Very unrefreshed in the morning with CPAP. UARS suspicion

[dekaneros11]

Hi guys, 

it's my first time posting here, i'm looking for tips regarding my therapy, since i wake up arguably worse than before CPAP.


Diagnosis (at home polygraphy): mild OSA, AHI: 11.1 (all hypopneas), ODI: 4.7, min O2: 92%. 

Why UARS suspicion?
 - AHI consisting of only hypopneas
 - smaller maxilla (lead to deviated septum and hypertrophic rhinitis) + mandibular retrognathism (tongue collapse when sleeping - confirmed by sleep endoscopy)
 - flow limitations in OSCAR + waking up unrefreshed

CPAP therapy:
 - 2 months in, i had 1-2 days of initial euphoria but downhill from there
 - i adapted to CPAP pretty quick, i still wake up sometimes during the night, but i also get nights without waking up at all
 - got put on 6-12cmH2o APAP, narrowed it to 7-11 and kept fiddling with settings during this time 
 - currently using a N30 w/ mouth tape; i also have 2 FFs, F40 and F&P Evora, but i can't get them to seal at all (probably because of the beard).
 - seeing flow limitations in OSCAR, not too bad (images attached), but i'm guessing they are the reason i feel unrefreshed


 - the bottom line is that physically i can say i feel better, the tensions in my head and chest are lower on average, but i wake up completely unrefreshed, much slower than before and with a huge brain fog; i know that 2 months in is still early, but the nature of the brain fog in the morning and during the day makes me thing it's not just because of the adaptation period


I'm currently still experiencing with pressures and EPR, i'm on constant 8cmH2o w/ EPR 1or2 right now, because there are some good waveforms with this pressure, but still wake up very groggy. As you will see, the waveforms have 2 peaks, but there are periods they are pretty round. I am also suspecting that the micro leaks i get with the N30 are also disrupting my sleep, and as a result i bought the F&P Brevida a couple days ago. Unsuccessful purchase currently, my nose still hurts 2 days after using it, the FL mean is much worse and it leaked the whole night. I'm not gonna attach a photo with the Brevida since i don't think it's suggestive as of now. 

All in all, from what i've learned until now, the OSCAR data doesn't look thaaat bad, but i wake up like i got hit by a truck (a different truck than before CPAP, but still a truck).

I'd appreciate some advice based on my OSCAR data, i'm pretty low currently and don't really know what to do. I know BIPAP would be the next option, but maybe there's still somthing to try with CPAP.


All attached pics are with the N30 for now. 

 
Thank you.

---

Attaching the corresponding zoom-ins, with the exception of 8cm with EPR 1, because of quota.

[DaveSkvn]

Hi Dekaneros11,

I've been working on flow limitations myself and got fed up of eyeballing the detailed flow graphs so I wrote a web page to suck in a Resmed file and grade each inspiration for some common flow limitation issues. You can have a go at it here (your data doesn't go anywhere - its processed in the browser): https://www.fortaspen.com/sleep/ There's a intro page with a couple of examples. The lower the index numbers at the start of the lines the better. If you do have a go I'd use the nights when you've used fixed pressure (the pressure going up and down could affect the results). Put a couple of screen shots up and I can take a look.
 
The results of my investigations would not shock anyone that's been around the forums. For flow limitations, upping the pressure doesn't seem to have much effect. What does have an effect is EPR / Pressure Support. For me the flow limitation index was directly linked to the EPR value - higher EPR -> lower flow limitations - lower EPR -> more flow limitations. I'm looking to have a go at bi level to try higher values of pressure support.

I have to say I think the flow limitations reported by Resmed are only those that they use to manage the OSA algorithm. They may not be looking for or reporting the FLs that are causing you (or me) issues.

One other thing that made a big difference for me was the soft foam surgical collar. It keeps the neck straighter and the chin up. Its quite cheap and is worth having a go with if you have not already.

[dekaneros11]

Hi Dave, 

Thanks for your reply.

This is such an amazing tool man. Having a metric that can correlate better (not necessarily 1:1) with the vraying degrees of one's fatigue when waking up is so helpful. Especially when both UARS and Flow Limitations seem to be harder to grasp than usual OSA. I could get lost in this data for a long time. What did you use to code this stuff?

Regarding the EPR - flow limitation relationship, i can say that mostly i've noticed the same thing in OSCAR, however the Glasgow index seems to not have such a strong relationship to the EPR used. I guess this could also be due to the unweighed calculus of the index, since i see many unreasonable waveforms in OSCAR that weren't flagged as having flow limitations. I can say however that the lowest Glasgow index i saw correlates from what i remember to having a better day afterwards. 

I have a suggestion for the tool, is it possible to add some stats on the main page that you see in OSCAR, like pressure used, ahi, flow limitation, leak rate etc.? If not directly from a file on the SD card (don't know if you can get them from the same .edf or another file), maybe just some fields where the user can manually enter the values, so that maybe if he wants to take a scrrenshot, it will have all the data there. 

Regarding the soft cervical collar, i have one, but didn't try it with CPAP. I had a tentative when i was trying to make F40 work, but i couldn't fall asleep, i felt too restricted. 

I can't attach photos because of the 5MB quota, do you know when it refreshes? 
This could also be something to add for the tool (i know it's very easy to ask   ), a method to export the results in text form, so you could quickly send to one another. 


For the moment i'll leave the overall index here:

 - 8cmH2o, EPR 1:
      - FL 95%: 0.08

      - GI: 1.87 
         - Significant: Double Peak - 0.4, Variable Amp - 0.38, Skew - 0.31, Top heavy/No pause - 0.25

 - 8cmH2o, EPR 2:
      - FL 95%: 0.02

      - GI: 1.75
          - Significant: Skew - 0.48, Variable Amp - 0.47, Top Heavy - 0.22

 - 9cm H2o, EPR 1:
      - FL 95%: 0.06

      - GI: 1.94
           -Significant: Variable Amp - 0.44, Skew - 0.37, Double Peak - 0.31, No pause/top  heavy - 0.26

 - 9cm H2o, EPR 2:
      - FL 95%: 0.02

      - GI: 1.75
         - Significant: Variable Amp - 0.39, Skew - 0.38, Top Heavy - 0.3, No Pause - 0.26

[dekaneros11]

now i realise that i said that the Glasgow index doesnt correlate that strong with the EPR, but in these 4 examples it does

[Old Steve]

I don't know if this will help you or not.  You can have OSCAR show you other smaller events that the machine does not report in AHI, but may be causing arousals.

If you want to try it go to the OSCAR program, then to top left of the screen and Click on OSCAR, then Click on Preferences, then Click CPAP.  then Click the Box "CUSTOM CPAP USER FLAGGING" then Click OK.  It will take a minute while it recalculates events.  These events do not show up in your AHI but will allow you to see more of what is going on.  

OSCAR will continue to show these events, if you want to turn this feature off you will have to go back into OSCAR and turn it off in the same area that you turned it on. 

Good luck with your treatment and welcome to the forum.

[DaveSkvn]

Thanks for giving that a shot. Its nice that someone else has had a go at using it!

Your results are broadly in line with mine so far. I did 3 days on EPR 0, 1, 2 & 3. This was the index output.

   

As you can see when EPR is upped, the index drops a bit. Cleaner breathing. It won't surprise anyone reading this forum.

I set EPR at 3 and did a few days at a few pressures. This was the output.

   

No effect. Moral of the story: if flow limitations are your problem then EPR/Pressure Support will make an impact, increasing the pressure probably won't.

You might want to have a go at your own tests with EPR. Set a fixed pressure and do a few nights on EPR 0, 1, 2 & 3. I think you'll feel better on 3. The next stage, if you need it, would be bi-level for higher pressure support (which is where I'm heading) - again that is in line with Apena Board folk wisdom.

My own data indicates the following are affected by EPR: Skew, Spike, Multi Peak, Vari Amp & No Pause (to an extent). Flat top, which is a pretty strict test, doesn't change much. "Top Heavy" is probably not strict enough - tends to rise when other problems are solved. Resp Rate & Multi Breath will only trigger for very bad breathing - like I had up to December - I expect your values are around zero, like mine are now.

The thing is written in Javascript (GPLed here: https://github.com/DaveSkvn/GlasgowIndex). I'll have a look at adding download/additional info fields. The machine data (pressure etc) is not in the BRD file and monkeying with multiple files would not help usability.

Happy fiddling

[dekaneros11]

I don't know if this will help you or not.  You can have OSCAR show you other smaller events that the machine does not report in AHI, but may be causing arousals.

If you want to try it go to the OSCAR program, then to top left of the screen and Click on OSCAR, then Click on Preferences, then Click CPAP.  then Click the Box "CUSTOM CPAP USER FLAGGING" then Click OK.  It will take a minute while it recalculates events.  These events do not show up in your AHI but will allow you to see more of what is going on.  

OSCAR will continue to show these events, if you want to turn this feature off you will have to go back into OSCAR and turn it off in the same area that you turned it on. 

Good luck with your treatment and welcome to the forum.

Hi Steve, thanks for your reply and fir the suggestion, didnt’t know that.

I activated it and yeah, it flags many events that look like arousals. 

Thanks for giving that a shot. Its nice that someone else has had a go at using it!

Your results are broadly in line with mine so far. I did 3 days on EPR 0, 1, 2 & 3. This was the index output.



As you can see when EPR is upped, the index drops a bit. Cleaner breathing. It won't surprise anyone reading this forum.

I set EPR at 3 and did a few days at a few pressures. This was the output.



No effect. Moral of the story: if flow limitations are your problem then EPR/Pressure Support will make an impact, increasing the pressure probably won't.

You might want to have a go at your own tests with EPR. Set a fixed pressure and do a few nights on EPR 0, 1, 2 & 3. I think you'll feel better on 3. The next stage, if you need it, would be bi-level for higher pressure support (which is where I'm heading) - again that is in line with Apena Board folk wisdom.

My own data indicates the following are affected by EPR: Skew, Spike, Multi Peak, Vari Amp & No Pause (to an extent). Flat top, which is a pretty strict test, doesn't change much. "Top Heavy" is probably not strict enough - tends to rise when other problems are solved. Resp Rate & Multi Breath will only trigger for very bad breathing - like I had up to December - I expect your values are around zero, like mine are now.

I’d be really interested to see some results for someone before and after Bilevel. 

Would you say that there’s a good correlation between EPR and how you feel in the morning for you? I’m asking because i’ve had some good days after EPR1, and some very bad on EPR2. I know it’s not the only thing that matters, but i’m curios if you can certainly say “yeah, i clearly feel better”.

Thanks for the github as well

[DaveSkvn]

"Would you say that there’s a good correlation between EPR and how you feel in the morning for you?"

Before I found Oscar in mid December (and for years before) I had a scheduled nap at 0930 to 1100 every morning - woken by alarm. Generally alert for the rest of the day. The Glasgow index was about 2.8 to 3.2 every night.

EPR of 3 made a clear difference to the flow limitation figures in Oscar and reduced but did not eliminate the spells of high respiratory rate (up to 50 bpm). Glasgow index 2.3 to 2.6. Still had the nap.

Tried the soft collar one night and woke the next morning feeling strangely light headed (Glasgow Index 1.6). I kept the old routine but didn't nap long.

The pressure was 13 which is aerophagia territory for me. Once the pressure was reduced out of the aerophagia zone, the index is now around 1.4 to 1.5 and I only nap some days. I think if I avoid exercise early (which I used to do every day to trigger the nap at 0930) I can get away without a nap - but this is work in process. I'm currently on the borderline. I've ordered a bi-level machine - which I'll have a go at using in a few weeks time - to see what happens next.

Wish me luck...

[dekaneros11]

That’s good to hear man, seems like you’re on the right path. 

Good luck with the bilevel! Hopefully you’ll get the relief you’re looking for.

The “generally alert” part is what i’m really struggling with, the flow limitations dont look  bad in Oscar and Glasgow compared to yours, but i wake up like crap.

I’ll give give EPR 3 and cervical collar a go too and see what happens.

[Winter247]

Wow, this resource is incredibly cool. Thanks for making it and for sharing it.