New CPAP user - Titration Study - UARS

Hi !

Firstly, I'd like to say thank you for everything you folks do, this forum is an amazing resource.

A few months ago I was diagnosed with "OSAS", and UARS and was put on CPAP despite my sleep study showing a low AHI but high RDI. I've had chronic insomnia for over 10 years and sleep apnea seems to run in my family. I started my CPAP journey at the end of January. It's been uncomfortable to say the least, with leaks, nose sores, frequent awakenings in the night, etc. Last night was my first "good" night; I only woke up twice. I have not been one of the lucky folks to feel amazing after a few nights on CPAP.

The whole UARS diagnosis has been frustrating, and my GP doesn't know anything about it, and it the diagnosis itself seems controversial.

After reading everything I could find here on the topic, I twiddled with my CPAP settings a bit, turning up EPR and also upped my pressure significantly from my prescribed 5cm-8cm starting point.

I seem to mainly see CAs on my OSCAR data, which seems odd to me as none were detected on my sleep study. I also think I see a fair bit of flow limitation, but I'm a newb so you never know. I wake up lots so some of the data is misleading, I'm probably getting some false positives.

The main reason I am writing today, is to ask for some advice for this CPAP titration that is scheduled for tomorrow night. My main issue is fragmented sleep. The daytime fatigue is so hard to deal with. I've read over and over that CPAP has limited success for UARS patients, (as opposed to ASV) and I am wondering if you guys have any tips on how to advocate for myself, so that I can either have higher success w/ the CPAP machine, or possibly try for a prescription for BiPAP instead. Maybe I should go in prepared with a few screencaps of my OSCAR data, to show my sleep doctor what is going on. If you guys think this is a good idea, I'd appreciate some advice on what information to highlight.

Thanks so much for everything!



Equipment:
Machine: Resmed Airsense 11 on Autoset
Mask: Resmed F20, N20 airtouch
Soft cervical collar

Can you post last night's Oscar here hopefully showing your new settings.

About the titration study: what’s essential is that the titration include time on a bilevel machine. Ideally you’d also get time on an ASV too.

It’s common to start UARS patients on a regular machine. Sometimes they are effective. But when they aren’t, a different machine may be called for.

Explain that you are not more rested using the regular machine and that you understand that for UARS treatment with an regular APAP machine may not be effective. State that you assume your titration will include time on a bilevel and an ASV.

I’d really like to see what your flow limitations look like, ditto a zoomed in view of a typical segment of your flow rate, maybe a 5- minute view. FLs are among the symptoms associated with UARS.

Thanks for your fast responses! Hopefully I'm doing this right. I turned down my minimum for the last few nights, thinking I should maybe get closer to my prescribed settings.

Here is a link to last night, (I didn't sleep very well, so who knows how accurate this is):

https://imgur.com/a4QAvRQ

This is the best night I've ever had on CPAP:

https://imgur.com/mfLZTE3

And this is before I was using the cervical collar w/ full face mask. I was having lots of leaks during this time, the nasal mask didn't seem to work for me:

https://imgur.com/JWmYRsJ

I asked to try out the bilevel, and the office said that it won't be possible, as I have to titrate my CPAP and then have a consultation with my doc in a few months first. I'll give it another shot tonight when I get there.

I worry that the titration will show you have a low RDI at just about any settings, and that this is all the doctor will pay attention to. But fingers crossed the titration will be more productive than that.

Meanwhile, my own two cents: increase EPR to 3 -- that's your best tool for reducing flow limitations -- and turn off the ramp. Make sure your minimum is at least 7 so you can get the benefits of EPR all night long.

Your CAs are inconsequential, except that they reflect arousals.

Keep us posted!

Are you aware that when you use EPR exhale pressure relief you are actually using "bilevel" settings.
Bilevel just means 2 distinct pressures. One for inhale and one for exhale. The difference between the 2 is called pressure support.
So your machine is functioning as a bilevel when you use EPR set to 2. There is a drop in pressure of 2 cm when exhaling.
Now your machine is limited to a setting of 3 for EPR so at most you can get a 3 cm drop.
Now the real bilevel machines (there are many different models) offer a more than 3 cm drop during exhale or otherwise called pressure support on a bilevel machine.

ASV is a type of bilevel model machine but it isn't the only type of bilevel machine. There are several different models from nothing more than a glorified apap like you are using up to the ASV model.

Your machine was never really designed to report or treat UARS. The subtle changes characteristic of UARS are NOT something the machine looks for or the auto adjusting algorithm is design to change the pressures for.
So your OSCAR data really isn't going to help you all that much because it isn't looking for the things you MIGHT be having if you do have UARS.

You are going to have to go by how you feel more than what the data shows.

And having a titration sleep study without a Pes device (needed to actually document UARS) isn't going to help you much because you don't really have all that big of a problem with OSA.

What you need more than a bilevel is a titration sleep study using a Pes device....at least first.

Thanks a lot Miss Emerita!

I turned the EPR down to 2 (from 3) on the 4th of April, because on the 3rd of April, (my settings were min 8 - max 18, EPR 3) my AHI was all "centrals" and was higher than it had ever been since starting the machine, over 2 an hour. Maybe that's just because I started to sleep better though, haha.

I think I'm just being too hasty with all my recent changes and I will take your advice to forgo ramp, and increase my EPR to 3 and just stick with that for a good chunk of time.

--

Thanks Pugsy,

Yes, I've read that bilevel machines can offer higher EPR pressure support than my machine, which may be helpful for folks in a similar position. I asked if I could be studied with a Pes device. This clinic does not offer that as an option, and if I cancel my appointment, I have to pay 200$. Perhaps I can try it again one day with the Pes.

In terms of going by how I feel: I am barely hanging on, every single day is a struggle... I suppose I'll just stick with it and try to stay hopeful.

Thanks a million to both of you for your help!

Can you blow up that area in last night's study to at least this big:



I think that might be CBA.

Hi Rubicon,

https://imgur.com/a/RKU0rSz

Here is a zoomed in pic.

Thanks a lot!

Given the randomness of the pulsations IMO this is CBA and no determination of FL can be made.

Thanks for your reply Rubicon, my machine did not detect any flow limitation in that specific section, I believe I can see that on the graph. So I'm not sure why we are highlighting it. I'm more confused than ever!

You need to divide the problem into 2 parts:

How much of the night is due to inherently bad sleep; and

How much of that bad sleep can be attributed to sleep-disordered breathing (OSA, UARS, whatever).

You need to go over your reports in 1 - 2 minute sections to try to differentiate this.

And frankly, I'm kinda leaning towards your basic sleep quality being poor, and you need a hefty dose of sleep hygiene.

Also, it helps if you avoid being female, especially perimenopausal.

To the OP: CBA stands for cardioballistic artifact. I have it; lots of people have it; it's nothing to worry about. It most often shows up between breaths in the form of little oscillations around the zero line. Those are tiny changes in your airway caused by the beating of your heart.

I think Rubicon is also inclined to think the "dented" inhalation curves we see in your blow-up are also CBAs. I'm not so sure; I think that's a fairly unusual phenomenon. I'm more inclined to think the dents indicate flow limitations. Not all FLs are flagged by your machine -- only the ones its algorithms are programmed to detect. It'll be interesting to see whether you have fewer dented curves when you increase the EPR.

But quite apart from all of that, you certainly should pay attention to the guidelines for better sleep. At first I didn't, and then in desperation I did. That didn't lead to a miraculous change, but it helped!

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