Help Interpreting Watchpat and General Advice

[newuser1002]

Hey all,
I recently did a watchpat one while on my normal CPAP therapy to see my numbers as a baseline value and was hoping you guys could help me improve my titration. Here's the watchpat data along with the corresponding OSCAR data: https://imgur.com/a/yNGslqF.

My situation: I'm pretty sure my UARS is caused by nasal obstruction from my enlarged turbinates (as a result of repeated allergy exposure) and present allergies. Really bad cognitive symptoms for the past 3 years, songs constantly in my head and very difficult to concentrate, general anhedonia, fatigue, you know the drill. I started CPAP, but am only like 30% cured from my subjective experience, even though my numbers are low (e.g in the watchpat above, 1.6 AHI and 8.8 RDI). I know some may doubt my symptoms are all from UARS from these low numbers, but the story aligns so perfectly for when my symptoms started. And my subjective experience of my symptoms the next day correlates extraordinarily well with how obstructed my nose was the previous night, as it varies night to night.

Based on my situation, my plan is basically to do the following (in parallel):
1. Fix my nasal obstruction.
a. Bandaid fixes - currently using extra strength breathe right strips. Will try different types of masks to see if they work better. Hot shower at night.
b. Fix my allergies - I already use Nasacort and Azelastine (antihistamine) nasal sprays, saline rinse, dustmite protected everything + air filter + vacuum. Probably will start allergy shots immunotherapy.
2. Titrate better.
a. Increase my numbers until I plateau and can't stand the effort of breathing required
i. If not good enough, consider BiPAP. Try higher PS until plateau. Try ASV.
3. Myofunctional exercises (tongue training and chewing gum exercises). My sleep doctor claims it is an underrated method, and my tongue is apparently very weak. I've also mouth breathed for the past 3 years and I think my jaw is quite recessed. So maybe this will help, but I'm fairly skeptical as it doesn't align with my initial hypothesis.


Lastly, if all else fails, I'll need to attack my enlarged turbinates head on.. As I think this is the root of my problem, I really should be doing this first, but surgery is so expensive... Considering turbinate reduction vs EASE. Somewhat pessimistic about this as well due to stories of people getting ENS, or turbinates growing back, or simply symptoms not improving as much as they hoped. Especially in my case my numbers are so low already.

Let me know if any of you have any advice on how to better titrate based on my Watchpat/OSCAR or any advice on my general direction. Thanks!

[Centennial1]

I've no intent to derail your thread, but did have a question that you or others might be able to provide a quick answer.
I also had a Watchpat study done (while temporarily OFF therapy) and I noticed that your report had values for pAHI3%, but my report had only values for pAHI4%.
What is the difference between these two ? What does the 4 or 3 represent?

[Miss Emerita]

I've no intent to derail your thread, but did have a question that you or others might be able to provide a quick answer.
I also had a Watchpat study done (while temporarily OFF therapy) and I noticed that your report had values for pAHI3%, but my report had only values for pAHI4%.
What is the difference between these two ? What does the 4 or 3 represent?

Those numbers refer to the percentage drop in desats that is used in identifying events.

[Miss Emerita]

To the OP, a few thoughts:

On the Oscar chart, you had a small cluster of OAs, and your flow limitations were also somewhat clustered. This suggests that you may be tucking your chin down toward your chest a little, which can put a bit of a crimp in your airway. If you use a high pillow, or several pillows, try using a low, firm pillow instead. You might also experiment with using a soft cervical collar to keep your head in a good alignment.

You're doing a good job of tackling your nasal problems, and while it's smart to start allergy shots, the results might take at least several years to emerge.

I'm not sure what you think the benefit of increasing your pressures or using a bilevel or ASV machine might be. Could you say more about that?

I see that your time on the machine (and your time with the WatchPAT) was just a little over 7 hours. I also see that on both nights you went to bed at around 3 a.m. This raises some questions in my mind about the extent to which you follow the guidelines for better sleep. They initially struck me as too vanilla to be much use, but in desperation I tried them and they helped:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

Bear in mind that you may be one of those people who needs 8 or more hours of actual sleep to be fully rested. Also bear in mind that your schedule may be exposing you to more light and noise during the second half of your sleep time than a different schedule would.

Finally, has your primary care physician run any tests to see whether some additional problem is plaguing you? Examples include thyroid problems, low testosterone if you're a man, autoimmune disease, Lyme disease, anemia.

[newuser1002]

Hey Miss Emerita,

Thanks for the response! Looking at my flow limitations, I previously just attributed it to my turbinates getting even more enlarged during REM sleep, as it coincides quite well. However, it isn't an exact match - perhaps the flow limitation a combination of additional turbinate enlargement AND chin tucking (as I was supine for most of my REM sleep, and it's indeed clustered). What's the reasoning for a firm pillow? Is it because if you're supine and you sink into the pillow, your mouth may open? My pillow set up right now is kind of weird, I use two stacked on each other - the top one is soft and sinky and for allergies, and the bottom one is a sturdy couch pillow. The top one is this: https://www.amazon.com/gp/product/B0096 ... UTF8&psc=1. Any pillow recommendations? I'll buy a soft cervical collar and give that a try as well.

My thoughts on increasing pressures and using bilevel / ASV come from the general notion I've picked up from some threads of people with UARS saying to tackle flow limitations using higher pressures and higher pressure support. Here's one example, from a user named "jcoleman" who seems to have had a very similar experience to mine on apneaboard: http://www.apneaboard.com/forums/Thread ... -breathing. His main idea is to aggressively tackle flow limitations. Increasing IPAP should help with lowering the effort of breathing and thus reducing arousals. Regarding ASV, that'd be more of a final resort, but I've seen a few people find success only at the ASV in reddit.com/r/UARSnew (namely, the moderator of the subreddit).

Regarding general sleep hygiene, I totally agree that is always an area of improvement that I'm striving to work on! I follow most of the guidelines you listed, but I'm sure I'll see some improvement from sleeping more and earlier. I've done blood tests and found I had low vitamin D, so I've been supplementing that now. Testosterone is ~450 which is a bit low for 22M, but that may be a result of my sleep problems, I'm guessing. I haven't tested for autoimmune disease, Lyme disease, or anemia, but based on my story of how my symptoms started from me moving to a new apartment I was very allergic to, and the ENT saying I have enlarged turbinates, I'm fairly confident I have sleep apnea / UARS and that's causing the issues even though my AHI/RDI is relatively low. Also sleep apnea runs in my family - my dad, grandpa, and aunt all have it (possibly more who are undiagnosed). I also had a "brain map", where the doctor told me that I had more slow brain waves than usual, suggesting I was very tired. Open to pushback on this idea though, if my numbers are too low for you to consider it possible to cause the severity of my symptoms.

[Miss Emerita]

The firmness of the pillow is less important than its being fairly low. This helps you keep your head in proper alignment with the rest of your body. That said, if you have a low pillow, you'll probably want it to be firm so you get some support.

Your flow limitation graph is busy, but it isn't awful. Can you zoom in to an area that doesn't have FL markers to see how the flow rate looks? If you see a lot of obvious dents, peaks, or plateaus on the inhalation phase of your breaths, that indicates FLs that aren't picked up by the ResMed algorithm.

But if you're right that your FLs are caused by conditions inside your nose, more pressure and more pressure support are unlikely to help you. Those affordances can be very helpful for problems in the pharynx, where sagging tissues cause FLs, but what's inside your nose is more rigid and can't be budged much at all by the pressures a PAP machine can generate.

There's another piece to the puzzle to be aware of: FLs are very bothersome for some people and don't matter at all to others.

Can you move out of the apartment that you feel is causing nasal problems?

[newuser1002]

I've since moved out of that apartment thankfully; I stayed there between 06/19 and 03/20 (COVID) but it seems my turbinates haven't recovered much. I definitely still have some allergy exposure nowadays, as my nose is always clearest on Sundays when I vacuum, but not nearly as much as my time in that apartment.

But if you're right that your FLs are caused by conditions inside your nose, more pressure and more pressure support are unlikely to help you. Those affordances can be very helpful for problems in the pharynx, where sagging tissues cause FLs, but what's inside your nose is more rigid and can't be budged much at all by the pressures a PAP machine can generate.

Hmmm, when I go to bed I'm always always have nasal congestion to different degrees depending on the night (moreso with more allergy exposure, but also seemingly random at times). Breathing through my nose becomes quite difficult. However, when I put on my CPAP, I'm able to breathe much better through my nose. Breathing out is sometimes a bit of a struggle because of the congestion + EPAP, but with EPR, it is less of a struggle. My impression from this observation is that:
1. More pressure will help me breathe through my nose easier despite the nasal congestion
2. More EPR will help me tolerate the difficulty breathing out

I've felt my nasal turbinates by hand and they feel quite rigid, so you're definitely right about that. Based on my observations and reasoning though, would you say it is possible that more pressure and more pressure support could actually help me?

Here's also some pictures of my flow rate graph zoomed in to a minute width with -60 to 60 height during a REM sleep session as marked by the Watchpat: https://imgur.com/a/JLELV7b. I'm not an expert at reading these, so I'm really curious about your opinion on these!

[Miss Emerita]

I wonder whether it's the humidity level of the air you're getting that is helping your nose. That is something a fair number of people notice. Some need more humidity for a stuffy nose; some do best with none. So it's the unique needs of your nose that would be at work. You might try to notice whether you can breathe easier through your nose after you've been in a steamy shower for a while.

Just so you know, the little squiggles around the zero line probably reflect the cardioballistic effect. It's just your heartbeat telegraphing itself into your airway. Absolutely nothing to worry about.

In several of the graphs, you have what to my eye is arousal breathing -- e.g., on the left in the first one. Arousal breathing tends to be deeper and more irregular than asleep breathing. But if you are in fact in REM, perhaps you aren't really having a bit of a wake-up. Hard for me to say.

In some of your inhalation curves, you can see dents on the top. For example, in the second graph, most of your inhalation curves show dents. This certainly can indicate flow limitations.

[newuser1002]

I wonder whether it's the humidity level of the air you're getting that is helping your nose. That is something a fair number of people notice. Some need more humidity for a stuffy nose; some do best with none. So it's the unique needs of your nose that would be at work. You might try to notice whether you can breathe easier through your nose after you've been in a steamy shower for a while.

I still feel like it's the pressure mainly at work, since it's an immediate effect and my turbinates still feel large. Sometimes when I take a hot shower, my nose suddenly unblocks itself and the turbinates shrink up, but it generally takes a few minutes. Compared to the pressure, which is more like air is just blasting through my nose despite the turbinates being blocking. Another related example is that sometimes I take off my mask at night in bed (out of curiosity, or sometimes since I feel like I'm getting "too much air"), and the moment I take off my mask, I can notice that my nose is still blocked. I think this is separate from humidity, which is actually my turbinates shrinking and being unblocked. Unfortunately, I haven't had much success with mask humidity - I've tried a few times and it actually made my congestion worse at a few different numbers, but not a comprehensive test. I'm down to try experimenting with that again, since it SHOULD help given that it helps me in the shower sometimes...

In several of the graphs, you have what to my eye is arousal breathing -- e.g., on the left in the first one. Arousal breathing tends to be deeper and more irregular than asleep breathing. But if you are in fact in REM, perhaps you aren't really having a bit of a wake-up. Hard for me to say.

This is a topic I'm confused about - my Watchpat showed many "arousals" but I stayed in the same sleep stage. I assumed that arousals automatically imply I wake up or at least go to a lighter stage of sleep. How do I have arousals during my REM sleep but still stay in REM?

In the flow rate graphs I sent, are the long inhales of concern? Such as on the right side of the first graph or the 5th graph. My guess is that indicates some level of airway resistance, imagining each inhale takes a long time to actual get the air moving..?

[Miss Emerita]

Those times at the zero line are simply pauses between breaths. There's no reason to think they reflect a full or partial obstruction.

[robysue1]

This is a topic I'm confused about - my Watchpat showed many "arousals" but I stayed in the same sleep stage. I assumed that arousals automatically imply I wake up or at least go to a lighter stage of sleep. How do I have arousals during my REM sleep but still stay in REM?

Sleep staging is traditionally done in 30-second "epochs" in a traditional in-lab sleep test, and I would assume the WatchPAT uses an epoch of at least 30 seconds for scoring the sleep stages. An arousal can last as little as a few seconds. Hence, the arousals are scored as discrete, short-lived events inside the longer 30-second sleep staging epochs.

So yes, during an arousal you've temporarily aroused into a lighter sleep stage or wake, but the arousal may not have lasted long enough to trigger scoring a whole 30-second epoch as a different sleep stage.

In the flow rate graphs I sent, are the long inhales of concern? Such as on the right side of the first graph or the 5th graph. My guess is that indicates some level of airway resistance, imagining each inhale takes a long time to actual get the air moving..?

The right side of the first graph, along with most of the other graphs, appear to be pretty normal sleep breathing. It's not uncommon for there to be a brief "pause" between the main part of the exhalation and the beginning part of the inhalation. But when the inhalation itself has a nice round shape to it, there's no real evidence of flow limitation going on.

Having said that, it does look to me like there are a few flow limited breaths in the second graph. As for the fifth graph, there are a few breaths that might show some flow limitation and the overall size of the smallest of these breaths looks like it might be getting small enough for a machine to think about whether to score a hypopnea---if the noticeably smaller breaths last for at least 10 seconds and they are clearly different from the surrounding breaths. (Hypopneas are not scored by xPAP machines if the inhalations very gradually decrease in size over a long period of time.). The last graph also has some breaths that look like they are flow limited.

In other words, if you are using a Resmed machine, it would be useful to look at these breathing snippets in conjunction with the Flow Limitation graph to see what the machine was making of the the inhalations with funky shapes.

[newuser1002]

@robysue1 Ah that makes a lot of sense, thank you! Sorry for such a late response.

Based on my research on this forum, I've decided to get a Bipap and just posted a new thread asking about advice on how to titrate it. By any chance, could you take a look at that thread if you have the time and let me know your thoughts? Thank you so much, really.

[Rubicon]

Note the flow limitations occur exactly during my REM sleep.

I'd like to offer the opposing "Wet Blanket" position.

White, Malholta, et al reported

REM Sleep Detection

The sensitivity, specificity, and agreement of the algorithm to detect REM sleep in different OSA severity groups ranged between 59% and 94%. For normal subjects, these were 62.7 ± 28.3, 92.9 ± 4.7, and 88.5 ± 4.6, respectively; for mild OSA these were 68.9 ± 20.1, 91.9 ± 6.1, and 87.9 ± 5.6; for moderate OSA 66.9 ± 25.9, 92.2 ± 5.8, and 88.5 ± 5.9; and for severe OSA 59.2 ± 31.1, 94.2 ± 5.4, and 90.0 ± 5.3, respectively. The overall agreement of PSG scored REM sleep and the PAT recorder scored REM sleep was 88.7% ± 5.5%. The severity of OSA (and the location of acquisition) did not have a substantial effect on the algorithm accuracy with regard to REM sleep detection. The 2 methods provided similar REM latency and REM percentage (237 ± 148 vs. 225 ± 159 epochs and 14.4% ± 6.5% vs. 19.3% ± 8.7%, respectively).

https://jcsm.aasm.org/doi/10.5664/JCSM.1078

I, of course, will defer to MaffLady in re: interpretation of statistics, but my take on the above is that there were plenty of people in the study where REM identification wasn't even close, and certainly nowhere accurate enough to base major clinical decisions upon.

You've got this massive block of final REM with a total of 33.09% and no reason for that to be. In addition there's all kinds of heart rate crap that suggest significant arousal and/or wake. Since arousals cause sleep stage changes, especially in REM, an uninterrupted block like that is nearly impossible.

IIWY I'd load that night into SleepHQ or send the Oscar file to look at that area to get a better understanding of what's going on.

OTOH will the BiPap (I love saying that to get the OCDs going) help, perhaps as a comfort measure?

Guess it couldn't hurt.

[Rubicon]

[newuser1002]

I actually believe it. No chance that there's not a bunch of fragmentation (it shouldn't be one large chunk), but for me, my flow limitation strongly correlates with my REM sleep. I think this makes sense, as my flow limitation is caused by my hypertrophied turbinates, which I heard swell more during REM sleep.

Here's the OSCAR chart for that day, for reference: https://imgur.com/a/DkJS0v4