Root cause of my OSA?

[loopib]

Hello all! I've been lurking on this forum since my OSA diagnosis in early 2017. I have so many thoughts on the sleep apnea experience that I will write down one day, but I'll say that this community is a godsend to patients like me who interact with the medical system once every few months. From the supportive and insightful advice to the open source OSCAR software, you all rock!

Some background: I'm a late 20s male, 5'9" 160lbs, with positional OSA (latest PSG shows AHI 15.3, min O2 desat 89%, almost all hypopneas, no centrals). I was originally titrated at 8 cm of H2O but purchased an APAP and have used a variable range that averages 12-13 since the beginning. A year and a half after diagnosis, I had a tonsillectomy, turbinectomy, and a UPPP. This helped a bit, especially with snoring, but full PSG done post-surgery shows similar/slightly worse numbers than initial diagnosis. I also have a fairly severely deviated septum that hasn't been fixed and a bit of an overbite, mallampati 4/fairly large tongue for my mouth. I'm a natural mouth breather at night, so I regularly tape my mouth shut now. In addition to CPAP use, I have tried custom MAD, mouth tape, chin strap, soft cervical collar, nasal splints, nasal spray, nasal rinses, side sleeping, etc. Basically everything under the sun. No matter the combination of things I use, I'm only able to get my AHI down as low as 4-5 as per my APAP, and still see O2 desats into the high 80s. I still experience brainfog/fatigue during the day.

I'm trying to determine what the root cause of my obstruction is. My understanding is that APAP works as a pneumatic stent to prevent airway from collapsing. But I'm still not able to get my AHIs to go under 4-5 despite pressures as high as 15-16. Anything higher than that, I have issues tolerating it.

My theory is: My nasal airway gets compromised at night when lying down. This causes mouth to open and tongue to fall into my airway.

If my tongue is falling into my airway, I don't imagine CPAP would help which is consistent with my experience. I'm considering getting a DISE to identify what the actual cause/site of my obstruction is. Does anyone have any thoughts on this? Much appreciated!

[idkwhatimdoing]

If you're opening your mouth wouldnt that mean you need a full face mask? I'd try that and see.

[loopib]

If you're opening your mouth wouldnt that mean you need a full face mask? I'd try that and see.

I do use a full face mask, the F10. Thanks!

[Pugsy]

What is the event category break down of that AHI that wants to run 4 to 5 ish and you wish were lower?
Maybe the kind of event you are having flagged doesn't respond to more pressure...
or maybe you simply need more pressure...15 to 16 isn't horribly high. We have people here using over 20 cm all night long to stent their airway open.

[loopib]

What is the event category break down of that AHI that wants to run 4 to 5 ish and you wish were lower?
Maybe the kind of event you are having flagged doesn't respond to more pressure...
or maybe you simply need more pressure...15 to 16 isn't horribly high. We have people here using over 20 cm all night long to stent their airway open.

Thanks Pugsy. I have attached screenshots for a few nights

[SleepyPaolo]

Your CA and obstructive event counts are similar even with no EPR. However, your flow limits are consistently high. EPR will help fix flow limits, but likely increase CAs further.
You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.
Your ventilation seems a little low, probably due to the flow limits.
If it were me, I'd try your titrated fixed pressure of 8cmH20 and EPR set to 3 for a few nights and observe the results. I'd be expecting lower flow limits and obstructive events. CAs may remain high for some time as your body gets used to the increased ventilation.

[jimbud]

You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.

Jan 31
Large Leak - 0.00

Feb 1
Large Leak - 0.00

Feb 4
Large Leak - 2.00

????

Would not bother me.

JPB

[Pugsy]

As I expected....a good chunk of the AHI is CA/clear airway apneas or central apneas.
They don't respond to pressure since the airway is open.
Some of yours flagged I see are right at known awake times and I am betting you weren't even asleep when those were flagged.
If you aren't asleep...they don't count.
We can have false positive flagging happen in any event category but centrals are quite common.
The machine only senses air flow. It doesn't have any way to know if you are asleep or not and our awake breathing can and will sometimes cause the machine to flag some sort of apnea event.

Watch the videos here.
http://freecpapadvice.com/sleepyhead-free-software

My own AHI runs around 1 to 2 most nights but I had a 4.6 night the other day. 80% awake/arousal related false positives. I have some back issues that mess with my sleep a lot.
I have seen my machine flag and respond to a couple of OAs that obviously were NOT real asleep apnea events.
So before getting in a panic about your AHI....go figure out if you were really asleep when they got flagged.
And remember....we can't do anything about centrals even if they are real.
And we don't need to unless you are having a lot more that are real then you are having now.

[Pugsy]

You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.

Huh? He had one time he was in large leak maybe 10 minutes where it went to maybe 30 L/min. The machine is still fairly accurate up to around 35 L/min and even if it was much higher 10 minutes in large leak isn't a big deal.

Unless leaks are waking the OP up...they are NOT an issue.

Your CA and obstructive event counts are similar even with no EPR. However, your flow limits are consistently high. EPR will help fix flow limits, but likely increase CAs further.

Again huh? Not everyone has EPR causing centrals...those that do are a very, very small minority.
Using EPR normally causes FLs to increase because of the drop during exhale....

I am betting the bulk of his centrals are awake/arousal related anyway.

[Pugsy]

Your Flow limitation graph is a bit active though.
Are you experiencing much nasal congestion?
You've limited your max to 15 cm and consistently your pressure graph is maxing out at 15 cm.
Flow limitations are something the machine will try to limit with more pressure and probably the main reason your pressure gets maxed out.

If you are having a lot of nasal congestion...the machine doesn't know where the FL is coming from and it will still try to increase the pressure but nasal congestion FLs won't respond to higher pressures.

If you aren't having a lot of nasal congestion you need to open the max up and let the machine try to kill those FLs....those FLs could very well be causing sleep quality problems.

I would NOT suggest making the changes of reducing the pressure to 8 and adding in EPR of 3 and expect the FLs to reduce.
All that will do is most likely greatly increase the OAs and hyponeas and make the FL graph uglier....but it's your choice.

As far as the official titration pressures....that doesn't mean much. I came out of an in lab titration with a recommendation for fix 8 cm as well but it didn't address what I need in REM stage sleep...which is in the mid teens. I didn't get much REM during the titration.
It's one night in a foreign setting where we often don't sleep so great. Sometimes they get it right but most often they don't because we simply don't sleep the same in that lab with all the wires as we do at home.

[SleepyPaolo]

You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.

Huh? He had one time he was in large leak maybe 10 minutes where it went to maybe 30 L/min. The machine is still fairly accurate up to around 35 L/min and even if it was much higher 10 minutes in large leak isn't a big deal.

Unless leaks are waking the OP up...they are NOT an issue.

Your CA and obstructive event counts are similar even with no EPR. However, your flow limits are consistently high. EPR will help fix flow limits, but likely increase CAs further.

Again huh? Not everyone has EPR causing centrals...those that do are a very, very small minority.
Using EPR normally causes FLs to increase because of the drop during exhale....

I am betting the bulk of his centrals are awake/arousal related anyway.

Increasing ventilation in people with flow limitations often causes CAs if you've been used to lower levels of ventilation. I didn't know that's rare, where have you formed that opinion from?
EPR provides pressure support for the inhale which helps with flow limits, it certainly does in my case and most that I've seen on forums. Again, where are you forming your opinion from?

I've noted drop in event detection accuracy and treatment effectiveness with leaks over 20ish, this is with both the Resmed Airsence and Philips Dreamstation machines, YMMV.

[Pugsy]

You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.

Huh? He had one time he was in large leak maybe 10 minutes where it went to maybe 30 L/min. The machine is still fairly accurate up to around 35 L/min and even if it was much higher 10 minutes in large leak isn't a big deal.

Unless leaks are waking the OP up...they are NOT an issue.

Your CA and obstructive event counts are similar even with no EPR. However, your flow limits are consistently high. EPR will help fix flow limits, but likely increase CAs further.

Again huh? Not everyone has EPR causing centrals...those that do are a very, very small minority.
Using EPR normally causes FLs to increase because of the drop during exhale....

I am betting the bulk of his centrals are awake/arousal related anyway.

Increasing ventilation in people with flow limitations often causes CAs if you've been used to lower levels of ventilation. I didn't know that's rare, where have you formed that opinion from?
EPR provides pressure support for the inhale which helps with flow limits, it certainly does in my case and most that I've seen on forums. Again, where are you forming your opinion from?

I've noted drop in event detection accuracy and treatment effectiveness with leaks over 20ish, this is with both the Resmed Airsence and Philips Dreamstation machines, YMMV.

Don't you think that if it were common for EPR or any form of exhale relief to cause central apneas that maybe it wouldn't be one of the few things that most medical people say it is okay for the patient to change at will?

As to where I get my opinions....hmmmm....over 10 years on cpap....reviewing thousands of software reports....some medical education and experience that I had for over 30 years that I have had...and a heavy dose of common sense.

Your are the 3 rd person in over 10 years I have seen say that adding EPR reduces the Flow Limitation...3rd...out of thousands.
I think you are the uncommon one.

You are entitled to your opinions and ideas...the OP is entitled to try your ideas if he/she wishes....I just don't happen to agree with you and I am entitled to speak up when I don't agree with someone. We all get our say...right or wrong.
But when someone thinks that 10 minutes in a large leak that barely hits 30 L/min warrants a dire "you have to fix your leaks" ...sure makes me wonder about what else they think they know.

In a nutshell...I pretty much disagree with everything you say and I am not going to ask where you got your opinions from because I really don't care. Doesn't matter to me one twit.

Have a nice day.

[loopib]

Thank you all for the input so far. I will watch the videos pugsy linked, but quickly wanted to say that yes: I do have significant nasal congestion at night when laying down. I take nasal spray to help with it a bit but deviated septum could be the main cause. I have seen a couple sinus surgeons and they both have said my sinuses are fine. Turbinates have been reduced. I'm going to try sleeping with upper half of mattress on an incline tonight with CPAP settings as they are and see what happens.

My current setup is mouth tape, cpap, side sleeping, nasal spray. I suspect however that I roll on my back at some point no matter best efforts (even tried sleeping with a backpack on filled with a pillow to stop rolling over).


edit: couple more data points from last two nights attached below

[Pugsy]

With the known nasal congestion and your own statements about not tolerating higher pressures....I doubt seriously that allowing the machine to go trying to kill the FLs with more pressure would accomplish much. More pressure doesn't fix nasal congestion anyway and if more pressure causes more problems than it fixes...not worth it.
If you did decide to try more pressure again...adding in EPR might help tolerating it better and the chances of EPR causing real centrals isn't very high. Should it happen that you are in that minority....cross that bridge if/when you come to it.

I do suspect a good chunk of your AHI is going to be false positives. More of an indication of poor sleep quality in general and the poor sleep quality itself can be responsible for crappy daytime feelings.

I don't know what to think about your oxygen levels though. It's normal for O2 to drop during sleep anyway but to fall below 90 is unusual unless your baseline normal awake level is in the low 90s to start with.
This is something I think best discussed with your doctors..... unless the time below 90 is so brief that it's maybe a loss of contact artifact.
People have low O2 levels because of other health problems besides sleep apnea.

[SleepyPaolo]

You do need to control leaks better, two of the three nights are not good and the results can't be relied upon.

Huh? He had one time he was in large leak maybe 10 minutes where it went to maybe 30 L/min. The machine is still fairly accurate up to around 35 L/min and even if it was much higher 10 minutes in large leak isn't a big deal.

Unless leaks are waking the OP up...they are NOT an issue.

Your CA and obstructive event counts are similar even with no EPR. However, your flow limits are consistently high. EPR will help fix flow limits, but likely increase CAs further.

Again huh? Not everyone has EPR causing centrals...those that do are a very, very small minority.
Using EPR normally causes FLs to increase because of the drop during exhale....

I am betting the bulk of his centrals are awake/arousal related anyway.

Increasing ventilation in people with flow limitations often causes CAs if you've been used to lower levels of ventilation. I didn't know that's rare, where have you formed that opinion from?
EPR provides pressure support for the inhale which helps with flow limits, it certainly does in my case and most that I've seen on forums. Again, where are you forming your opinion from?

I've noted drop in event detection accuracy and treatment effectiveness with leaks over 20ish, this is with both the Resmed Airsence and Philips Dreamstation machines, YMMV.

Don't you think that if it were common for EPR or any form of exhale relief to cause central apneas that maybe it wouldn't be one of the few things that most medical people say it is okay for the patient to change at will?

As to where I get my opinions....hmmmm....over 10 years on cpap....reviewing thousands of software reports....some medical education and experience that I had for over 30 years that I have had...and a heavy dose of common sense.

Your are the 3 rd person in over 10 years I have seen say that adding EPR reduces the Flow Limitation...3rd...out of thousands.
I think you are the uncommon one.

You are entitled to your opinions and ideas...the OP is entitled to try your ideas if he/she wishes....I just don't happen to agree with you and I am entitled to speak up when I don't agree with someone. We all get our say...right or wrong.
But when someone thinks that 10 minutes in a large leak that barely hits 30 L/min warrants a dire "you have to fix your leaks" ...sure makes me wonder about what else they think they know.

In a nutshell...I pretty much disagree with everything you say and I am not going to ask where you got your opinions from because I really don't care. Doesn't matter to me one twit.

Have a nice day.

1. My intention was to offer my knowledge and experience of a very similar situation to the OP for their consideration. I did not intend to provoke an internet argument with anyone. I apologise if my experience or opinion has offended you. When I asked what your opinion was based on my intent was to learn if the there was something to learn from, I asked about your opinion because I didn't want to just say 'you're wrong and I'm right' because that is childish and not what this forum or me personally is about.
2. Your response above is defensive, unprovoked and quite rude. I'm going to assume that's out of character for you, and so I hope that all is well with you.

I'm happy to explain and give evidence for my opinions if you're interested, but I'm not prepared to continue an argument with you. This forum is about sharing experiences to help each other.