What are the right questions? Normal AHI. So Tired. New to Oscar.

[menmh]

I've been using cpap since 2019. Started off with mild apnea. I had a Dreamstation and then the replacement. It went fine until late last year when my AHI suddenly started spiking, often higher than my original diagnosis. The big change has been weight loss (which I thought was supposed to make things better).

DME therapist started me on ResMed Airsense 11 with full face mask. The AHI went back to normal range, but I am still so tired. I'm trying to get as much data as I can so that when I see the sleep doctor at the end of March, I can come armed with questions and what to press for more information on.

I don't really understand what I am looking at with the oscar data. When I zoom in, it looks to me like the flow rate is wonky (that's a technical term right?) in several areas that aren't flagged with anything.

I've been trying to watch a bunch of the YouTube videos on how to interpret the information, but it is just going over my head.

What should I be focusing in on? What can I do to try to improve things myself before seeing the dr?

Thanks!

[SeePak]

Menmh

The right question, hmm.

how bout, why are there so many people lately that have preponderance of CA events?

Check out all you can about Hi Loop Gain, heavier than normal breathing, and you will find the answer.

I have been providing this information in many of the posts i respond to, for now, i will suggest....

Reduce your EPR to 0 , 7 cm min.  11 cm max, 

and see what happens with the CA events and how you feel.

I will gladly give more info. once you try that.....

[DaveSkvn]

Hi menmh,

You ask about what to look for in an Oscar trace. Having a look at yours...

• Event flags: A fair number of CAs and a handful of hypopneas. Overall at a level that a sleep clinic would not consider actionable (AHI 2.9).
  
• Flow rate graph: At this zoom level doesn't tell you much. If OAs and Hs are clustered and then blank it can tell you the issue is positional.
  
• Leaks: need to keep well below the dotted red line (24 l/min) which you are doing, no problem
  
• Flow limitation: you want that to be blank.
  

You will probably want to have a look into flow limitations. Flow limitations are caused by partial blockages in the upper airway. You can be sleepy because of apneas/hyponeas or because of flow limitations or a bit of both.

https://www.apneaboard.com/wiki/index.ph...limitation

The CPAP machines only record certain flow limitations that they find useful for managing OSA. A low figure (say 0.1 or 0.2) does not necessarily mean you have no problem. The key figure to look at is in the right hand box. Against "Flow Limit." under the column "95%". You have 0.07. That means 95% of the time your flow limitation score was under 0.07. I would say that needs to be 0.04 or below. Ideally zero of course - but low enough that flow limitations do not affect your sleep which will be different from person to person.


Things to try: soft foam surgical collar (keeps the neck straight and the chin up), it certainly helped me. Activating EPR often helps flow limitations.

Which brings me on to what @SeePak was saying. ERP can, in some people, trigger CA events. If you are up for it, I would suggest you do some tests. For 3 nights each, set EPR to 0, 1, 2 and 3 and see what that does to your CA events and flow limitation 95% number. From my tests, the EPR will reduce the flow limitation number (but I do not have the CA event issue, only had two last night). You may have to balance the CA events against any reduction in flow limitations you get - but you would need to do the tests to start making that judgement.
 
Good luck

[menmh]

Thanks for the ideas. I'll have to think about the collar; the only time I've worn and slept in one was after a car accident and it was very uncomfortable. I'm a side sleeper and was thinking about trying one of those cpap pillows. 

I used a dreamwear nasal pillow for years until things went crazy late last year. When I got the new machine I tried an F40 for three months and it was hurting my nose, so now I'm trying the AirTouch. Much more comfortable on my nose and skin, but I seem to be getting some leak issues.

I tried the settings SeePak suggested last night. It made a certain amount of sense to me b/c the DME therapist reduced me from 3 to 1 the last time we met. I feel like the difference between 7 and 8 was noticeable in terms of starting pressure and being comfortable falling asleep. I'm probably going to bump that back up to 8.

Last night my AHI was lower, but I had more leaks.

Looking through other threads, I found the user flag setting and turned that on. Not sure what I'm looking at with that, lol.

Are there any areas I should be investigating more carefully? Will a sleep doctor look at the flow limitations? My original study and script came from my PCP. Since I've still been tired and had something weird going on, she referred me to the actual sleep neurology clinic. It has been a long wait, and I want to make sure I make the most of it when I get in there.

I attached last night. I had to take a nap yesterday before changing the settings, so zoomed over to just the night part. I also included the the first CA, which happened before leaks started, and a cluster of the UF events.

Thanks all! I really appreciate the help!

Thanks for the help.

[menmh]

It occurs to me it might helpful to show what I mean by things went crazy last year. Here is my AHI overview from my entire time using cpap.

[SeePak]

menmh
 
thanx for the Overview, get a lot of info from that!

seeing how the CA events became prevalent as well as OA, i would bet that EPR was turned on, probably to 3 and your min. max pressures were not adjusted up to reflect that, so you had the obstructive events.

I am just looking at your other data you posted, will comment shortly......

Looks like you are mouth breathing in your Leak Chart.
The leak goes up and then flattens out.
The flow rate chart will show a narrowing as well, however you have a very wide range on your flowrate chart.
Could you adjust that for -100 to +100 ?

What is UF2 on your Event Chart?

Dont need to see the Zoom unless someone asks for that, I know you want explanation for some of those things, no problem, lots of resources on the WIKI site for that, will give you some links in a bit. ( I now include below in my signature )

Also, i have some links you could check out below my post. I will be including more as i get this setup.

Edit:  I think you could use 7cm min.  to 10 cm max, or even 9 cm max. 
Mouth breathing and leaks could go down once you find the lower pressures that work.
Just gotta try and see how your charts respond, and how you feel after a few days.

[DaveSkvn]

There are pretty clear signs on your detailed flow rate graph of flow limitations - even when its as zoomed out as it is (you can zoom-in in Oscar by right-clicking on the word "Flow Rate" at the left and selecting option "y-axis" and setting "override" and -40 to +40).

   

Will a sleep doctor look at the flow limitations? Probably not. They are geared up to treat OSA which is managed using the AHI. Once the AHI is in range (less than 5) they typically disengage. Insurers accept OSA exists using the AHI so will provide payment when it is detected. Anything else to do with sleep will require hard work by the doctors to get the insurers on board.

If you have daytime sleepiness because of the flow limitations but with AHI < 5 you will be classed as suffering from "UARS". As this video points out there is no definitive test for UARS so getting insurers engaged will be a struggle. 

https://www.youtube.com/watch?v=HCiPtQhN9uk

There is no academically rigorous proof that flow limitations lead to poor sleep/daytime sleepiness. See this from 10 years ago:

https://www.sciencedirect.com/science/ar...0516#f0015

Its just that many people have found that taking action to reduce them leads to being more alert during the day.

As I said the things people find useful: soft foam surgical collar & EPR (with bi-level machine for more effect). But as SeePak points out, EPR can lead to CAs.

[menmh]

Thanks again for the help. I'm still getting used to the etiquette of this particular board. I've attached a full view of last night with the UFs turned off (I'm not really sure what they are looking at, events less than 10 seconds maybe?)

I think I'll keep the setting for a couple of nights and see if I can do better with the leaks, and then trial different settings. 

DaveSkvn -- that video was very helpful. I will be watching some more from him soon! The paper was also interesting. I actually had preeclampsia with my oldest, so to see there might have been link was fascinating. I wish they had explained why they chose post-menopausal women for the first part of the study though.

The DME thought I may have started mouth breathing at night, and suggested the full face mask. Is mouth breathing still an issue with the full face mask? 

I'll be seeing a sleep doctor at a major university/teaching hospital. Maybe I'll get lucky and have an eager med student or new resident who wants to figure out all the things, lol.

[SeePak]

mnmh

In my experience, i am much better with LESS mouth breathing using the FFM.

I believe it is better due to the pressure helps keep mouth closed possibly, but also for Hi Loop gain individuals, i think there is a dilution aspect going on.
Depending how much tolerance to 'air hunger' or CO2 buildup you have, the FFM provides some re-mixing which helps keeping you breathing cause CO2 levels dont drop as much.

I think your mouth breathing will decrease once the pressure is optimized.

Are you aware of proper tongue position, roof of mouth, just behind front teeth?

Just doing that all day will help a lot, i did me.

I have nights with NO mouth breathing now.

Also, i really do believe that LEAKS are almost exclusively mouth breathing, unless you really have issues keeping the mask set and aligned on your face.

I dont think you need to put much into adjustments, but you can check WIKI for mask adjustment procedure and all kinds of pertinent info, see bottom of my post and signature.

Not too tight when you put it on, pressure will make it tighter when pressure is started.

Looking forward to seeing your results improve!

EDIT:  BTW, somehow you have too large of an image, missing the bottom left of your sleep details?
Would be real good to see Tidal volume either there and/or on a chart.

[menmh]

Thanks SeePak. I've only had the mask for about 2 wks and it is much bigger than I'm used to. I'm a bit of an active sleeper, so that might be playing into the leaks. When I got fitted for this mask, the therapist recommended putting my hand on my cheek beneath the strap to avoid over-tightening, but I think I will go through the suggested steps in the wiki to make sure it seems right.

I don't really think about tongue placement during the day, but I see how that could make sense. One of the other videos by the doctor in the one that DaveSkvn recommended has exercises. I may give those a try too. https://www.youtube.com/watch?v=wNscQ3bG...vj&index=6