ESP was supposed to fix my sleep apnea but it made it worse

[Unkikonki]

I'll try to keep this as concise and fact-based as possible, so feel free to ask clarifying questions if needed.

It's been 9 months since I had ESP (Expansion Sphincter Pharyngoplasty) done, and not only have I not experienced the slightest improvement, but I now cannot even fall asleep without ASV. As I relax and start to fall asleep, there seems to be significant resistance during inhalation. My breathing becomes more shallow until I need a big corrective breath that wakes me up. I do not think this is central sleep apnea as this didn't happen before surgery. Sure, the quality of my sleep was terrible if I slept without ASV, but I could at least fall asleep. If feels like ESP somehow made the obstruction worse.

Has anyone had a similar experience? What do you think I should do next?

OBSTRUCTIVE SLEEP APNEA DIAGNOSIS AND TREATMENT TIMELINE:

March 2023: Initial diagnosis - PSG L2. AHI 26.6
June 2023: Bilateral turbinoplasty + septoplasty
July 2023: Transoral biopsy of uvula lesion (probably pointless)
September 2023 to January 2024: CPAP (ResMed AirSense 10 AutoSet APAP)
January 2024 to present: ASV (ResMed AirCurve 10 CS PaceWave). I had to switch to ASV due to treatment-emergent sleep apnea that didn't resolve on its own.
March 2025: ESP surgery (surgeon predicted a 75% chance of success since he suspected lateral pharyngeal wall collapse as the main cause of obstruction)

FAQs

Have you seen your surgeon after surgery?

Yes. I didn't raise any concerns at the time because I was still using ASV with good results and hadn't attempted to sleep without it.

Have you done another sleep study after surgery?

I'd like to, but how am I supposed to do a sleep study if I can't fall asleep?

Any other relevant information?

My surgeon noted that my epiglottis is V-shaped. He thought this was due to lateral pharyngeal wall collapse, but it's possible he was wrong and that epiglottic collapse is actually the main obstruction

What my gut tells me:

Enough guessing or sloppy diagnosis based on questionable techniques that cannot truly replicate what causes sleep apnea. I think a DISE (drug-induced sleep endoscopy) is the best next step to properly identify what is actually causing my sleep apnea.

[ChicagoGranny]

If you still have your AutoSet machine, use it for one night. Get a free account at SleepHQ.com, upload your data, and then post the link in this thread. I'm skeptical that you have treatment-emergent central apnea.

[Unkikonki]

If you still have your AutoSet machine, use it for one night. Get a free account at SleepHQ.com, upload your data, and then post the link in this thread. I'm skeptical that you have treatment-emergent central apnea.

I was renting the machine but I can share the old data if that helps.

Why are you skeptical? It's a rather common side-effect of CPAP.

[ozij]

Why are you skeptical? It's a rather common side-effect of CPAP.

https://journal.chestnet.org/article/S0 ... 2/abstract
Treatment-Emergent Central Sleep Apnea

TECSA is a “dynamic” process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients.

https://link.springer.com/chapter/10.10 ... -57942-5_8
TE-CSA affects roughly 5–10% of OSA patients treated with continuous positive airway pressure (CPAP) and is associated with conditions that predispose to central sleep apnea including heart failure, atrial fibrillation, and opioid use. The trajectories of TE-CSA vary, with resolution occurring in about 50%, persistence in 25%, and late development (weeks after CPAP initiation) in another 25%.

Let's say it happens in 10%, even 15%. Persists in 25% of those 15%. Let's call that roughly 4% of the total population of CPAP users.

Do you consider 4% common?

Those of us who've been hanging in here long time really prefer to see data before we say anything.

Have you done another sleep study after surgery?

I'd like to, but how am I supposed to do a sleep study if I can't fall asleep?

The study will show why you can't fall asleep.

[Unkikonki]

Why are you skeptical? It's a rather common side-effect of CPAP.

https://journal.chestnet.org/article/S0 ... 2/abstract
Treatment-Emergent Central Sleep Apnea

TECSA is a “dynamic” process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients.

https://link.springer.com/chapter/10.10 ... -57942-5_8
TE-CSA affects roughly 5–10% of OSA patients treated with continuous positive airway pressure (CPAP) and is associated with conditions that predispose to central sleep apnea including heart failure, atrial fibrillation, and opioid use. The trajectories of TE-CSA vary, with resolution occurring in about 50%, persistence in 25%, and late development (weeks after CPAP initiation) in another 25%.

Let's say it happens in 10%, even 15%. Persists in 25% of those 15%. Let's call that roughly 4% of the total population of CPAP users.

Do you consider 4% common?

Those of us who've been hanging in here long time really prefer to see data before we say anything.

Fair enough. Could you check the data below from when I was on CPAP please? No flow limitations, yet 15–30-second periods of no breathing at all, multiple times throughout the night. Are you going to tell me those don't look like centrals? Turning EPR off reduced the number of events a bit, but they were still quite persistent and were destroying the quality of my sleep. In fact, sleeping with CPAP at the time made me feel worse than no CPAP.

The study will show why you can't fall asleep.

Could you elaborate on this? To what extent can a sleep study reveal this? Will it only show whether it's OSA, central or RERA?

[Pugsy]

All those central flags you see.......they aren't the cause of the poor sleep...they are a symptom of your poor sleep.

Those are NOT real asleep central apneas....they are post arousal awake pauses in breathing that earned a false positive central flag.
They are NOT treatment emergent central apneas.

Now why you aren't sleeping so great....million dollar question but it's not because of any central apneas.

[Unkikonki]

All those central flags you see.......they aren't the cause of the poor sleep...they are a symptom of your poor sleep.

Those are NOT real asleep central apneas....they are post arousal awake pauses in breathing that earned a false positive central flag.
They are NOT treatment emergent central apneas.

Now why you aren't sleeping so great....million dollar question but it's not because of any central apneas.

I've never heard of post arousal awake pauses and a quick google search didn't reveal much. Would you mind elaborating please? Where can I read more about it?

Also, I've been sleeping very well since I switched to ASV. Those events you described as "post arousal awake pauses" completely disappeared when I switched from CPAP to ASV, so whether those are actually centrals or not, my decision proved correct. My current enquiry is about not being able to fall sleep without CPAP/ASV after ESP surgery (Expansion Sphincter Pharyngoplasty) though.

[Pugsy]

Would you mind elaborating please? Where can I read more about it?

Sorry, but I don't have the time or energy to repeat what I have said in the past to explain post arousal central apneas.
I have been extremely ill and still not doing well but I have explained it in great detail a gazillion times in the past so take some time and just read what I have posted. The data is out there though....keep looking.

The ResMed ASV machine won't flag centrals.....it dumps any centrals or OAs in the unidentified basket. If you aren't seeing much in terms of UAs being flagged then if there aren't any centrals then it doesn't really matter what cpap showed since you aren't using cpap anymore.

I have zero experience with the procedure you opted to have...sorry. If you are still having trouble sleeping then maybe you need to look elsewhere for whatever the problem might be.

Again.....talk to your medical care team about your problems.

[zonker]

I've never heard of post arousal awake pauses and a quick google search didn't reveal much. Would you mind elaborating please? Where can I read more about it?

try Google with the search terms "post arousal central apnea".

[Unkikonki]

I've never heard of post arousal awake pauses and a quick google search didn't reveal much. Would you mind elaborating please? Where can I read more about it?

try Google with the search terms "post arousal central apnea".

Thank you. If I understand correctly, the difference between central apnea and post-arousal central apnea (APAC) is that the latter is triggered by an arousal (flow limitation, leak, movement, etc).

There does seem to be a big swing in my breathing before the event, but I'll have to look at the data more carefully to see if that's what happens before a cluster begins. There's also a bit of leaking, although I'm not sure if it's significant enough to trigger APAC.

I'm now using a P10 with perfect sealing (almost no leaking at all). What I could do is set my ASV to CPAP mode for one night and match the pressure to my current EPAP. I'm not sure how useful that would be though, since ASV is working wonderfully for me. What I really want to understand is why I can't fall asleep at all without ASV after ESP.

[zonker]

Thank you. If I understand correctly, the difference between central apnea and post-arousal central apnea (APAC) is that the latter is triggered by an arousal (flow limitation, leak, movement, etc).

unfortunately, i'm not wise enough to help with your problems. I just know how to Google.

[ChicagoGranny]

Which drugs/dosage/timing? Caffeine?

[ozij]

It's been 9 months since I had ESP (Expansion Sphincter Pharyngoplasty) done, and not only have I not experienced the slightest improvement, but I now cannot even fall asleep without ASV.

Also, I've been sleeping very well since I switched to ASV.

Then why attempt to sleep without it?

My current enquiry is about not being able to fall sleep without CPAP/ASV after ESP surgery (Expansion Sphincter Pharyngoplasty) though.

Could you elaborate on this? To what extent can a sleep study reveal this? Will it only show whether it's OSA, central or RERA?

Some people's sleep is disrupted by breathing problems. There are all kinds of breathing problems that will impact sleep. In your case, it's possible that once the obstruction in you airway were taken away, and you could finally reach deeper stages of sleep, other problems appeared, and those are taken care of by ASV.
Other people suffer from disrupted sleep caused by issues that have nothing to do with breathing.
Pain, stress, ambient noise, to much screen use before sleep , caffeine, all kinds of medications, including opioids and anti-depressants, restless legs syndrome, and what have you.

A sleep study can reveal what is disrupting a person's sleep whether it's breathing related, or not.

However, if you're sleeping well with ASV that's wonderful. Why not let things be? Is it that you expected ESP to let you sleep without a machine, and now you're disappointed? That's understandable, but it's possible that taking care of that obstruction revealed a problem that ASV can solve for you.

You can sleep, and sleep well - though you do need a machine to achieve that.

[Unkikonki]

Then why attempt to sleep without it?

Because that was the point of having ESP done in the first place, to be able to achieve restful, high-quality sleep without the need for a machine, which is extremely inconvenient in many ways. I also ended up going for ESP out of desperation, as not even ASV was being effective at the time. Paradoxically, I finally found a way to achieve consistent, effective sleep on ASV once I realised that the ESP procedure had been in vain and that I had no choice but to stick with ASV.

Other people suffer from disrupted sleep caused by issues that have nothing to do with breathing.
Pain, stress, ambient noise, to much screen use before sleep , caffeine, all kinds of medications, including opioids and anti-depressants, restless legs syndrome, and what have you.

A sleep study can reveal what is disrupting a person's sleep whether it's breathing related, or not.

I seriously doubt that my issue is caused by anything other than a breathing disorder. I'm fit, athletic, not under an unbearable amount of stress, keep my caffeine intake under control, take no medications, have no other conditions...

However, if you're sleeping well with ASV that's wonderful. Why not let things be? Is it that you expected ESP to let you sleep without a machine, and now you're disappointed? That's understandable, but it's possible that taking care of that obstruction revealed a problem that ASV can solve for you.

You can sleep, and sleep well - though you do need a machine to achieve that.

Correct, I was expecting ESP to allow me to sleep without the machine. Now, the fact that I cannot even fall asleep at all without ASV is very concerning, as it makes me 100% dependent on ASV. I'm grateful that ASV is working well, but to me CPAP/ASV should never be a permanent solution, or at the very least, not the only option to achieve decent sleep.

It seems to me that a DISE is the only way forward. I'll discuss another sleep study prior to DISE once I see my surgeon next month.

[ChicagoGranny]

I cannot even fall asleep at all without ASV is very concerning

This sounds like a strong fear of falling asleep without the machine. You might want to experiment with some relaxation techniques or even ask your doctor for a mild sedative for temporary use.

Your ASV is not designed to help you fall asleep. It's designed to keep you breathing when you do fall asleep.