meantime.

[jdougc]

What if you tried cpap mode with a pressure of 10.4 cm and increase it by .2 cm, if no issues in a few days?
But if you feel rested, nevermind.

[NightmaresOfTheBottom]

That's an idea I could try.  First, I think I'm going to collect more data with mouth taping at APAP 10-12.

I'm also back to tracking pulse changes (PC) with a Nonin pulse oximeter (it doesn't sync to SleepHQ unfortunately).  Will upload some new screenshots from OSCAR showing it when I have a few more days.  The most recent days showed average PC around 50-60 which seems quite high and seems to indicate many arousals not flagged as events by Resmed.

I recently acquired a Dreem unit to track sleep stages.  I haven't had a chance to try it out yet with the modded Dreem Android app, but curious to see how well it correlates to PC.  My sleep study indicated many non-respiratory disturbances.

Basically I'm taking the full court press approach and am willing to try any and all possible solutions and technology to improve my sleep quality.  I know it's possible because there are occasional days when I wake up energized and refreshed, and those days are amazing.

[NightmaresOfTheBottom]

I received my CBCT scan and results back today.  It's cool to be able to view the raw files in 3D and see my entire upper airway.  

It seemed to confirm my suspicions that despite my low average AHI with APAP, I have structural issues with my airway due to how narrow it is that are likely leading to my continued feelings of fatigue.

Can anyone comment on the significance of 72.1 mm^2 minimum upper airway cross-sectional area?  Is this evidence of UARS?  

Trying to figure out the next steps.  Not really interested in any surgery, but am looking for ways to further improve my APAP treatment based on this new knowledge of my airway.  My sleep doctor is not open-minded enough to discuss these issues with her.  I'm on the waitlist for a different sleep doctor.

Thanks





I've pasted the contents without any PII below:

Clinical Notes: “Diagnosed obstructive sleep apnea with residual symptoms and CPAP intolerance. Requesting airway volume
analysis, jaw/tongue position, and nasal passage assessment. Seeking evaluation of anatomical contributors
to sleep-disordered breathing.”

Radiographic
Technique:
This study is a large field-of-view (FOV) Cone Beam Computed Tomography scan (CBCT) of the maxillofacial
complex.

OBSERVATIONS

Area of interest -
Airway:
The minimum upper airway cross-sectional area is 72.1 mm2 and volume is 8.7 cc.
The tongue and soft palate are slightly posteriorly positioned due to retruded position during scan
acquisition.
The soft palate measures ~ 39.45 mm in length and ~ 13.82 mm in width.
Using Invivo 3D software, at the interocclusal space, the pharyngeal airway spaces measure ~ 16.99 mm
medio-laterally and ~ 9.89 mm antero-posteriorly.
There is mild soft tissue enlargement with the nasopharyngeal adenoids, and mild-moderate symmetrical
and bilateral enlargement with the palatine tonsils, right sided palatine tonsilloliths are noted.

Dentoalveolar: Missing teeth: Third molars and set of four maxillary and mandibular premolars.
The generalized bone levels are approaching the cervical third.
Prominent palatal torus and mandibular lingual tori noted in the canine-premolar region bilaterally.

TMJ: Right and left TMJs: Bilaterally condylar volume is reduced, there is mild-moderate antero-superior
condylar surface flattening with intact cortical outlines, and mild flattening and sclerosis with temporal
bone components.

Condyle-fossa relationship: Teeth appear in maximum intercuspation, both condyles are posteriorly and
supero-laterally positioned in the glenoid fossae, indicating reduced posterior and superior, lateral
radiographic spaces.

Sinuses: There is mild peripheral mucosal thickening with the maxillary sinuses, intact borders and patent ostio-meatal
complex bilaterally.

Nasal Cavity: The nasal cavity appears clear with intact borders, and nasal septum is deviated to the left side with spur
formation contacting the inferior turbinate.
There is slight asymmetry with right and left internal nasal valves, with narrowing on the left side with
possible soft tissue thickening.

Cervical Spine: Early osteoarthritic changes are noted with the visualized osseous aspects.

IMPRESSIONS

General Impressions:
Airways: Reduced upper airway cross-sectional findings suggestive of increased risk of sleep disordered
breathing:
1.
note retruded tongue/soft palate morphology, soft tissue enlargement with palatine tonsils
bilaterally, nasal septum deviation and narrowing and possible soft tissue obstruction of left sided
internal nasal valve are all contributory factors, if clinically indicative, appropriate specialist
evaluation/referral is recommended for appropriate management.
a.
TMJs: Osseous findings are indicative of functional remodeling changes with hypoplastic condyles, a
developmental process or degenerative joint disease, radiographically stable:
2.
condyle-fossa relationship bilaterally suggestive of increased risk of internal derangement, like disc
displacement.
a.
b. correlate with clinical findings for active TMDs.
Within limitations of this imaging study, negative for radiographic signs of appreciable dento-alveolar
apical and osseous pathology.

[LaurenceShaw]

If you use a chin strap, make sure that the strap fits under your chin and only pulls straight up, not back at all. Pulling the jaw back can make your apnea much worse.

Yes, beware/be aware that traditional neoprene chin straps aren't designed to actually work well.  Traditional chin straps wrap around the tip of the chin and the top, back of the head, the problem being that the jaw joint (which is just in front of the ear) is located on the line between those two points.  This is illustrated on the More Info page of Supplier #37.  That means that traditional chin straps force the jaw almost directly into the jaw joint, which is the least effective angle to be applying force for this purpose.

I'd suggest you look into the Knightsbridge Dual Band chin strap, since (as jdougc recommends) the straps pass under the jaw and lift vertically to work with the natural rotation of the jaw.  (Please use the link of Supplier #37 rather than a keyword search or you will likely end up with a counterfeit.)

[NightmaresOfTheBottom]

Thanks for the suggestion.  I've ordered the Knightsbridge Dual Band chin strap and will try it out.

I looked into both orofacial myofunctional therapy and sleep dentistry device and ruled them out for now.  The costs are too high to justify: $5,100 for the sleep dentistry appliance and visits and $2,100 for the orofacial myofunctional therapy program, both paid out of pocket, with the potential to be partially reimbursed by my health insurance, which has an out of network deductible of $3,000.