Subject: Fragmented Sleep, FLs, Suspected UARS, REM Related. 5 Months of Optimization + EERS

TL;DR at the bottom! This post in its entirety is an 8-10 minute read. OSCAR screenshots for those who like graphs: https://imgur.com/a/EXnYbeI

Hi there - I've been lurking on this forum ever since my first sleep study, mild sleep apnea diagnosis, and CPAP prescription 5 months ago. I also caught a diagnosis of Delayed Sleep Phase disorder and was told I enter REM almost immediately upon falling asleep. At that time I was also diagnosed with asthma and got a maintenance inhaler and omnaris, a corticosteroid nasal spray, which has cured my life-long nasal congestion issues. I can smell things now. Who am I? I'm a 24 year old male, 5'11 183lb. I just graduated with a physics bachelor's a year ago and have been painstakingly looking for work since.

I was prescribed a ResMed AirSense S10 Autoset for Her in March of this year, 5 months ago. I started with an N30i. My CPAP was set at 4-6 by the doc. After the first night of feeling suffocated, I set it to auto 5-15 and EPR 3. Temp 30, Humidity 5 keeps my airways happy all night. I experienced my first decent sleep and woke up feeling hopeful for the first time in many years.

The N30i was great, but I had to learn to sleep on my back because I found it leaked too much on my stomach, my preferred sleep position for my entire life (mouth hung-open, drooling). It worked well, but I kept taking it off at night - I couldn't get more than 3 hours the first 2 months of therapy. Since the pandemic hit, both my DME and sleep clinic/doc's office closed down so I've been unable to get any help from them. I went out of pocket to try an F30i, an N20, and a P30i. The P30i stuck and got me my first few nights of 6h+ uninterrupted. I still take it off for 1-2 hours in the middle of the night, but I've learned to put it back on ASAP so I get 6 hours most nights with my CPAP. Leaks are at <5L/min. I've been optimizing my CPAP since day 1 according to advice of users on this thread - Pugsy, you are a national treasure - the rest of the sleep-mentors on this board whom would make a list too long, you are an inspiration to me. 5 months later, I think I've done well for myself but turn here as I've exhausted everything I could have tried and feel there's something I'm missing.


So here's the meat of the situation:
Since day 1 my S10 CPAP has been bumping my pressure to 11 every night, sometimes to 14 - without fail - so I almost instantly raised my range to auto 10-14 and eventually fixed it at about 11. This seems to eliminate all OAs, but I struggled with an AHI of 8 owing all to CAs, the occasional hypopneas, a RERA or two, plus a supplementary avg 11/h user flags (UF1 at 5s 20% FL, UF2 at 5s 50% FL). Worst of all, I was waking up every hour or so with air coming out of my mouth, ending up without my mask for the rest of the night. I started mouth taping. That helped, but I was still waking every hour and flinging my mask off as air entered my mouth and blew up my cheeks. I tried a cervical pillow, a cervical collar, and finally got a chinstrap a month ago. Mouthtaping plus the chinstrap enabled me to finally sleep for about 6 hours with my P30i. However, the CAs, weird flow rate graphs, FLs, arousal with blown up cheeks and occasional middle of the night mask-flinging persisted, to a lesser degree. My respiratory rate hovered at a median 25, and 95% at 35. FLs at 95% from 0.1 to 0.3.

After months of lurking on this forum, I discovered EERS for my CAs - and I was so grateful. I fashioned a DIY EERS with the short N20 tubing stuck to the top of my P30i with electrical tape plus extra segments of regular tubing I cut into 6 inch segments, at least until I got the Whisper Swivel II - horrifyingly difficult and expensive to obtain in Canada. Cost me 40 bucks and a month stuck in shipping. The DIY fix worked best at 12" EERS - my AHI (and CAs) fell to about 2/h. TV went up from ~350 to 500. Resp rate went down from ~20 med to ~16 med. However, the FLs persisted with a vengeance. I swapped my DIY fix for the Whisper Swivel II when it arrived, which seemed to have been even less comfortable than my DIY fix. I started taking my mask off in the middle of the night for hours at a time, and my AHI from CAs was at about 4. My primary concern was still the FLs and high respiratory rate I could not treat with EERS. It's at this point I paid attention to some of the nights I had at the beginning of my CPAP journey with snippets of sleep containing no events, a smooth respiratory rate, no FLs - and to my dismay it was at a pressure of 6 with EPR 3 (on just two occasions - but I had never seen such a perfect sleep graph for myself). And so, I commenced a new self-titration, starting at 6 EPR 3 all the way up to 10 EPR 3 in fixed CPAP mode. I spent a few nights at each setting in pressure increments of 0.2-0.4, taking notes from OSCAR and recording what I did when I had good sleeps. At pressure 7.6 EPR 3 I had seemed to reduce the sleep fragmentation due to FLs I saw in OSCAR, and going up to pressure 10 did not reduce this further. So I stuck around 7.6, trying EPR at 1, 2, 3, and off. None of these seemed better than the other and I was still getting FLs with obvious IFLs, and periods of arousal with 35 respiratory rate. Since then I've been bumping my pressure back up in increments of 0.2 to slowly work back up to 11 and higher in hopes of reducing the IFLs, with the slower adjustment letting my body be more comfortable - and so avoiding pressure-induced CAs without the need for EERS which seemed to make my sleep less comfortable. I'm finally up to a pressure of 10 tonight. You're a real hero to me if you got to the end of this paragraph

During the analyses I described above, I noticed a ton of palatal prolapse looking events - an abrupt discontinuation in the exhalation curve to a flatline at 0 on the flow rate graph followed by irregular breath/flow patterns. I've read every single thread on this forum about palatal prolapse. This month I've attempted to test this hypothesis by taking naps while at my most awake in the middle of the day. I noticed for the first time I wake up IMMEDIATELY after falling asleep and seeing a flash of a dream - with a snort and a flapping sensation at the back of my mouth. I've since replicated this by falling asleep and waking up to this sensation every 5 minutes for the duration of 30 min naps. Turning off EPR did not improve FLs in the slightest, as suggested in many palatal prolapse threads. I have a huge tongue, as evaluated by a previous GP/doc, which I thought might cause this. I have been since the start practicing "tongue mewing"/training my tongue's posture as suggested in this board to keep it from falling back into my mouth - hasn't seemed to help yet. I tried what I could - I got a tongue-retaining device which is a suction bulb into which you stick your tongue and it hangs outside your mouth. An Amazon search will bring up a picture - let me know if this is unclear and I'll post one. The tongue retainer was terribly uncomfortable. It also precluded my use of mouth tape and I again began flinging my mask off, air coming out of my mouth. I also tried a boil-and-bite "snore guard" mandibular advancement device off of Amazon. The snore-guard/MAD made my teeth hurt - which was fine - but even with mouth tape and a chin strap air began coming out of my mouth again, mask-flinging and all. The clearance between my teeth afforded by the MAD made the mouth tape and chin strap inadequate. Finally, I know that an FFM might avoid palatal prolapse - but the F30i blew up my mouth in such a way that I couldn't even fall asleep with it at any pressure above 9. I hated it - keeping in mind I put in so much effort to get used to nasal pillows after mouth-breathing my whole life - and more importantly, today, I don't think palatal prolapses are my main issue.

My sleep doc just reopened 2 weeks ago at which time I had an exceptionally unhelpful appointment with him (ratemds backs me up with 10 scathing 2-star reviews for him - but I digress). I brought up a ton of OSCAR charts and snippets which I've analyzed over the past months leading me to believe I have a mixed bag of CAs, some palatal prolapse events, and most importantly, unexplained inspiratory flow limitations. The doc informed me that CAs even at 10/h are not an issue - that they do not treat those - and that my suspected palatal prolapse events are "signal loss" on the machine's end. He ignored the flow limitations and inspiratory peak plateaus I brought up. That was that. When I brought up to my sleep doc the palatal prolapse and that perhaps it was position and/or tongue related - I was dismayed to hear from him that while my AHIs were 13, as originally diagnosed and disclosed to me - that was just on my side, and predominantly CAs. My AHIs were 35 on my back, a mix of CAs and obstructive. Sleep doc says my position doesn't matter since CPAP treats the apneas - well, I haven't found this to be the case and now I'm training myself to sleep on my stomach again and have fashioned a backpack to keep from rolling onto my back. I spent the last few months painfully training myself to sleep on my back to reduce leaks. Turns out I've been screwing myself. Go figure - at least my back feels a bit better. I've got a referral to a new sleep clinic last week, but that may take a while and I'm told Ontario insurance will not cover another sleep study.

The last 2 days I've been sleeping on my stomach. I tightened my P30i to avoid leaks - I'm used to it by now so its OK, even when tight, and my leaks are again at <5L/min but now on my stomach. I confirmed with a nap while I was fully awake that sleeping on my back causes my sudden awakenings much more forcefully than sleeping on my stomach or side. It may be of interest that I can easily make a snoring sound while on my back, but hardly at all on my stomach. However... I still get long periods of high FLs (95% FL at 0.15) and respiratory rate spiking from 15 to 30, and a sudden change from an OK-looking flow graph to a very ugly one, and finally I wake up with my heart pounding. My "awake-naps" show me this happens exactly when I start to fall asleep and dream (an effect which I was hoping would have subsided by now).

Due to the stubborn FLs and frequent arousals I continue to experience, I have suspected UARS for a while. My sleep doc didn't like this idea. I didn't like it because - well, what am I going to do to fix it? So I explored other avenues such as playing with my pressure, sleep position, and tongue/jaw. If I understand correctly, the appropriate treatment for UARS is BiPAP. Why UARS? I see tons of IFLs and poor flow rate without any events in my OSCAR graph nights after night. My IFLs appear to correspond to "Upper airway reopening after initial collapse", class 2 flow limitation from this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688581/. I see a ton of other much weirder IFLs all night. Aside from the obvious IFLs in my flow rate graph, I suspect I have mild COPD from years of rather hardcore marijuana smoking (the only thing that allowed me to sleep before CPAP) and severe bi-annual bronchitis infections accompanied by asthma. The corticosteroid inhaler prescribed by my sleep doc is helping tremendously with this... but I still have FLs. I know, I know, why did I do nothing all this time if I couldn't sleep? Well, I've been dealing with my medical issues since graduating. Really, I was just a kid before then. All I can say is that now, I'm doing my best.


And that finally brings us to today. My latest 30-minute "awake-nap" was most telling, as I slept on my stomach and still experienced arousals every 5 minutes as I dozed off into a dream, waking up immediately to a pounding heart. This corresponds to OSCAR showing a perfect flow graph and respiratory rate with no FLs for 5 minutes, then suddenly IFLs appear and respiratory rate shoots up. Repeat. I'll leave this off with some OSCAR screenshots - it's tough to pick from the hundreds I've taken for my own needs. I've tried to make it short, but in being descriptive to match the length of this post, it may seem excessive. Sorry - and again, you are a hero to me. I've included my 30 minute nap from today, and the past few nights of sleep - each with an overview and a snippet of "good sleep" periods with pretty flow rate graphs and "bad sleep" periods with enigmatic flow rate graphs. Also, a representative snapshot from just one night of what I suspect are palatal prolapses.

At this point, here's my working hypothesis: I doze off and enter REM/dream -> loss of muscle tone -> emergence of IFLs and poor flow rate -> CO2 goes up -> HR goes up -> body wakes up out of REM -> respiratory rate goes up to blow off CO2 -> I wake up. Rinse and repeat.

TL;DR: CPAP prescribed 5 months ago. 13 AHI on my side, mostly (likely misappropriated) CAs. 35 AHI on my back, mixed apneas. Have tried to optimize for 5 months myself before asking for people's time (looking at you, Pugsy). Autoset bumping pressure to 11 and sometimes to 14. CAs, FLs, high resp rate, arousals persisted. EERS significantly reduced CAs but reduced comfort. No relief from FLs and arousals. Self-titrated from 6 EPR 3 up to 10 EPR 3. Eliminated CAs, No relief from FLs. Some palatal prolapse events regardless of pressure, mostly eliminated by sleeping on my stomach. Have been "tongue mewing"/training my tongue's posture for 4 months, have tried a cervical pillow, cervical pillow, chin strap, mouth tape, tongue-retaining device, boil-and-bite MAD. Getting 6h+/night, low AHI, but no relief from FLs and arousals. Much improved daytime fatigue but still unable to get through the day without long naps. Suspect UARS due to obvious IFLs in flow rate graph, conscious arousals with high heart rate happening corresponding to FLs, skyrocketing respiratory rate, all in a repeating pattern. Seems to be REM related. I love CPAP... but please, help me.

This post must seem absurd - I tried to keep it simple, and here we are. I've edited it for readability so much that I think it can only deteriorate now! I've done everything I could, spent countless hours this month reading OSCAR graphs and writing notes instead of applying for jobs (to which I feel I would fail the interviews unless I can figure out my sleep). I need your help. If you read any portion of this post, you have my personal and unabated gratitude - I hope to be able to pay it forward one day soon.

Cheers.

Comprehensive Imgur album with 15 OSCAR screenshots with descriptive captions: https://imgur.com/a/EXnYbeI

A few screenshots attached for a quick view.

Good morning.

I approved your post last night right before bedtime and had no time or energy to really read through it. So now after some morning coffee and maybe a slightly clearer mind...I gave it a try. Congratulations on rivaling myself for novel writing...didn't think it was possible but I think I met my match.

At this moment I have more questions than answers but I am always up to a challenge when someone is having problems sleeping and they want to improve things. Been there and actually doing that myself at this time so I have great empathy in that regard.

So let's roll up our sleeves and get to work. When someone is willing to work I am always more than willing to try to help.

So correct me if I am wrong but I get the sense that the OSA side of things seems to be well treated but your sleep is still crappy. You probably wake often during the night and as a consequence you feel like crap during the day. Is that correct?

You are in Canada...they do things differently up north. I understand that fact. Heck down here in the USA docs often throw up their hands and say "OMG we fixed your OSA and have no idea why your sleep is still crap and you feel like crap because you shouldn't feel like crap". Personally as someone who has had their own struggles with sleep quality I think it is a bullshit cop out but I digress. I am never satisfied with just quitting trying to improve anything as long as someone is willing to do the work to try to fix a problem.

So some questions just to clarify things in my mind as to what we are dealing with.
Your sleep study you had done...was it done in a lab or at home? What was the official AHI and diagnosis?
Your primary complaint is still not sleeping well and waking often and feeling like crap during the day????
Do you take any medications of any kind even OTC? If so, what?
Do you drink alcohol much especially in the evening before bedtime?
Do you use any sort of recreational drugs? Send me a PM if you do and wish to him this information private.
You are young...I assume no other health issues that you are aware of that might impact sleep but have you had the usual routine labs as part of a physical to rule out problems?
What specifically are your primary complaints? like poor sleep quality, wake often, fatigue during the day, need to nap during the day, etc?

I did briefly look at your album and some of the zoomed in flow rate. I do see evidence of some flow limited breaths. Have you ever tried the for Her auto algorithm? I am unsure as to just how much FLs correspond to UARS but these machines were never really designed for UARS diagnosing or treating. The very subtle changes that make up UARS really can't be seen or sensed by these machines. My hope for the future is that as more is learned about UARS as a separate problem that these machines will get better at showing us data that helps us figure out if UARS is part of the problem or not.

So answer my questions please and we will roll up our sleeves and get to work. It won't be fast, easy or quick. I wish I could tell you differently but if you have read much of my stuff....I am most often brutally honest. Fixing OSA is actually the easy part. Fixing crappy sleep that isn't from OSA isn't nearly so easy. I wish it were...been there and done that myself.

Hi Pugsy Never thought I'd get your personal opinion on my issues. What a feeling.
I'm known for writing research papers, not novels - so it's warming to know I am comprehensible as rated by someone whose style I appreciate.

The OSA side is taken care of indeed, in my opinion. I do wake up often, but it's down to a couple times a night now - more on this later. Since starting CPAP and getting my settings more-or-less comfortable, I wake up feeling pretty good, though crash very quickly thereafter making for a crap day indeed. Correct.

The doc's stance is just as you describe - the OSA is gone. Pay for the CPAP and move on. I've certainly felt a guilt over trying to go for "perfect" when others are struggling with near-suffocation in their sleep - but I'm learning to get over it, help myself, and then help others.

Now for your questions:

Sleep study was overnight, in a lab, properly hooked up. I could not fall asleep - let alone on my back, which I had never done before. The wires were fine - I just couldn't sleep at that point without some help (more on this below). I spent 8 hours in bed and slept 2 hours during the study. Split between my back and my side, as instructed.
Official AHI 13, diagnosis of Delayed Sleep Phase Disorder. Doc was reluctant to properly diagnose apnea as I had to explicitly ask to try CPAP, to which he thankfully obliged.
Speaking to my doc 2 weeks ago, he additionally revealed 35 AHI recorded on my back at the sleep study - meaning the 13 AHI was on my side.The predominance of CAs in the original 13 AHI is the official diagnosis.

Primary complaints are often waking, feeling like crap mid-afternoon and beyond - about 2-3 hours after waking.

I take Vyvanse 60mg, a prescription stimulant as an ADHD treatment first thing in the morning, >15 hours before sleep. I was on Adderall for the past 3 years before Vyvanse, so this isn't new to me. Diagnosed by psychiatrist.
No other meds except the asthma (Symbicort inhaler, Omnaris nasal spray, both corticosteroids). Zero OTC meds.
I don't drink any alcohol, never have. Certainly wouldn't start now - I'm already exhausted and confused over my flow graphs!
I used to smoke marijuana, and quit for the first time since childhood when I got the CPAP 5 months ago. It enabled me to sleep. I thought it was anxiety preventing my sleep... maybe, but turns out OSA/SDB was the primary culprit.
To ease the transition and stave anxiety - unemployment post-graduation has produced a lot of that - I've used CBD. I dose at a moderate level, vaporizing it for the past few months (it was a tough transition - sorry, lungs) and now I'm using an oral tincture at night. I undoubtedly feel it helps me fall asleep and avoid racing thoughts.
Without the THC, I've had a seriously tough time falling asleep - I've finally taught myself in the past two months to the point I can fall asleep in 15 minutes and I'm not scared to go to bed, expecting hours of restlessness. That's a first in my life.
I quit the caffeine two months after starting cpap - so, 3 months ago. Another first in my life.
I smoked cigarettes for a year as an undergrad during my research periods - academia and all its charm, y'know - and vaped nicotine for the past 2 years before finally quitting 3 months ago. Thanks, CPAP.
I would accept a lecture on smoking as someone with SDB. I've lectured myself for so many years and it only just stuck now - so I could always use another lesson!
No other drugs, recreational or otherwise. So, an ADHD stimulant in the morning plus asthma meds. CBD tincture at night (about 100mg).

I'm young indeed, though born a month premature and barely survived birth according to family, followed by a tumultous childhood and death in the family. I undoubtedly have heightened levels of anxiety and I've considered that as an aspect of my SDB. I just can't pin it perfectly, not without help.
Suspected hypothyroidism for years, finally ponied up and begged my GP for thyroid bloodwork a month ago to finally rule it out - happy to report a normal Thyroid (at least, most likely, based on my normal TSH). Excellent liver and lipid values. Kidney is a bit on the low end but not alarming - may have just been dehydrated that day! If I may insert a quick rant - GPs don't really appreciate a young healthy-looking guy wanting answers to his perceived health concerns.
Heart checked 2 years ago - normal ECG. Though I've dealt with palpitations for years, I think those are anxiety induced. They've been cut by an order of magnitude since starting CPAP. History of heart attacks in the family - it pains me to think of the help my father and grandfather may have had from CPAP.
Before the pandemic, at least, I was an extremely active guy - I even hold the Canadian junior national bench press record. I have a bad knee (ugly ultrasound, got a referal and waiting on an MRI for 5 months now - thanks, pandemic!) which precludes running, so the past 4 months my only exercise is a ton of pushups and 2 dog walks - it keeps me more or less sane.
I'm looking forward to rejoining a gym, but I think you'll find amusement in the irony of my seeking better health and lessened anxiety through exercise - while the thought of entering a gym and catching the spooky "COVID" scares the hell out of my asthmatic lungs.

Let's recap:
Pretty healthy. ADHD. Bad knee. Bloodwork great including thyroid. Childhood anxiety, lessened by self-administered CBT.
Vyvanse in the morning and CBD at night. No drugs, alcohol, stimulants of any kind otherwise.
Primary complaints: Wake often unless using CBD - then, just 2-3 times a night - fatigue and poor concentration 2-3 hours post-waking, inescapable need for at least one nap even when sleeping 7 hours. Displeasing OSCAR stats w.r.t high FLs, respiratory rate.

Phew. I think that covers it. Maybe too much. I prefer to answer questions before they arise.
I used the For Her algorithm for the first 2 months before moving to fixed CPAP mode. I found For Her changed my pressure erractically (to my eyes). I couldn't understand why, based on my flow rate, and neither could my sleep doc 2 weeks ago. I now understand it must have done so due to persistent FLs - however, the spontaneous increases from the minimum pressure to the maximum every single time caused arousals more than the algorithm was worth.
I chalk it up to partially poor algorithm w.r.t complex SDB/UARS, and my not being used to pressures 11-14 which For Her constantly chased. I'm sure it would go higher than 14 if I didn't limit it, but at pressures >12 I can hardly fall asleep due to the difficulty in exhale (even with EPR 3).

I've raked the literature on SDB and UARS concerning algorithm advances - I've even looked into hacking my own machine to see if it's possible to make use of state of the art algorithms in current literature. Not possible as far as I can tell. The good news, although maybe not yet for us, is that there are very real resources now being devoted to machine-learning assisted algorithms focusing on identifying SDB, even for fringe cases like palatal prolapse. They're getting good results. I'm sure these will serve the next generation

I was expecting a reprimand for the complexity of my post. I would probably scoff at myself thinking - who has the time for this? Give someone an inch - that's you, Pugsy - and they'll take a mile - that's me. You may let-open the flood gates of brutal honesty should it advance the conversation.

Hope this adds clarity, though it may add confusion in proportion. Looking forward to an enriching conversation.

Here's last night. I'm at 11 EPR 3 without CAs for the first time ever. Without exaggeration, the very first such day! DIY Sleep backpack is doing a good job as well, I suspect. Flow graph is tighter and stats are improving. One of my better sleeps to date. Full disclosure, by the way... I set my CPAP clock back 6 hours to avoid it splitting data at noon. I'm still having trouble with the delayed sleep phase disorder - I think due to fatigue in the day and compensating by job-searching in the early night. My sleep schedule is not as perfect as it appears in these graphs. Snippet 1 from last night, palatal prolapse looking weirdness. Snippet 2 from last night. Event-free weirdness with high respiratory rate (REM related?) Current trajectory is to increase in increments of 0.2-0.4 in fixed mode, as I can tolerate, and see what happens. Beginning to worry about difficulty of exhale.

Cheers!

CPAP can't fix phase disorder sleep and if you sleep at out of phase times, I think the sleep will be lighter and easier to arouse from, even without apneas.
But CPAP still keeps your O2 from dropping so you should stay healthy as long as you get enough total sleep. A lot of great thinkers had that disorder.

The for Her algorithm is sort of more sensitive to FLs and it doesn't surprise me that it might go up and stay up with the pressures because of the FLs. It works well for some people and not so great for others. You will find that everything, and I mean everything, about cpap or SDB comes with a huge YMMV sticker. I actually used it for quite some time because I just wanted to try it out. I like to experiment with just about anything new because after 11 years on cpap this stuff is boring as all get out and it helps me learn when I can experiment.
Now sometimes the experiments don't work out so great and what I learn is "man, that was a stupid idea" but I always learn something.

When you post your general big detailed reports would you post these graphs on the right right side
Events
Flow rate
Pressure (the regular line and not the mask pressure line) the regular line is more useful in your situation.
Leak
Flow rate

I don't need the respiration rate graph. I know it looks rather active but it's not really so much and I think we are getting some ballistocardiographic echo causing the respiratory rate to be slightly elevated. It's a weird little blip thing causing the machine to think you are breathing faster than you really are.
viewtopic.php?f=1&t=177820&p=1335527&hi ... c#p1335527
The little bumps seen between the breaths. Your respiration rate isn't any higher but the machine thinks it is. Typically when we see this echo artifact the machine doubles the respiratory rate but if I go counting each breath I get about 12 per minute and not the 25 shown. So set that worry aside. It's something that just happens and nothing you can do about it and it isn't anything bad.
You may or may not have been in REM. This is something we see often.

I understand a bit about Delayed Sleep Phase disorder and that's a whole different can of worms to be opening so won't go there at the moment.

Another question....It sounds like you are trying to avoid sleeping on your back because it worsens your OSA. This is common but is it possible that wearing the backpack thingy is affecting your sleep quality? Meaning if you could sleep on your back do you think you would sleep better? My own OSA is worse in REM...to the tune of 53 AHI in REM and only about 12 in non REM. I don't try to avoid REM nor would I because the body needs each and every sleep stage in the normal cycles so I just let the machine sort out what I might need in terms of pressure during REM. So something to think about....sleep in whatever position you are the most comfortable sleeping in and trust the machine to do a good job as long as we help it out with a good baseline starting pressure.

Your FLs still look a bit ragged. See the graph below as to what normal and not so normal breaths look like.
I am unsure as to how much of this relates to your problem but there is a reason the machine has a built in "let's go killing FLs" in its auto adjusting algorithm.

Have you ever had your vitamin D levels or testosterone levels tested? If not....something to ask your doctor to have done and yes I know he will roll his eyes and say you won't need it but it needs to be ruled out.

I need to study up on your meds a bit so more on that later. I don't know if there has been enough real research done on the effects of CBD oil or THC on the sleep stages themselves to learn much. I will see if I can find something beyond my own personal experience which is extremely limited. Remember I am twice your age and my old body just doesn't react the same.

Can you look back in your OSCAR reports and get me a quick screen shot in my preferred format of a night where you use the for Her mode? Both a general detailed report and a similar zoomed in image of the flow rate as you did above.
There is no need to redo the image above though. Just from here on on use the format I prefer and if I need anything different I will just ask.

I know there is a reason for the Vyvanse but it isn't doing you any favors. I suspect that the afternoon/mid day need to nap is the "crash"
https://www.floridarehab.com/drugs/vyva ... wal-detox/
The half life for the primary component of the medication is fairly fast and depends on how quickly the person metabolizes the drug.
Essentially you crash because the speed drops out of your system...a form of withdrawal.
Plus it has an additional component that stays in the system a lot longer and can actually mess with the sleep stages themselves.
It's actually a combination of drugs and while the half life of one component is fairly short...the other one is fairly long and it will accumulate and affect sleep quality or sleep architecture.

We need the normal sleep stages in the normal cycle and normal percentages in each sleep stage for the restorative powers of sleep to work their magic.

Steroids will also affect sleep quality. This is commonly known. They can and will affect the sleep architecture. Doesn't matter if it is a pill or an inhaler or a nasal spray.

Regarding medications and how they affect how we feel. All meds come with baggage and we have to do the old risk vs rewards thing when it comes to meds. Obviously with a history of asthma we need our inhalers. If we have a stuffy nose and need a nasal spray then we need it to breathe. I simply can't sleep if my nose isn't clear...just won't happen so I totally get it.

So my non medical thoughts at this point....probably a combination of things causing your sleep to be less the optimal in terms of quality. Partly maybe the FLs seen on the machine reports...partly medication side effects. At this point I haven't found much on CBD oil yet as I am a bit short on time but will look more later.

Then we factor in the other life stressers.....Covid, at home, unemployed looking for a job...life sucks. I woke up this morning thinking this very same thing myself. Things we can't so easily do much about except know they can and will affect how we sleep and feel during the day.

I do think there is some room for improvement with the SDB stuff. Your FLs are ragged looking so whether it be UARS or just ugly FLs...worth trying to improve that aspect of things and see how much it helps or not. Will it alone be the miracle fix...to be honest I doubt it but it is worth trying.

Tell me again what you did with your mask to alter carbon dioxide so you could reduce the central apneas. I couldn't quite wrap my head around it since I see you are still using EPR.

I will read up on CBD oil later. It's something I have been meaning to do myself anyway.

too much weight lifting will ruin your sleep. My sleep improved a lot when i stopped lifting weights. You will just have to sleep extra during the day and take naps. Your body wants to stay in light sleep to get the extra metabolic work done.

Pugsy, apologies for the delay. Visiting some family for the weekend - won't post those graphs due to the confounding factor of a different bed.

First, as per your advice I slept tonight with the For Her algorithm to get some fresh data instead of posting an old graph, as I haven't use that mode in about a month. Graphs attached in your requested format. I wasn't including pressure as I had it fixed, though I studied your sticky on how to post graphs before signing up! I'll include it from now on.

I want to start by noting that the difference between the 2 graphs on page 3 of the thread you linked "UARS flow rate questions" is exactly the kind of improvement I am going after - to smoothen the flow curve on exhale, presumably from reduced resistance to expiration as the user in that post saw the improvement by switching to BiLevel. From the little info on expiratory pressure intolerance I have found - much of it featuring Krakow - the jagged/squiggly line on the exhale indeed seems to signifiy expiratory intolerance. In that case, with that post as evidence and according to Krakow - BiLevel seems to be a promising route. On that note, this appears to be the same priced as a used AirCurve 10 Vauto, but for a new machine: https://www.cpapclinic.ca/CPAP-store/Re ... logID=1676 Is there something I missed, or is this a potential steal?

You're right about the cardiographic echos - that's exactly the pattern I'm seeing. I indeed count half the respiratory rate in the flow graphg vs the respiratory graph, consistent across all my sleep nights, and so the high respiratory rate seems to be a red herring. However, I find that this pattern also coincides with a flattening of the expiratory curve, and so I am inclined to take the doubled respiratory rate as indirect evidence of a breathing issue - there must be a reason it only appears in certain portions of the night.

Since the respiratory rate is responding to cardiographic echo artifcats, I hypothesize that the cardiographic echoes only appear WHEN my expiratory flow curve is flattened - perhaps due to expiratory intolerance - allowing cardiographic echoes to stand out, and at that point the respiratory rate mistakenly counts these artifacts as breaths. In that case, my increased respiratory rate is an indirect indicator of portions of the night with increased flow limitations on the exhale.

As far as REM - the only connection I see to it is the loss of muscle tone leading to difficulty in expiration and so, expiratory intolerance. That also coincides with my observation of the respiratory rate coupling to portions of the flow curve with increased FLs. That's my guess, anyway.

As for back sleeping - I purposefully trained myself to sleep on my back the last few months to avoid leaks from masks. However, I now realize sleeping on my back worsens my OSA at least in part due to the relaxation of my tongue during sleep blocking my upper airways, perhaps by pushing on my soft palate. At least with my current AutoSet CPAP, I don't find that it can overcome that obstacle. So, I started to train myself to avoid sleeping on my back. The backpack thing I've only been sleeping with for a few days now, and have only noticed a decrease in UF1 and UF2 events. For this reason, I believe I sleep better on my stomach than on my back. I certainly wasn't sleeping better a few days ago before starting the backpack. I'm sure it causes some disturbances when I try to roll onto my back - but at this point I am taking those over the confounding factor of sleeping on my back for portions of the night.

Vitamin D and testosterone levels were checked last year - all normal. Have always supplemented vitamin D. No low testosterone symptoms at the time (excluding fatigue, which I owe to sleep issues).

The chart comparing OSCAR flow limitation patterns I've studied on many occasions - I find that none of them perfectly apply to me, but neither do I have the "normal flow morphology" graph in any of my nights. The "expiratory mouth breathing" pattern looks a lot like palatal prolapse, however, and I do see that on occasion.

As for Vyvanse - I understand the ramifications of a stimulant medication, and it's something I've studied extensively. I actually for this reason went off of all stimulant medications for a year, about 8 months ago. I started up again as I saw no improvements to my sleep quality, same mid-day crash, same daytime fatigue without stimulants and noticed an overall decrease in my quality of life. I actually inquired specifically with my GP about the daytime crash and he firmly believes it is something I would experience with or without the medication - at any rate, I'm not convinced it's the primary factor. I find I fall asleep well even immediately after taking a stimulant, during a crash, or in the evening. There is actually a solid body of research showing improved sleep on stimulants in those with ADHD. Anyway, all I can say for certain is I'm likely going to keep up the ADHD treatment until I can optimize my SDB. At that point I hope the optimized sleep will replace the need for stimulant medications. Until that time, it would be costly to drop the medication altogether (weeks until normalization) to see its effect on my breathing. I think I would like to optimize that first.

As for the mask modification and EPR - the modification is named "EERS" after "Enhanced Expiratory Rebreathing Space". it aims to increase CO2 by adding "rebreathing space" so that you inhale a fraction of your exhaled air which aims to stabilize CO2 dips from over-ventilation by CPAP. It's a fix for pressure-induced central apnea from what I understand. There's a quick overview here, with the construction detailed and studies referenced: http://www.apneaboard.com/wiki/index.ph ... ace_(EERS). I found it indeed cut my centrals at least in half - but it also reduced the comfrot of my sleep and did nothing to fix my FLs. I find I experience less centrals at higher pressures than I did a few months ago, so I've left out EERS for now to reduce the variables affecting my breathing. I've tried EPR on an off, and find turning it off does not reduce my CAs but does make it very difficult to exhale and increases the likelihood I unconsciously take the mask off at night.

In sum - I am seeking to improve my flow curve which will hopefully eliminate FLs. I am particularly leaning towards the need to smooth my expiratory flow curve, flat portions of which seem to introduce cardiographic artifacts impacting respiratory rate measure. For months I've had the notion of UARS as a possible cause of the jagged flow curve, and now that I have increased my pressure I am seeing more flattening of my flow on exhale. All this points me to the possibility of BiLevel being the next step. As for the back sleeping - I feel it's something I can return to once I figure out what's going on, perhaps with a higher IPAP offered by BiLevel. I can't think of any medical issues except UARS that may be inducing my FLs at this point in time. I hope to drop ADHD medication once I figure out the FLs and hope improved sleep picks up the slack. For now, here are my graphs from tonight using the For Her algorithm, with max pressure at 20 so the machine can make its own decisions. I was sleeping on my stomach or side owing to the backpack - no arousals that I remember in this shorter-than-average sleep. Next steps: Waiting on sleep clinic to call me and considering the purchase of a used AirCurve 10 Vauto BiLevel from secondwind.

mastaCappy - I appreciate the input. I understand the delayed sleep phase disorder is something I'll have to tackle separately. I appreciate the reassurance - I'm working on it. As for weightlifting - it's luckily not a factor at the moment with the gyms closed! I'll take that advice into consideration when getting back into serious exercise.

Here's tonight: Pressure around 11, which I'm fairly used to. Lots of apparent double-peaked FLs, although most aren't recorded as FLs. Squiggly line at the end of the exhale (cardiographic echo) promoting suspicion of expiratory intolerance: Pressure at the peak of the night, around 13.5 which I'm not used to. Double-peaked apex of the inhalation curve still shows up, though seemingly less often than at 11.5. Squiggly line on exhale again points me to expiratory intolerance, UARS, and BiLevel:

You are correct. Not a whole lot of change in the flow rate pattern tending to show FLs with the for Her mode.

EPAP is your most critical setting so that would be your minimum pressure minus your EPR setting to give you EPAP.
When you use EPR you are actually creating a bilevel pressure situation that will essentially mimic similar settings on a bilevel machine.

If we are seeing UARS here....the machine responding to FLs isn't necessarily going to be enough response. UARS subtle changes in the airway simply aren't part of what drives the auto algorithm to increase the pressures. The data from these machines don't really help us when we are dealing with UARS. FLs by themselves don't always equal UARS and UARS by itself may not show much in the way of FLs either.

Unless you can find some place to do a titration sleep study in a lab with a Pes device in place to figure out pressure needs....it's going to be trial an error being your only option. Good luck with that....heck, even here in the US those places are very few and very far between. Now it can be done bit finding a place that does them isn't easy at all. Most doc still tend to pooh pooh off the UARS diagnosis as it is.

You have read Dr Krakow's stuff....when you are talking about bilevel as being a possible way to go were you referring to his preference for ASV bilevel and not so much regular bilevel? You do know there are several different kinds of bilevel machines out there that do different things?
Your current machine when using EPR at 3 is working just like a bilevel machine (not ASV kind) with PS of 3. It's the same thing....feels the same and works the same. Of course you are limited to 3 PS with the EPR max of being 3. With a regular real bilevel you have higher PS options and that will help a lot with the exhale relief sometimes needed at the higher pressures.

I wouldn't use fixed mode though unless you end up wanting something like 16 fixed with EPR at 3. The machine wants to go higher because of the FLs and the FLs are a bit ugly so there is a reason the machine wants to go higher. Even the for Her mode went higher because of the FLs. So the FLs are a for sure probably an issue and the UARS is a maybe issue.

I think your plan to gradually increase your pressures is a good plan and about all you have available right now.
The only thing I would add differently is auto mode so that the machine can go up to try to kill the FLs.
Either that or a fixed mode with a really high minimum pressure to start with which I don't think you will like since you are already saying there is some difficulty exhaling and being comfortable with the increasing pressures.

The machine will try to deal with FLs but it won't do a darn thing for anything UARS related though. Simply won't do it and if the minor changes that point to UARS fall below the criteria for a FL...nothing will happen.

I'll be talking to a sleep clinic tomorrow - likely will be some wait for the consult, an even longer wait for a study, and as you mention likely pushback against a BiLevel prescription, let alone a PES titration.

I've indeed read Krakow's stuff. I'm very aware of the different types of BiLevels, and a little less aware of precise differences. When I say "Regular BiLevel" I am referring to a Vauto BiLevel (as I think Vauto may be a huge help to self-titration). I am referring to a regular BiLevel - I know Krakow prefers an ASV, but I think that might be overkill as I don't have many centrals these days and I understand ASV may be a whole new beast in terms of comfort and getting used to it. At any rate, a resmed ASV is another $600 (used at secondwind) on top of a Vauto, and since it looks likely I'll be paying out of pocket that's not insignificant for a decision made without a doctor (who might not agree anyway...). I also undersatnd that an ST/Spontaneous Timed BiLevel is for more complex cases of respiratory disorders, is a good chunk more expensive, and from what I understand is a significant sacrfice in terms of comfort.
And so, I'm considering the purchase of a AirCurve 10 Vauto BiLevel, as I see one for $1120 CAD for a new machine at the moment from a Canadian supplier - seems to be a steal. It's a big decision, it's an expensive one - but I have spent months and I would like to take care of this so I can stop spending my days analyzing my sleep.

I'm thinking that since an EPAP of 6 eliminates OSA, keeps my exhale comfortable and the exhale portion of the curve smooth, I will use that with a starting PS of 6 to get an IPAP of 12, EPAP 6.

I'm going to try the regular Auto mode tonight and see if it differs. Otherwise, I'm going to sit at 12 EPR 3 for now as I can't really tolerate higher pressures and this takes care of my IFLs, mostly.

Be extremely careful of the PS setting if you do end up trying one of the regular auto bilevel machines like the VAuto.
Too much PS can cause centrals to worsen. Causes too much carbon dioxide wash out. Some people can handle it just fine but some can't.
I have a friend who gets around 15 centrals per hour with PS of 4 and essentially none with PS of 3....so be careful there is sometimes a fine line.

Yes...ASV would be overkill but Dr Krakow didn't use it to deal with centrals. He used it to smooth out the respirations or breathing. His theory was that minor respiratory irregularities caused the sleep problem and if you use ASV to smooth things out...people slept better....and he had a lot of success with that theory but he also titrated people on the ASV in his lab so he could actually see the breaths changing with the pressure changes.
I have used ASV myself and not had a problem with centrals. I tried it on a lark just to be trying something different. I would occasionally see it "treat" a central with a big burst of PS but didn't happen often as I didn't have many centrals. Otherwise it works essentially like an auto bilevel. I bought one when I found a screaming hot deal on one and I just wanted to give it a try. Ended up selling it after using it for a couple of years to someone who had a real central problem and needed it worse than I did.

For what it's worth, I bought a lightly used ResMed VAuto Aircurve from forum member LSAT. I knew my AHI with the Airsense 10 Autoset was way too low to get a prescription for a bilevel machine or to get insurance coverage. With pressure support of 4.8, I've seen a major change in flow limitations. I'd go higher still -- as you note, not all FLs are tagged, and I still see more than I'd like -- but centrals and aerophagia keep me where I am.

I definitely feel more rested with the drop in FLs (though an unrelated pain problem still messes with my sleep). See attachments for before/after graphs.

Like you, I have cardioballistic artifacts, but they don't come and go. The only time they're absent is during an obstructive apnea. (They can still be seen during centrals.) The VAuto interprets the fluctuations around the zero line correctly; the Autoset didn't miscount my respiration rate, but it did mistime my inhalations/exhalations.

Hope this is of some help!

Pugsy - good point on the PS. I am seeing centrals emerging again at my current minimum pressure of 12.
I'm hoping I'll adjust to the PS, and if not, I will try the EERS modification again as mentioned above to decrease CO2 wash out.

As for ASV - I see now that is something to consider. I remember one of his lectures comparing ASV to regular CPAP suggesting that smoother breathing improved therapy - it must have fallen out of my mind. It sounds to me like you had about equal success on the ASV as the Vauto - I understand our cases are different though.
If my issue can simply be solved with a low EPAP and high IPAP, a Vauto should do the trick. That would be banking on the decent chance I don't have more complex respiratory irregularities than FLs.
Did you notice any comfort differences between the ASV and Vauto? Perhaps the "blast of PS" wasn't ideal with only few centrals?
At any rate, I am considering the chance that an ASV would better suit me. Seems like a bit of an overkill. I think I'll go with the best deal I can find, whether it be a Vauto or ASV. At this point, I'm pretty convinced the CPAP/APAP can do much more to reduce my FLs.
Will be posting graphs using Standard Autoset with pressure minimum at 12 tomorrow morning.
Since there's less to discuss at the moment in the absence of additional data - how did you personally find the bleep to compare to other nasal pillows? It's something I was eyeing for a long time before I settled with my P30i.

Miss Emerita - your input is actually a big help. I didn't consider my near-zero AHI as a deterrent from a BiLevel prescription. You're right, though - I've already been dismissed with my FL concerns by my current sleep doctor, and I can easily see the same being done if I should ask for a BiLevel prescription given my "perfect" therapy, at least on the surface. Your input here is making it a lot easier to pull the trigger on a BiLevel myself, considering I see a pretty smoking deal on one at the moment. So the absence of AHIs is something I haven't considered w.r.t. a sleep doctor's opinion - thank you!

Maybe I could advise about the centrals at higher PS - EERS, as mentioned in one of my previous posts on this thread, may take care of pressure induced centrals. That's my plan should I require it. But it won't take care of aerophagia, and I'm sorry I've got no advice on that front.

I can relate to the pain issues causing trouble with sleep - I do believe CBD has reduced my knee pain somewhat. My knee bothered me for years until it got a bit better on its own. These days I just use the CBD for its anxiolytic effects, but I do believe the analgesic effects are something to consider for certain people (e.g. those intolerant to pain medications).

Your "before" graph of FLs looks like a carbon copy of many of my own. The difference is stark and encouraging me to go for BiLevel. That is indeed helpful

When I went to the ASV trial I had been on auto bilevel for quite some time. Granted a lower PS (I chose 4 PS because I simply liked it better and felt more natural like to me) and remember my OSA is definitely REM dependent and I would often see pressures 6 to 8 cm higher during probable REM when on apap. So higher pressures weren't something I hadn't ever dealt with and they never bothered me and I slept right through them and would only know they happened when I looked at the reports the next day....no matter if it was apap or regular bilevel or the ASV when it would blast me with 22 cm for a couple of breaths for a random central. They simply never bothered me. I never had aerophagia issues or anything like that and PS for me hasn't ever been a central trigger but I am full aware that for some people it can be a critical trigger. I can use 5 PS comfortable but anything above that I simply wasn't real comfortable with. Too unnatural feeling more than anything else.

But remember....I have also never had any sort of real problem with FLs either. No matter what machine I ever used my FLs are pretty much non existent. It's always been that way for me. My main problem was plain ordinary REM dependent OSA for the most part.
My OSA didn't even manifest itself until I was in my mid 50's and good old Mother Nature gave me the curse of menopause. She's a real bitch sometimes. My own issues...pretty much classic post menopausal OSA without other complicating factors.

The biggest complaint I hear from people who try ASV and those pressure bursts when the PS kicks in for centrals they are awake and they should be asleep and the machine doesn't know anything about sleep status. These people are pausing their own breathing while awake and the machine thinks "OMG a central so I need to force my human to breathe" and the person of course doesn't appreciate it.
While asleep...you won't notice that big PS for just a couple of breaths but while awake it will likely knock your socks off. There are ways to get the machine to not be so quick to want to give that burst while awake by establishing a lower auto back up rate with nice slow even breathing while the machine is calculating the breathing cycle but for some people they just have trouble getting that done for any number of reasons. When people have insomnia issues and trouble falling asleep it can be rather disturbing.

Since I had used bilevel for some time before even trying ASV.....it was never an issue for me.

I would see the IPAP go to 22 to 24 during a central because of the PS burst. I wish I had access to those old detailed reports but I just looked and it was the S9 Adapt (the older brother of the AIrCurve 10 ASV) and those detailed reports seem to be absent from my software.
I would see it more than just once or twice though and always slept through them.
It is late and I am tired and off to bed but tomorrow I will go fire up ResScan and see if those old detailed reports are still available in ResScan...they are gone from OSCAR/SleepyHead. So I can show you that it actually went rather high more than one or two times a night and I can tell you they never ever woke me up.

Also remember that I started cpap therapy in 2009. We didn't have low rate graphs or breath by breath detection...heck we didn't have anything differentiating between central apnea or obstructive apnea. So I went for several years with pretty much just some basic graphs and numbers.

I was in tall cotton to get the report below. No way to see anything other than what is shown and no way to evaluate anything.
These machines have come a long way from back then but they still aren't perfect and they can't always give us enough clues to answer our questions when things aren't resolving all our issues like we would want. This was long before SleepyHead or OSCAR was even a gleam in the eye of the person who first gave us SleepyHead and then OSCAR was developed. Heck...I didn't even have a SD card...I had a smart card and a special card reader to get this.

FWIW....I actually really liked ASV and I think I used it for at least 2 or 3 years. The old computer with those files on it has died and I don't have all of the data available and what I do have I only have summary data. My model was the S9 model and it did weird things to old detailed files.
It responds differently to FLs and OAs and hyponeas on the obstructive side of things besides what it did for the centrals.
It was a faster response which meant I could use a less minimum pressure for the bulk of the night and that is always a good thing.
But then again...I didn't ever have the FLs that you seem to be having so my experience doesn't really matter since my problem isn't your problem. If I found a screaming hot deal on another ASV (the ResMed brand because I also tried the Respironics ASV and didn't like it) I would snatch it up in a heartbeat again. They are expensive and hard to find but sometimes screaming hot deals can be found.

Heck...I found an AirCurve 10 VAuto with 86 hours on it locally for $350 US....it went to a guy in Europe who was in the market for one.
My current AirCurve 10 VAuto...I paid $400 US for it and it had a grand total of 8 hours on it. Deals can be found.
I don't do Canadian conversions well in my head but you can figure it out.
The S9 ASV Adapt....I paid $500 US for it and it had 800 hours on it and I bought it from a guy in Canada. Go figure that one.
I haven't run across a screaming hot deal for the AirCurve 10 ASV yet.

Bear in mind that if you did find an ASV....I think there is a limit as to the PS range available meaning I think that you can't go as low with minimum PS as you can with the regular VAuto. I want to say it is 5 PS minimum above the minimum EPAP but I can't swear to it.
So while it can function like a VAuto....it's not an exact duplicate of settings available because with the VAuto you can use less than 5 PS if you wish.

Have you looked at secondwindcpap.com? They are in the US but they do sell internationally and no RX is required when selling internationally. I can't buy from them without a RX for one of those specialty machines but anyone outside the US can.
They are good people and I know people all over the world who have used them.

If I stumble on a screaming hot deal here again locally....I will let you know immediately but they are few and far between here in the area where I live. Most of the sleep docs in my area still are prescribing the half ass bricks that I wouldn't have if they gave one to me.