UARS / Rem Apnea?

Hi all,

Newtime poster and been using my CPAP for just about a year now. While I have seen noticeable benefit, my therapy has always been inconsistent and seems to have stabilized around a level that does not leave me really feeling rested. I have a few suspicions on what it is, and have been doing a ton of research. I'm devoting as much time as I can right now to iron out these issues and would really appreciate any opinions or guidance.

I've attached both of my sleep studies, the initial one and the titration study because I believe they both have clues as to what's going on. I've also included a couple typical nights in OSCAR with detailed waveforms for events.

Firstly I want to explain what I'm feeling right now and the path i've taken, which is that I feel as though my sleep is disturbed and my energy level reflects that. I don't feel great but I don't feel awful either. Once every two weeks or so I'll have a night where I sleep incredibly well, with no disturbances and I feel how I feel like i should feel after a good nights sleep. I also will almost always be disturbed and half awake about 5-6 hours in and either I wake up or push through it. On OSCAR, my data usually reflects this. On these rare nights, my AHI is very low, usually just around 1 or below 1. But on the regular night my AHI is usually in the high 2s to mid 3s. I want to be clear that it seems as though the pressure does a great job at resolving obstructive events, I will usually have at most 1 OA and 1-2 hypopneas which I believe if the machine is reading it right is mostly okay. The overwhelming majority of my events are clear airway events. I've read that a true central apnea and a disturbance event can usually be distinguished by the waveform of the flow rate and leak rate, indicating a large movement like a turn or a sigh and based on that I am decently sure that these are disturbance events.

Based on this information, I deduced that these events could likely be attributed to environment, congestion, CPAP setup or hygiene. So I've been focusing extremely hard on these factors. I sleep in a room that fluctuates between 68-72 degrees, with 45-51% humidity. I find these conditions comfortable. I have a white noise machine, and use a comfortable sleep mask so light and noise do not disturb me. For congestion, I use saline sprays, gels, and regular flonase to keep my airway clear and I have found that it works very well. I do not wake up feeling choked and I don't have noticeable flow limitations which leads me to believe it is well managed. My CPAP is a Resmed autosense 10 setup at a pressure of 8.0, with EPR off and humidity at 5. I find these settings comfortable and keep the frequency of the OAs or hypopneas way down. I use a Resmed P10 with a chinstrap and mouth tape. In part with my efforts to fix this once and for all I have been exercising perfect sleep hygiene, with exercise and consistent scheduling etc.

So it seems as though the potential causes listed before are not an issue. I then looked into the common causes of these clear airway events and came upon a couple possible problems. For one, CO2 concentration could be causing me to stop breathing. But reducing pressure did not help the frequency of them, nor does it seem worth it to keep going down since it increases frequency of obstructive events. Another possibility which is one of my chief suspects at this point, some form of rem apnea or rem dysfunction. As you can see in my sleep studies, I had delayed REM onset of over 5 hours in the titration study, and in both studies pretty much as soon as I entered REM I was immediately kicked out of it from events. Furthermore, in OSCAR the timing of these disturbances and clusters of clear airway events seems to roughly match a REM cycle (please correct me if im wrong) aswell as happening in the middle of sleep periods with highly varying flow rate which mr lankylefty says can be indicative of REM.

My other main suspect is a form of UARS. Also noted from my studies, in the titration study the technician successfully got my obstructive events down to 0, but the results still observed a really high RDI with a total of 72 RERAs. Is it possible that these RERAs are being picked up as clear airway events or not being picked up at all and im continuing to have such a number of events? This is an area I'm not well researched on and have no idea what RERAs look like in OSCAR or what leftover UARS is like.

Sorry if i've provided a bit too much information I'm just trying really hard to get a consistent good nights sleep and im looking for any help I can get. I just purchased lankylefty's speak with a sleep technician service to review this information, and am trying to make an appointment with my sleep doc but i expect them to be very very booked. Thank you for reading and please leave any thoughts/advice/opinions I appreciate every perspective.

OSCAR:
https://imgur.com/a/ynEwWGv

sleep study 1:
https://drive.google.com/file/d/1dz3Ymv ... sp=sharing
sleep study 2 (titration):
https://drive.google.com/file/d/1sn0MnP ... sp=sharing

welcome to the zoo!

i'm mainly responding to this to get it bumped back up to the top, where more knowledgeable people can respond.

the only things i can see to comment on-

why are you on straight cpap pressure rather than auto?

that seems to me to be a lot of centrals. but i know less than zero about centrals.

so i'll shut up now and let someone else take over.

good luck!

zonker wrote: ↑

Mon Apr 05, 2021 9:51 pm

welcome to the zoo!

i'm mainly responding to this to get it bumped back up to the top, where more knowledgeable people can respond.

the only things i can see to comment on-

why are you on straight cpap pressure rather than auto?

that seems to me to be a lot of centrals. but i know less than zero about centrals.

so i'll shut up now and let someone else take over.

good luck!

Hello!

Thanks for reading all that and trying to help i really appreciate it

I experimented with auto pressure for a while, mostly to make sure that I wouldn't get obstructives with my min level. But from my understanding (and someone please correct me if im wrong) variable pressures can occasionally cause clear airway events or disturbances from the fluctuating pressure. So i switched to a stable pressure based on that and also i believe lankylefty mentioned that being on a stable pressure with no EPR can sometimes help get rid of those clear airway events. So that was my logic.

Unable to review your sleep studies because it requires a password and log in to the google document storage.

From what I have read it isn't common to have clusters of central apneas only during REM....obstructives yes but centrals no.
If your centrals look more like arousal related breathing centrals I would be looking more for the cause of the arousals if possible especially since on the nights where arousals are reduced you say you sleep better and the number of centrals/CAs are also reduced.

It is normal to have an occasional central apnea randomly throughout the night....so don't panic over an occasional central.

Without seeing more zoomed in details and based on your history....I suspect the central/CA flags you are seeing are more of a symptom of poor sleep quality than the cause of the poor sleep quality.

aznfreezie wrote: ↑

Tue Apr 06, 2021 12:05 am

Hello!

Thanks for reading all that and trying to help i really appreciate it

as predicted, someone more knowledgeable came along.

you are in good hands with pugsy.

Pugsy wrote: ↑

Tue Apr 06, 2021 5:45 am

Unable to review your sleep studies because it requires a password and log in to the google document storage.

From what I have read it isn't common to have clusters of central apneas only during REM....obstructives yes but centrals no.
If your centrals look more like arousal related breathing centrals I would be looking more for the cause of the arousals if possible especially since on the nights where arousals are reduced you say you sleep better and the number of centrals/CAs are also reduced.

It is normal to have an occasional central apnea randomly throughout the night....so don't panic over an occasional central.

Without seeing more zoomed in details and based on your history....I suspect the central/CA flags you are seeing are more of a symptom of poor sleep quality than the cause of the poor sleep quality.

Hey Pugsy,

I updated those links i think they should work for anyone know!

I actually read a lot of your posts on this particular subject and learned quite a bit from you already, thank you very much for the content you've shared. I think that I definitely thought the same as what you expressed on this post on my initial investigation. But the past 2 weeks where I've really been focusing on cleaning up areas that could be causing these disturbances resulted in no meaningful reduction in these events despite me improving a ton of areas that affect sleep quality. I'll keep focusing on it though.

I would love to give all the useful information i can, what kind of zoomed in details should I include?

I was looking more into UARS and it seems like my data is at the least similar. I tend to have these patches where I encounter a flow limitation, my flow rate jumps around a bit, then I shift in bed and have a "central". I also quite consistently have flow limitations that lightly correlate with the awakenings, as well as the source of my OSA being physical (large tonsils, small airway, large tongue) which I believe are often related to UARS? I'm going to include one of these data points. Please let me know what you think

https://imgur.com/a/TrPm8hK

Thank you for reading and responding!

You did a great job providing a detailed analysis of your sleep and keeping a close record of things that might be impacting it.

While I don’t have too much info to provide as to what might be causing the issues that you explained, I can greatly relate to this post and have similar data on Oscar with a lot of fake centrals and a couple of real centrals. A few real central’s can be common from what I hear.

One good thing about your study (although its a pain to have) is that it looks like they were able to say you have moderate UARS. I suspect I have that too and it is a pain to figure it out and dial in adequate settings.

You mentioned nasal issues. Have you had your airway examined by an ENT? Although I’ve read conflicting studies about how much nasal issues such as a deviated septum or enlarge turbinates can contribute to sleep apnea, my doctor is strongly urging me to have my nose looked at as it could be contributing to the issues I’m having with therapy and possibly being highly sensitive to breathing changes. Some food for thought for you.

One more thing, could mask leaks be contributing to your arousals?

Doce wrote: ↑

Tue Apr 06, 2021 7:11 pm

You did a great job providing a detailed analysis of your sleep and keeping a close record of things that might be impacting it.

While I don’t have too much info to provide as to what might be causing the issues that you explained, I can greatly relate to this post and have similar data on Oscar with a lot of fake centrals and a couple of real centrals. A few real central’s can be common from what I hear.

One good thing about your study (although its a pain to have) is that it looks like they were able to say you have moderate UARS. I suspect I have that too and it is a pain to figure it out and dial in adequate settings.

You mentioned nasal issues. Have you had your airway examined by an ENT? Although I’ve read conflicting studies about how much nasal issues such as a deviated septum or enlarge turbinates can contribute to sleep apnea, my doctor is strongly urging me to have my nose looked at as it could be contributing to the issues I’m having with therapy and possibly being highly sensitive to breathing changes. Some food for thought for you.

One more thing, could mask leaks be contributing to your arousals?

Hi there,

Thanks for taking the time to read and respond! I hope you figure your situation out aswell, I'm just starting to learn about UARS but it's relieving to atleast find something that can describe what's happening to me especially with the absence of real data.

I did actually already get a septoplasty and turbinate reduction. That along with management of humidity and allergy medication has me quite sure that nasal congestion is not a factor.

As for mask leak, I believe numberwise it's generally normal but I will look into it some more. It seems like i only consistently get those singular big jumps and they're always paired with the arousal breath or movement before one of these fake CAs. I think maybe the leaks could be making the arousal more impactful? Like a movement + a blast of air and noise is more disturbing than just a movement without a doubt. I'll rewatch some fitting advice and go for a really well fit mask tonight.

I really appreciate your suggestions thank you!!