Info needed about PES testing, UARS, and flow limitations

Is PES testing beneficial to have, for people already on BIPAP/BI-LEVEL? Or is it only for detecting undiagnosed OSA/SDB, that otherwise looks fine on a regular sleep study with low AHI numbers? Can more pressure actually be harmful and cause respiratory events?

I found another sleep doctor that does PES testing, but not sure how it would benefit me. I'm already on BI-LEVEL, and my AHI is usually < 2 most nights. But I keep having nights with flow limitations, and pressures rising even though i dont have events.

I already use a dental appliance, soft cervical collar which helped in past bring my pressures down. But now they are going back up again last few nights. Also last night, I had burning sensation in my stomach at 3:55am. Woke up, took anti-acid. That seemed to help. Would that cause these issues at night during sleep?

Your pressure goes up without your seeing any events being flagged because something else is causing the machine to sense an air flow restriction or reduction even though it's not bad enough to earn a flag.
In your case it's the flow limitations...think of them as the airway trying to close off but not quite getting to a point to earn a flag and it doesn't grow up to the point of earning a flag because the machine increased the pressure and held the airway open...the machine did its job.

Look at the flow limitation graph and the pressure graph. It's easy to spot why the machine increased the pressure.
Flow limitations and snores are part of the driving force behind the auto adjusting algorithm. It's designed to try to prevent them from happening.

What would would you do different if the PES test confirmed UARS? That's the main question.
Would having UARS confirmed or not change anything for you....even if it was just in your mind? Does your mind need that confirmation?

Sorry..I have nothing to offer about the stomach issues. Not everything is related to cpap or sleep apnea or any sort of sleep disordered breathing.

Pugsy wrote:Your pressure goes up without your seeing any events being flagged because something else is causing the machine to sense an air flow restriction or reduction even though it's not bad enough to earn a flag.
In your case it's the flow limitations...think of them as the airway trying to close off but not quite getting to a point to earn a flag and it doesn't grow up to the point of earning a flag because the machine increased the pressure and held the airway open...the machine did its job.

Look at the flow limitation graph and the pressure graph. It's easy to spot why the machine increased the pressure.
Flow limitations and snores are part of the driving force behind the auto adjusting algorithm. It's designed to try to prevent them from happening.

What would would you do different if the PES test confirmed UARS? That's the main question.
Would having UARS confirmed or not change anything for you....even if it was just in your mind? Does your mind need that confirmation?

Sorry..I have nothing to offer about the stomach issues. Not everything is related to cpap or sleep apnea or any sort of sleep disordered breathing.

Thanks. Not sure what I'd do different except for maybe trying some non-invasive procedures my ENT doctors can perform to open up the airway more. They have injection snoreplasty and palate tightening that can raise palate. And a couple other things.

Here is a message I got from this other sleep doctor. So apparently all they would do is confirm UARS and then adjust the machine. I'm not sure what other adjustments they could make to minimize the flow limitations?

I've already tried decreasing PS, and that made things worse. And I don't want to increase PS beyond 4, because it already feels like I'm breathing too deeply.
...................
Doctor email.....

"Even though you have been treated with bi-level for OSA, the treatment and pressure may not be optimal. You may not be having obvious apneas and hypopneas, but you may still be working hard to breath, something the bilevel cannot detect. If your still working hard, this can result in some of the symptoms your having, i.e. racing heart, acid reflux/heart burn, etc. In doing another PAP titration study with the Pes, we can tell exactly how hard your working to breath at night. If your still working hard with PAP, then yes, typically we increase the pressure or adjust the settings in some way, until we notice the effort to breathe is normalized."

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WarpedTrekker wrote: ↑

Thu Nov 29, 2018 11:42 am

I'm not sure what other adjustments they could make to minimize the flow limitations?

More EPAP pressure if the flow limitations are actually in the airway that is below the nose and behind the tongue and down. Pretty simple.
Now how much more is anyone's guess. It's going to be a trial and error thing and not really something easily done in a lab titration setting in one night.

Now if the flow limitations are actually in the nose itself and not the lower airway...then that's where surgical options come in.

So it kinda depends on which part of the airway those FLs are happening in.

Pugsy wrote:

WarpedTrekker wrote: ↑

Thu Nov 29, 2018 11:42 am

I'm not sure what other adjustments they could make to minimize the flow limitations?

More EPAP pressure if the flow limitations are actually in the airway that is below the nose and behind the tongue and down. Pretty simple.
Now how much more is anyone's guess. It's going to be a trial and error thing and not really something easily done in a lab titration setting in one night.

Now if the flow limitations are actually in the nose itself and not the lower airway...then that's where surgical options come in.

So it kinda depends on which part of the airway those FLs are happening in.

Okay I think I'm understanding flow limitations now. So if it's the tongue more pressure could help. Otherwise if nose and in mouth somewhere then more pressure probably won't help.

I'm beginning to think the remaining flow limitations are caused by my nose or mouth opening. Both are narrow and I have a deviated septum. Sometimes I use Flonase which seems to help me breathe a little better.

I already have my Dental Appliance adjusting my lower jaw forward as much as possible. So that should take care of my tongue for the most part. So I guess my nose is the issue and also when I open my mouth to breathe at night.

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I think if it were me I would just try more EPAP and not do the PES thing.
If more EPAP didn't help or made things worse somehow then I would be having a chat about fixing any nose issues I might have.
Fixing any nose issues would also likely help daytime breathing, comfort etc....win- win in my book.

Pugsy wrote:I think if it were me I would just try more EPAP and not do the PES thing.
If more EPAP didn't help or made things worse somehow then I would be having a chat about fixing any nose issues I might have.
Fixing any nose issues would also likely help daytime breathing, comfort etc....win- win in my book.

Okay. So the starting EPAP may need increasing? I can see how that can help at the beginning to stabilize the airway opening. But if my machine is increasing pressure to 16/10 already then not sure how increasing starting EPAP helps. I'm confused or not understanding something.

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The minimum EPAP is just a baseline starting point.
The idea behind more baseline is to do a better job of holding the airway open. Sometimes the airway closes up faster than the machine can increase the pressure in an effort to keep the airway open optimally.
Sometimes the airway tries to close off but maybe it doesn't trigger the increase pressure response soon enough for some reason.

Increasing the minimum EPAP just gives the machine a better jumping off point or head start in where it might need to go.

What is PES testing?

CPAPSteve wrote: ↑

Thu Nov 29, 2018 8:37 pm

What is PES testing?

Device used to test airway and esophageal pressures as an aid to diagnose UARS as opposed to regular OSA.
The people that have UARS only...won't have the dramatic airway flow changes easily measured by the normal sleep study devices.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827205/

From what I have read...doesn't sound real comfortable because I think it has to go up your nose to get down to the airway/esophagus area where the measurements are taken while asleep.

Pugsy wrote:

CPAPSteve wrote: ↑

Thu Nov 29, 2018 8:37 pm

What is PES testing?

Device used to test airway and esophageal pressures as an aid to diagnose UARS as opposed to regular OSA.
The people that have UARS only...won't have the dramatic airway flow changes easily measured by the normal sleep study devices.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827205/

From what I have read...doesn't sound real comfortable because I think it has to go up your nose to get down to the airway/esophagus area where the measurements are taken while asleep.

Right. I was told it goes up nose and down throat. Doesn't sound comfortable. My ENT did a similar camera scope down my nose and throat in the past, twice. He had to numb my nose. It was still uncomfortable having a small camera scope down there. And the numbing spray tasted bad.

So it sounds like UARS comes before OA. Which is why I'm hesitant to even go thru this sleep study with PES. But they claim it could show that I'm still having difficulty breathing at night with considerable effort.

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Ah thanks for clarifying. My wife should get a PES test since she’s got UARS!

CPAPSteve wrote: ↑

Thu Nov 29, 2018 10:41 pm

Ah thanks for clarifying. My wife should get a PES test since she’s got UARS!

These days esophageal pressure monitoring is used only to confirm "rare, doubtful cases" of UARS. It isn't needed to diagnose or treat most cases of UARS, which can be diagnosed with standard sleep lab recordings.

These subjects presented repetitive short (“transient”) alpha electroencephalographic arousals lasting 3 to 14 seconds that regularly interrupted the abnormally high inspiratory efforts. Standard PSG recordings of these subjects evoked the diagnosis of UARS from the presence of these repetitive transient arousals, increases in snoring just before the arousal, and an increase in inspiratory time and a decrease in expiratory time, which were determined with the use of well-calibrated sensors. No significant change in Sao2 was seen, and the respiratory disturbance index was low (<5).

A nasal pressure cannula and, in rare, doubtful cases, esophageal pressure monitoring must be included in all sleep studies to confirm the diagnosis of UARS.

-Principles and Practice of Sleep Medicine, 6th ed.

Stom wrote:

CPAPSteve wrote: ↑

Thu Nov 29, 2018 10:41 pm

Ah thanks for clarifying. My wife should get a PES test since she’s got UARS!

These days esophageal pressure monitoring is used only to confirm "rare, doubtful cases" of UARS. It isn't needed to diagnose or treat most cases of UARS, which can be diagnosed with standard sleep lab recordings.

These subjects presented repetitive short (“transient”) alpha electroencephalographic arousals lasting 3 to 14 seconds that regularly interrupted the abnormally high inspiratory efforts. Standard PSG recordings of these subjects evoked the diagnosis of UARS from the presence of these repetitive transient arousals, increases in snoring just before the arousal, and an increase in inspiratory time and a decrease in expiratory time, which were determined with the use of well-calibrated sensors. No significant change in Sao2 was seen, and the respiratory disturbance index was low (<5).

A nasal pressure cannula and, in rare, doubtful cases, esophageal pressure monitoring must be included in all sleep studies to confirm the diagnosis of UARS.

-Principles and Practice of Sleep Medicine, 6th ed.

So if you are already on therapy (CPAP bipap), then having PES testing is useless?
Because PES is only used to help find the hard to find cases of sleep apnea with people with UARS?

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WarpedTrekker wrote: ↑

Fri Nov 30, 2018 1:25 pm

So if you are already on therapy (CPAP bipap), then having PES testing is useless?
Because PES is only used to help find the hard to find cases of sleep apnea with people with UARS?

I'm not a doctor or therapist, but UARS can benefit from PAP therapy, and that is what Pugsy is working with you to optimize.

Pugsy already mentioned a really key point:

"What would would you do different if the PES test confirmed UARS? That's the main question."

You are already on a PAP machine. For many (maybe most) people with UARS, getting diagnosed and treated with PAP therapy is a big hurdle because their diagnosis will be missed in a simple AHI scoring. But you don't have that initial issue since you do have PAP therapy. So what do you think would be different about your treatment if you did get the invasive PES test?