Flow rate shape question

[gadgetmaniah]

Hello,

I've noticed that I experience a number of the flow rate shape that you can see in the attached screenshots in my sleep. Just wanted to ask - are these events that the machine is not classifying? Or maybe they're arousals?

Thanks

[gadgetmaniah]

A thought just occurred to me - could it have something to do with my EPR settings? I've noticed that my sleep was better with the Dreamstation even though I have the same pressure settings on both. On the Dreamstation I had A Flex either on 2 or 3. Perhaps it could be that the EPR of 3 that I have on the Resmed is delaying my inhalation? I could try turning it down to 2 or even 1.

[Dog Slobber]

Not one of those "events" last 10 seconds or more.

By definition, they aren't events and should not be flagged.

[gadgetmaniah]

Right, thanks. I imagine that they could still disturb your sleep though, especially if they are borderline events. I've been having very poor sleep since the past four to five days and this is only thing out of the ordinary that I could pinpoint in my OSCAR data. I do have quite a number of these throughout my sleep.

[Pugsy]

OSCAR doesn't do any flagging. OSCAR only reports what the machine reports, records, flags.

Those are very minor changes in flow rate and instead of being the cause of an arousal I think most are a symptom of an arousal.

At any rate....give reducing EPR a try. When you reduce EPR you effectively increase the average baseline pressure a little bit and that is what would be advised IF (big if) the "events" were real asleep airway flow reductions that just didn't quite make it to some sort of event category because of the 10 second minimum.

It's hard to give an apples to apples comparison between Flex and EPR because one (Flex) is more of a timing thing and the other (EPR) is more of an actual regular drop but it wouldn't hurt to try different EPR settings and see if it helps or not.
Exhale relief Settings aren't equal....setting of 3 on DreamStation doesn't automatically give you the same drop that EPR of 3 does and it's hard to explain but the timing of the drop with the DS can vary a bit with the force of your own breathing so you might not get a full 3 cm drop like you do with EPR set to 3.

Very minor differences but differences nonetheless.

Then there is always the "we don't sleep the same every night" variable for any number of reasons.

[gadgetmaniah]

OSCAR doesn't do any flagging. OSCAR only reports what the machine reports, records, flags.

Those are very minor changes in flow rate and instead of being the cause of an arousal I think most are a symptom of an arousal.

At any rate....give reducing EPR a try. When you reduce EPR you effectively increase the average baseline pressure a little bit and that is what would be advised IF (big if) the "events" were real asleep airway flow reductions that just didn't quite make it to some sort of event category because of the 10 second minimum.

It's hard to give an apples to apples comparison between Flex and EPR because one (Flex) is more of a timing thing and the other (EPR) is more of an actual regular drop but it wouldn't hurt to try different EPR settings and see if it helps or not.
Exhale relief Settings aren't equal....setting of 3 on DreamStation doesn't automatically give you the same drop that EPR of 3 does and it's hard to explain but the timing of the drop with the DS can vary a bit with the force of your own breathing so you might not get a full 3 cm drop like you do with EPR set to 3.

Very minor differences but differences nonetheless.

Then there is always the "we don't sleep the same every night" variable for any number of reasons.

Thank you for the reply. So I tried turning EPR off today, my sleep was not too bad but I can still see a lot of these arousals in my sleep. Do you think I should just ignore them? I'm not sure whether they are causing any problems or not as, though my sleep has improved a lot, I still haven't had the feeling of waking up completely rested and with the feeling that I've had a full night's sleep yet.

And I guess there would no way to treat these arousals anyways? I seem to experience them both during lower pressures and higher pressures so it doesn't seem to be related to my pressure settings.

[Pugsy]

guess there would no way to treat these arousals anyways? I

Depends on what might be causing the arousals whether or not you stand any chance of "treating" them.
If related to airway issues there is a chance that cpap can help but if they are spontaneous arousals and unrelated to the airway then cpap won't/can't fix them.
This is something we just have no way to know for sure what is the cause and that makes fixing them really difficult.

I still haven't had the feeling of waking up completely rested and with the feeling that I've had a full night's sleep yet.

Well....the one thing that really stands out to me is hours of machine use and I assume sleep.
The hours are short.....or are you just doing sleep sessions and keeping total hours separate because you turn off a session?
There's missing stuff on those reports and the calendar is hiding part of that missing information.
Turn off the calendar.

How many hours of sleep are you averaging?
Are those hours fragmented with very many wake ups?

Can you post the Statistics page for us to look at?

Aug 7 shows 4 hours and 35 minutes of use. 00:16 to 4:51
and then 3 hours and 48 minutes. 18:42 to 22:30
So are you having trouble staying asleep?
What did you do between 22:30 and 00:16?

Maybe you just have crappy sleep but not necessarily from airway issues and that is why you don't feel as rested as you want or expect...and of course maybe there's something else going on totally unrelated to the airway or sleep.
Maybe it's going to take months and months to actually feel as rested as you want and if the reason is poor sleep in general and not fixable with cpap....maybe expectations are a bit high.

There are lots of reasons people don't get good quality sleep that aren't related to the airway at all but they sure expect cpap to fix the problem when it really can't. It only fixes airway issues.
You are improved over without cpap....you admit that....you just want more and I don't blame you but maybe you need to investigate your sleep itself.
How come such a break between 22:30 and 00:16?

[gadgetmaniah]

Thanks for the reply!

Yes I think I do need to work on getting uninterrupted sleep. The gap that you point out - I think I naturally woke up at 22:30 (the timing is wrong by the way, I haven't fixed it yet - it was actually about 7 or 8 AM). I then had to do my morning prayers and then I spent some time on my laptop. One thing that I'm experiencing with the CPAP is that I get up much earlier than I used to, usually after around 6 hours of sleep, and I can't sleep more even though I have the feeling of lingering sleepiness. It goes away in a couple of hours. I have read about other people experiencing this too.

For example, today I got more than 6 hours of uninterrupted sleep. I woke up feeling alright - somewhat sleep deprived as usual and a little bit of tiredness - but then I felt a need to take a nap. So, after a couple of hours of being awake and having lunch I almost fell asleep in my bed but then my drowsiness just disappeared. I don't why this happens but this happens frequently with me.

The other thing is that I was still experimenting with different pressures with the Resmed. RIght now I've set it to 4-10 cm since I've noticed that my pressure remains on average around 6, which means that I don't necessarily need the higher pressure of 9 that I was using on the Philips. Also, I experimented using an older mask (Quattro Air) because I don't like the air flow of my current mask too much (BMC mask) but for some reason the Quattro Air gave me extremely poor sleep despite a normal AHI. It felt like I wasn't using even using a CPAP after waking up - I had been on bed most of the day for the past two to three days due to the tiredness. I've now started using the BMC mask again and the sleep is returning back to normal. I have also ordered a Contec pulse oximeter to see if my oxygen levels are stable during sleep.

I have also attached my statistics page. Note that the usage is 83% for the past month because on three or four days I used my Philips machine and had given my Resmed machine to my mother to test it on her.

By the way, I have also been thinking of getting a sleep study done. I think like I should make sure what the exact problem I have. Perhaps it's something like a low or borderline AHI but significant oxygen desaturation, or something like that, because I notice that I don't experience many obstructive events even at low pressures and they're usually they're the result of an arousal. On the other hand, I do feel much better on the CPAP (without it I could barely get out of the bed) so I do know that there is some problem that it is treating. I guess it would be useful to know what exactly the problem is though.

[Pugsy]

Overall average machine use is roughly 6 1/2 hours and by your own admission most of the time the use is fragmented.
Maybe you just need more sleep and less fragmentation. I do know that is easier said than done....believe me I know because I am battling similar issues.

Google "sleep stages" and look at the normal hypnograms and watch the progression into each sleep stage.
Maybe due to the fragmentation you aren't getting enough deep sleep or REM sleep.....

[gadgetmaniah]

Right, I see. I'll check this out. Thank you.

[gadgetmaniah]

OSCAR doesn't do any flagging. OSCAR only reports what the machine reports, records, flags.

Those are very minor changes in flow rate and instead of being the cause of an arousal I think most are a symptom of an arousal.

At any rate....give reducing EPR a try. When you reduce EPR you effectively increase the average baseline pressure a little bit and that is what would be advised IF (big if) the "events" were real asleep airway flow reductions that just didn't quite make it to some sort of event category because of the 10 second minimum.

It's hard to give an apples to apples comparison between Flex and EPR because one (Flex) is more of a timing thing and the other (EPR) is more of an actual regular drop but it wouldn't hurt to try different EPR settings and see if it helps or not.
Exhale relief Settings aren't equal....setting of 3 on DreamStation doesn't automatically give you the same drop that EPR of 3 does and it's hard to explain but the timing of the drop with the DS can vary a bit with the force of your own breathing so you might not get a full 3 cm drop like you do with EPR set to 3.

Very minor differences but differences nonetheless.

Then there is always the "we don't sleep the same every night" variable for any number of reasons.

Sorry for all the questions, but I just wanted to ask whether whether these arousals could be indicative of something like UARS? I'm guessing not, because it doesn't seem like that they're respiratory effort related and, as you say, they seem like symptoms of arousals. Just wanted to address this doubt I had in my mind.

[Pugsy]

For it to be UARS there has to be airway related arousal and to have an arousal we first have to have for sure sleep.
Unfortunately the subtle changes in the airway that might indicate UARS really can't definitively be seen on the data we can get from these machines. They were never designed for UARS treatment or detection.
Often we try to put this stuff under the microscope and see stuff that it really can't show us definitively.
Since these machines can't for sure even tell us if we are asleep which is a critical component needed to document UARS related arousal....we just don't know and don't have anyway to know with certainty if UARS is involved or not.
We can make educated guesses based on the data we have, which is limited...but that's about it.

The best these machines can do is the RERA flag which is the machine's educated guess based on the documented flow rate from people who have had in lab sleep studies that show definitive breathing patterns that follow a respirator/airway related arousal. When you see a RERA flag...it is saying that the breathing "looks like" breathing known to be associated with some sort of respirator related event/arousal. It can't say for sure because it doesn't know if you are asleep or not and being asleep first is a critical component of the definition.

The presence of a lot of RERA flags doesn't mean for sure UARS but it does raise suspicions.
The absence of a lot of RERA flags doesn't mean for sure a person doesn't have UARS either but I would lean towards no UARS if we aren't seeing many RERA flags.
Mainly because spontaneous arousals are much more likely to be the culprit anyway.

If you do have UARS at work here...not much you will gain by looking at the data the machine gives you because it really was never designed for UARS stuff. The auto adjusting algorithm isn't a good tool because it is designed for the reductions in air flow that go along with OSA and not the very subtle minor changes that go along with UARS. The cpap machine won't/can't deal with UARS stuff in terms of pressure changes.
You would have to just go with manual changes and rely on subjective feelings because the data from the machine isn't going to help. Subjective feelings is really hard to go by. We aren't used to it because we are used to relying on numbers for verification of anything.

Historically though....if UARS is involved there is a high likelihood that you will need a much higher baseline pressure than you are using or the machine in auto mode will think it needs to deliver.
I know one woman with documented UARS (sleep lab study with Pes device and then another cpap titration sleep study with Pes device) found she need 13 cm baseline pressure to deal with the UARS effectively but the machine was only going to 8 cm and her AHI at 8 was less than 1.0. This isn't the first time I have heard this type of scenario but is is the most detailed and remarkable that I have heard of.

Historically all UARS patients seem to need a lot more pressure to resolve unwanted symptoms.....and these are people who have documented UARs.
First thing obviously though...document UARS which isn't easy.
Or make plans to do a prolonged detailed titration of your own keeping a very detailed log of the experiment with very gradually increasing the pressures over a period of several weeks and giving each setting at least a week....
And the realization that none of all that is guaranteed to resolve your issues.
BUT....you got nothing but time on your hands anyway. Why not give it a try?
Bear in mind that with higher pressures comes the usual problems that higher pressures might cause...aerophagia would be the main one. Exhale comfort would be another and increased difficulty managing leaks and all of those also can cause sleep quality problems and potentially arousals. Damned if you do and damned if you don't kind of thing.

[gadgetmaniah]

Thanks for the detailed reply! I really appreciate it!

Yes, I think I will try increasing the pressures gradually to see what works for me. I have tried a baseline pressure of 9 for about a week or so (and even 10 for a couple of days) and I didn't experience much improvement, so now I'm jumping directly to a pressure of 12 cm. Let's see if this improves my sleep.

One of the reasons I feel my problem might be related to UARS/RDI related stuff is that my AHI has always been low. If I set my minimum pressure to 4, my average pressure only remains around 6 and sometimes late fives which gives a pretty low AHI reading. I have also noticed that a lot of the apneas and obstructions that I do experience, including the mini apneas that I have asked about in this thread, actually seem to happen following short arousals- which again we have no way to make sure are spontaneous or respiratory effort related.
Unfortunately I haven't had a sleep test and I'm pretty sure that they don't score RDI here in Pakistan (since I've read that even in the US many sleep labs don't). But anyways, let's see if increasing the baseline pressure has any positive effects.

[gadgetmaniah]

Hello,

I just wanted to share some more images which might be relevant. What's strange is that my sleep wasn't too bad with the CPAP until about a week ago. I am now regularly waking up very fatigued. There could be some other factors at play but I am not sure. I am not taking any medications.

I am attaching some screenshots of flow rate graph which I think look flow limited. The machine has marked them flow limited a few times. I'll also post some examples from my Resmed.

I have also noticed, especially looking at my older data, that my respiration rate looks quite erratic. I could post examples if needed. Looking at my older data, I can see that a lot of my breaths look flow limited with flat/almost flat shapes or erratic shapes with two little curves.

Now as you said it is pretty difficult to give a clear answer to whether I am experiencing something like UARS, but I wonder if this data can give some suggestion.

[gadgetmaniah]

From my Resmed data. I know the machine hasn't marked much flow limitation, but I wonder if, looking at the individual flow rate curves, there is flow limitation evident that might be the reason for my unrefreshing sleep.

Do you suggest that I try increasing my minimum pressure gradually to see if that fixes or improves the problem? Note that I did try a min pressure of 12 on the Resmed but that did not help and I woke up feeling even more fatigued.

Also, I have a couple of additional questions. Is it possible that I need a BiPAP to treat this problem? I have read that flow limitations are treated by Pressure Support and EPAP (though I don't think the machine that offers pressure support - the VCurve Auto - is available here). And, would it be worth consulting with an ENT to see if there are any significant structural problems that could be causing troubles with flow?