Treating flow limitations not logged by ResMed

I have noticed that after all the hard work on practicing good sleep hygiene, getting my dry eyes fixed and getting my settings to where I rarely have a pressure increase from minimum of more than 1cm.

That dry eye condition was a HUGE factor in my history and frustration of sleep disruption despite the low AHI. So any dial winging was from the period prior to May 25 when my eyes were always on fire 24/7.

However, even though I was feeling much much better than pre-pap and getting better sleep after the dry eye fix. I was still able to quickly fall asleep on the couch and yawning at church. So I wondered why was that the case if my numbers are so good and my eyes are not bothering me.

So I was looking at someone's therapy thread in the other apnea forum. And an advisory member (someone who has been very helpful to folks) told this person (who had great numbers but was feeling bad) to do those OSCAR changes to track unflagged events that may be or possibly disrupting their sleep. So I thought, OK. I did it and here I am. Odd though that the person who suggested doing this had zero suggestions on what direction to go to fix the issue.

Expat31. Sure that routine can find stuff, but they're just throwing spaghetti against the wall. They need to reverse the process. Identify a toxic event and then set up parameters to determine prevalence. IMO that routine was designed ONLY to quickly identify subclinical apneas and hypopneas.

Nocibur wrote: ↑

Tue Jul 15, 2025 4:23 pm

Expat31. Sure that routine can find stuff, but they're just throwing spaghetti against the wall. They need to reverse the process. Identify a toxic event and then set up parameters to determine prevalence. IMO that routine was designed ONLY to quickly identify subclinical apneas and hypopneas.

Well I wasn't going to name names. I know most of the members are on both forums. I just used the same user name on both, so I can't hide behind two identities So I didn't want to toss anyone under the bus that doesn't deserve it.

But yes, It was rather frustrating to have someone suggest that a pap user that's having issues set up a parameter in OSCAR that shows bad news and not give suggestions or really want to get involved. To paraphrase, I was told that as I have a 23 page frustration filled therapy thread over there it wasn't worth reviewing. Of which 90% is null and void because of the dry eye fix in May.

Truth be told. I'm fine with digging deeper in trying to make my or helping anyone else's therapy be the very best it can be. So here I am trying to figure out if this stuff is valid or even fixable if it is valid. But there has been something going on to cause those lingering disruptions.

When I see clusters of flow limitations like yours, I wonder if they are sort of positional "apnea" related. I put apnea in quotes as they were not 10 second events. But many of your flow limitations seem to line up with your 8 second user flagged events.
Are you on your back during some of the flow limitations and have soft palate or tongue falling back restricting your airway?

How did you rename the user flags, I like that, very useful description.

Jdougc74 wrote: ↑

Thu Jul 17, 2025 11:11 am

When I see clusters of flow limitations like yours, I wonder if they are sort of positional "apnea" related. I put apnea in quotes as they were not 10 second events. But many of your flow limitations seem to line up with your 8 second user flagged events.
Are you on your back during some of the flow limitations and have soft palate or tongue falling back restricting your airway?

How did you rename the user flags, I like that, very useful description.

To rename those flags. Just go to the events and double click on the "label" And start typing.

As for positional. I haven't slept on my back for 20 years. And OA's have never been an issue after my UPPP surgery 24 yrs ago. I had only 3 OA's, 2 central's in my lab study last year, but over 100 Hypopnea's. I have more clear airways than any other flagged event. But the UPPP can start to fail with the palate softening up after many years and the base of my tongue is verified as being rather large. And surprise, surprise. The tongue does not stop growing during one's life. And that is 'I think' what is causing the limitations.

However, Even now I have so much room in the main part of the throat because of that UPPP. If you held a gun to my head and demanded that I make a snoring or an Oink noise or be shot. You would have to just pull the trigger as i can't make those sounds post surgery. and that surgery is also why I'm prone to choking on food if I'm not careful.

I have since removed those flags and I'm just looking at my flow rate chart in more detail. And I see a common thing. And that's a growing waxing and waning of the volume of my breathing. Like a very small version of CSR. I guess that's periodic breathing? And a lot of deep breath recoveries/resets after the breathing gets shallow. My flow rate chart last night looks like a Porcupine because of those deep breaths. I did up my pressure another .2 to 12.6 last night and it never went above 13.18. What is kinda odd is that my OA's vanished and my H's went down dramatically at just 7cm. But my diminished flow rates continue even at 12.6cm. That seems quite the range and is the likely cause of those Clear Airways.

For now I'm just going to back off until my VA appointment on Monday where I will attempt to get an upgraded machine. If they won't. I will ask for a script and buy one myself.

Nocibur wrote: ↑

Tue Jul 15, 2025 2:59 pm

Frankly, ResMed doesn't GAFF about your sleep. I mean, they'd like to (like be able to exclude all Wake from calculations) but they're in the Breathing Business, not the Sleep Business. Sleeping is an assumption.

OTOH, back when Respironics was a player, they were a lot more concerned about sleep (at least the part that concerned their algorithm). They had this routine called the "Variable Breathing Layer". When breathing became erratic the algorithm make a few changes:

Variable Breathing Pressure Control

Once the variable breathing controller has been granted control of the pressure support system, it takes some initial action based on the action the auto-CPAP controller is taking. After this initial action, it performs an independent pressure control operation.

A prior pressure that is flat will cause the pressure delivered to the patient to remain at that level.

A prior pressure that is increasing will cause the variable breathing controller to initially decrease the pressure delivered to the patient at a rate of 0.5 cmH2O per minute. The magnitude of the decrease is dependent on the magnitude of the increase in prior pressure. The pressure decrease is intended to erase the prior pressure increase that possibly caused the variable breathing. However, the total decrease in pressure drop is limited to 2 cmH2O. After pressure decrease, the variable breathing controller holds the pressure steady.

A prior pressure that is decreasing will cause the variable breathing controller to initially increase the pressure delivered to the patient at a rate of 0.5 cmH2O per minute. The magnitude of the increase is dependent on the magnitude of the decrease in prior pressure. The pressure increase is intended to erase the prior pressure decrease that may have caused the variable breathing. However, the total increase in pressure is limited to 2 cmH2O. After pressure increase, variable breathing controller holds the pressure steady.

The pressure curve is provided for 5 minutes or until the variable breathing condition clears. Thereafter, the pressure is controlled according to the following:

The pressure is either maintained at a constant value, or it follows a decrease and hold pattern. The decision to hold the pressure or to decrease the pressure is made by comparing the current pressure with the snore treatment pressure. It is to be understood, however, that this duration can be varied over a range of durations.

If there is no snore treatment pressure stored in the system, which will be the case if the snore controller has not been activated, the pressure is held constant. If there is a snore treatment pressure, and if the current pressure is more than a predetermined amount above this snore treatment pressure, such as more than 2 cmH2O above the snore treatment pressure, the variable breathing controller decreases the pressure to a level that is a predetermined amount higher than the snore treatment pressure and holds the pressure at the lower level. The pressure decreases to the snore treatment pressure +1 cmH2O.

The duration during which pressure is provided according to the paradigms discussed above for region is set to 15 minutes or until the variable breathing condition clears. It is to be understood, however, that this 15 minute duration can be varied over a range of durations.

While all this may be pretty flashy there's 2 (at least) issues:

1. Almost nobody knew it was even in there, much less what it meant; and

2. Since VB was not excluded in the AHI calculation (which they wouldn't do cause they weren't certain if the VB was actually Wake) the AHI might not be a real "sleep" AHI.

That said, seems like there was some discussion trying to correlate VB with TWA...

One thing for sure nocibur. Getting beyond that last hurdle that's preventing better sleep is akin to shedding lbs in a diet. Sure, the first 50lbs just fell off. But the last 10 are laughing and giving you the middle finger.

And of course, everyone around you is telling you. You did great loosing 50lbs. Why worry about the last 10. That's kinda where I'm at in the apneaverse.

Nocibur wrote: ↑

Tue Jul 15, 2025 2:59 pm

Frankly, ResMed doesn't GAFF about your sleep. I mean, they'd like to (like be able to exclude all Wake from calculations) but they're in the Breathing Business, not the Sleep Business. Sleeping is an assumption.

Your AirSense 10 will know you’re asleep no more than three minutes after. That’s because the moment you turn on your machine, AutoRamp is looking for three things:

1. 30 breaths of stable breathing (roughly 3 minutes)
2. 5 consecutive snore breaths
3. 3 obstructive apneas or hypopneas within 2 minutes

Once any of those signs occurs, AutoRamp steadily ramps up your air pressure at a slow, comfortable rate until you reach your prescribed level.

Your AirSense 10 will know

Nope.

I mean, cancelling ramp when respiratory events appear?

Good idea.

Defining sleep as quiet breathing?

Sales hook.