New to CPAP, Need help reading OSCAR data

[spaceodyssey]

Hello everyone. I am a 22 year old female new to all this. Let me simplify as much as I can.
I was diagnosed with Obstructive Sleep Apnea with an AHI of 9.4 and an RDI of 17.7. Per Dr. advice, have been using an Autoset Resmed 10. It has been 4 nights and have gotten my AHI down to 0.5 (yay!). The problem is that I am still feeling super foggy with tired eyes. I understand that this could very well be cause I’m new to treatment and need to give it time. But I’m worried I have UARS and am treating it wrong, although I’ve read CPAP can help this. Technically, I know I do not meet the diagnostic criteria for UARS and am just calling those smaller apneas that for a lack of a better word. (Flow limitations?) The reason I think I may have UARS is due to my high RDI. I know RDI = AHI + RERAs. Considering my AHI has gone down 8.9 per hour, this means my RDI has gone down to 8.8 per hour. This is still a nasty amount of arousals potentially disturbing my sleep. Or am I mistaken, and I am not suffering of arousals as much as I think I am?.. Well, that is why I have attached images of my OSCAR data from last night. Essentially, what I'm looking for it flow limitations that have ended up in an arousal or RERAs. I just do not understand how to read this at all.

It would mean SO MUCH if someone could read/analyze my data for me, point me at any RERAs or flow limitations, anything that could be causing my fatigue, and maybe give me some pointers about adjusting my pressure. It is currently set to 6cm-20cm, soft setting is on, I use a pillow mask. I have seen some people online suggest turning on EPR (it's currently off) to take care of RERAs or other leftover arousals. Should I turn on EPR? I also wanted to note that since starting treatment, I am still waking up 2-4 times a night to use the restroom. Again, thank you. I am doing this to better understand this and myself.. and I really cannot afford another machine (perhaps a bilevel).

[Julie]

Do you take any medication? Have you looked up side effects (the kind affecting sleep)?

Your chart looks pretty good, but others with more knowledge of Reras, etc. should be along to comment on those.

[spaceodyssey]

I am not taking any medications.
Does my flow chart look normal? Are all those spikes, arousals? I thought a good flow rate was to be lacking of any spikes. So many questions, I'm sorry.

[Pugsy]

Are all those spikes, arousals?

Are you talking about the flow limitation graph???
If so...no those aren't arousals. They are just evidence of flow limitations.
You aren't having any RERAs (RE line at the bottom of the events graph) and you would be seeing those flagged if you had any arousals related to respiratory effort.
I doubt UARS because of the lack of RERAs to speak of.
But even if you do have some UARS going on...cpap is still what is used to deal with it.

Are you experiencing any nasal congestion at all? That could cause the increases you see on the flow limitation graph.

Nasal congestion can cause ugly flow limitation graphs but we can't fix nasal congestion with little tweaks of the machine.
CPAP machines can reduce flow limitations that occur in the airway below the nasal cavity though...either more minimum pressure or maybe adding in EPR.

How many times do you think you are waking up during the night?

Waking up 2 to 4 times a night for a 22 year old female....not normal. Do you have to pee frequently during the day as well?

How many hours of sleep (not just laying in bed but awake) do you think you are getting on average?

[spaceodyssey]

No, I'm talking about the flow rate graph.
As for the congestion, I sometimes wake up with one nostril congested but honestly it has stopped happening as much since starting CPAP.
I do have to pee a lot during the day. Didn't realize it was odd for someone my age to wake up to use the restroom in the middle of the night so much!
As for your last question, I fall asleep pretty fast once my head hits the pillow - so I probably truly sleep 6.30 hours to 7.00 on average

[Pugsy]

Arousals can't be seen on the flow rate graph in the big picture you shared....you need to be zooming in up real close to look for arousals.

The "spikes" you see....not arousals most likely but just a change in the breathing pattern. Like a big breath or something when turning over or sleep stage change.

Now the flow limitation graph...it's fairly active and could potentially be a factor in less than optimal sleep quality.
Enough flow limitations going on can disrupt sleep.
For this reason I suggest making ONE CHANGE right now and that is turn on EPR and set it to full time at 3.
See how you do with it.

Take a stroll though this thread.
viewtopic/t186231/Examplesmouth-breathi ... gging.html

If you have to pee a lot during the day...might be overactive bladder situation.
If this continues you probably should be talking to your doctor. You aren't having enough real apnea events to cause that many awakenings during the night. We can talk about that later. I just don't see how what little you have going on could cause that much nocturia and with the history of a lot of daytime peeing...makes me think something else is going on.

There is an online program called SleepHQ....there is a free version and a paid for version.
Get the free version and post a detailed report....it will allow us to zoom in on the flow rate to look for evidence of arousals. You could very well be having some arousals but they aren't related to respiratory issues causing them because we aren't seeing any RERAs being flagged to speak of. You can have arousals from any number of things...like waking up with a full bladder and needing to pee. I always have a lot of arousals but mine are from pain issues. I might remember 4 or 5 arousals/awakening but if I zoom in on my flow rate (which is your breathing) I can usually count 10 to 20 arousals.

Here is an example of where I had some asleep breathing and some arousal/awake breathing.
I circled the asleep breathing in red.



and another not so zoomed in on of the same time frame.
Asleep breathing again circled in red.

[Lucky7]

"For this reason I suggest making ONE CHANGE right now and that is turn on EPR and set it to full time at 3"

One question if I might ask: because there is a lot of conflicting information about this.

How does EPR fix flow limitations? Isn't it basically the same thing as pressure support on a Bi-Level machine?

Thanks

[Pugsy]

"For this reason I suggest making ONE CHANGE right now and that is turn on EPR and set it to full time at 3"

One question if I might ask: because there is a lot of conflicting information about this.

How does EPR fix flow limitations? Isn't it basically the same thing as pressure support on a Bi-Level machine?

Thanks

There are multiple ways to try to fix/reduce flow limitations assuming not nasal membrane in origin.
1. Add in EPR if not being used or increase it if it is maybe used at a lower setting.
And yes....EPR sort of functions like pressure support on a bilevel machine except EPR decreases the EPAP and PS increases the epap with each breath. End result is we use 2 distinct pressures with either. Splitting hairs really. It's not technically the same thing but that is what we end up doing. We used to call EPR on the ResMed cpap/apap machine the poor man's limited bilevel.
2. Increase the minimum or base pressure.
3. Various items to alter the airway positioning...soft cervical collar comes to my mind.
Sometimes people experiment with sleeping position.

How does using EPR (creating a bilevel situation) reduce flow limitations? Beats me....doesn't compute in my mind that a drop in pressure upon exhale (without an off setting increase in the baseline pressure) can hold the airway open better.
It defies logic (at least to me) that it would work but I have seen proof with my own eyes so I accept it as an option.

Adding in EPR can also cause other improvements. It's a very easy fix, simple to do and with the exception of potentially causing an increase in central apneas it won't hurt anyone. Sometimes we have to adjust the baseline pressure to offset that drop but I don't advise it until I see a need because sometimes it's not needed.
The number of people who have a problem with EPR is extremely small...like maybe 2%. Risk is tiny and potential for rewards is great.

[spaceodyssey]

Pugsy, here are my graphs for last night with a minimum of 7 and EPR of 3. I included 2 zoomed in ones where spikes were (excluding marked events) I feel the same as other days, eyes tired. To me, it the data looks worse due to more events, but what do you think in terms of arousals?

[Pugsy]

You were expecting zero arousals once you started cpap?

[Pugsy]

Your FL graph is much improved after adding in EPR.
But there seems to be an increase in the obstructive components of the AHI...not unexpected with the drop during exhale.
Probably should increase the baseline minimum pressure to compensate for the drop...maybe just a little 1 cm increase from 7 to 8 cm minimum.

Turn off the calendar and let additional information move up into the viewing area on the left side panel.

The 2 zoomed in flow rate graphs you shared....I don't see them being related to the airway reduction in air flow.
As to what caused them....no way to know.

[spaceodyssey]

Pugsy, here are my updated OSCAR results with EPR = 3 full time and APAP pressure of 9cm-14cm.
I will note that I woke up at 4am (to use the restroom), and could not go back to sleep. 6am is the time my alarm wakes me up. So rather than truly sleep 7hr35m it was probably around 5hr35. So you can ignore the last hour or two of the data, I was awake. Just like everyday, my eyes are burning. Going to use eyedrops to try to relieve this today.
PS I screenshotted 2 of the non-flagged spikes. What do you think? I am noticing that my flow limitation and snore went down. I see I'm still having flagged events such as OA and Hypopnea. Should I up my pressure? Thanks. https://imgur.com/a/tBS2ZxX

[Pugsy]

PS I screenshotted 2 of the non-flagged spikes. What do you think? I am noticing that my flow limitation and snore went down. I see I'm still having flagged events such as OA and Hypopnea. Should I up my pressure?

No...don't go changing anything else at this time. Let's use these settings for about a week and evaluate at that time.
Your body needs time to adjust to the new settings.

Most of the flagged events you see are happening during the time frame at the end of the night when you know you were awake and awake flagged stuff doesn't count.
The fix for "awake flagged events" (false positives for lack of a better word) can't be fixed with more pressure...instead we have to fix the "not being asleep" problem. Trust me...I know that is easier said than done because I have the same problem with my own sleep.

When you woke up to go pee at 4 AM did you have a painfully full bladder or what it more like "I am awake...I might as well go pee" kind of thing? I don't see what I would expect to see at 4 AM which is a break in the therapy when you would have got up and turned the machine off to go pee or if you didn't turn off the machine and let it just blow....I don't see what I would expect to see in the graphs. Did you actually get up and remove the mask to go pee at 4 AM?

Arousals.....we need to have a different discussion about your worrying about them but I don't have time at the moment to get into that discussion.

[spaceodyssey]

It was not painfully full but definitely full. As for the waking up and going to the restroom, I removed my mask but did not turn off my machine. Once I got back to bed, I put the mask back on and left the machine on.