Help with OSCAR flow rate/limitation

Malib · Post by **Malib** » Fri Jul 09, 2021 8:45 am

Hello,

I've been diagnosed with "mild sleep apnea" (10 AHI - unknown RDI???) about a month ago after a sleep study at the hospital. Was surprised because I've been having really heavy symptoms (intense fatigue, yawning all the time, intense brain fog, serious memory issues at 19 which is concerning, trouble concentrating... you name it). I was also diagnosed bipolar 2 and ADHD (inattentive subtype) but I'm well treated and stabilized (100mg Lamictal/lamotrigine + 18mg Concerta XR/methylphenidate a day)for both of those illnesses so I figured all those residual symptoms must come from some sleep disorder.
So I started to really suspect UARS given my snoring can really come and go, I'm a very anxious person + I have like 6x more hypopneas than apneas + RERAs were apparently not recorded during my sleep study, even though I had electrodes all over my head with normally means EEG, right??

After battling to get an APAP (AirSense 10 AutoSet) trial for a month (because I don't technically have "severe enough apnea" to warrant an APAP in France), the doctor started me on auto 5-12 cmH2O with no EPR a week ago. I quickly got used to the nasal pillows, but I was even more tired than without the APAP, like really zombie tired, even though my AHI was between 0 and 2. I then made some research which really makes me think I have UARS. So I browsed this forum (thanks guys!) and decided to try EPR on my own (I'm not really allowed to do that but screw it, I'm young, stupid and impatient).
I noticed a small improvement in both comfort and quality of sleep, with my AHI not going up, so last night I tried EPR 2 with a slightly higher minimum IPAP pressure (6 instead of 5). I think it's working quite well, I sleep better than without EPR, my flow limitations are going down and I feel that exhaling is a lot more comfortable, but the autopressure is still going quite wild at some times, so I'm waiting a couple nights more with those settings to see how my quality of sleep evolves. I don't have a way to measure RERAs, but I suspect I have far less micro-arousals during the night with EPR because I feel less tired and a tiny bit more energized.

Problem : my flow rate is still really ugly, and I need help understanding its meaning and how to help it. I don't quite understand where expiration and inspiration start, and what settings I need to adjust.

Is expiration when the curve goes up after dipping, and inspiration when it goes down after a peak? Or is anything above 0 an inspiration? I can't wrap my head around this. I think I'm dumb.

Here are my OSCAR charts with some example of flow rates, I hope I screenshot them correctly. Most of those CAs are false flags (arousal movement) and some are treatment-emergent (EPR?) which will go away, I think/hope. AHI still looks excellent.

Do I have an exhale flow limitation which can be fixed by a bigger EPR? Or is it inspiration limitation? Thanks a lot for your help!

palerider · Post by **palerider** » Fri Jul 09, 2021 5:27 pm

I see inspiratory fl, I'd change your pressure settings to a min of 8, 9 if you want to increase the epr, and also raise the max pressure, (preferably to 20, so you don't restrict the machine from helping you.)

Malib · Post by **Malib** » Sat Jul 10, 2021 4:32 am

palerider wrote: ↑
Fri Jul 09, 2021 5:27 pm
I see inspiratory fl, I'd change your pressure settings to a min of 8, 9 if you want to increase the epr, and also raise the max pressure, (preferably to 20, so you don't restrict the machine from helping you.)

Thanks, man! I will try that and report back. But are you sure it's not expiratory FL ? It really looks like it from everything I've looked up online. I thought inspiratory FL was like a "crushed" peak on top of the 0 line.

palerider · Post by **palerider** » Sat Jul 10, 2021 6:16 am

Malib wrote: ↑
Sat Jul 10, 2021 4:32 am

palerider wrote: ↑
Fri Jul 09, 2021 5:27 pm
I see inspiratory fl, I'd change your pressure settings to a min of 8, 9 if you want to increase the epr, and also raise the max pressure, (preferably to 20, so you don't restrict the machine from helping you.)
Thanks, man! I will try that and report back. But are you sure it's not expiratory FL ? It really looks like it from everything I've looked up online. I thought inspiratory FL was like a "crushed" peak on top of the 0 line.

See the non rounded humps on the third and fourth inhales?

Expiration looks fine.

Malib · Post by **Malib** » Sat Jul 10, 2021 6:34 am

palerider wrote: ↑
Sat Jul 10, 2021 6:16 am

Malib wrote: ↑
Sat Jul 10, 2021 4:32 am

palerider wrote: ↑
Fri Jul 09, 2021 5:27 pm
I see inspiratory fl, I'd change your pressure settings to a min of 8, 9 if you want to increase the epr, and also raise the max pressure, (preferably to 20, so you don't restrict the machine from helping you.)
Thanks, man! I will try that and report back. But are you sure it's not expiratory FL ? It really looks like it from everything I've looked up online. I thought inspiratory FL was like a "crushed" peak on top of the 0 line.

See the non rounded humps on the third and fourth inhales?

Expiration looks fine.

I see the inspiration bumps! I will bump up the EPAP for sure, 7 seems like a good starting point. Is my suspicion of UARS justified according to you?
So expirations are supposed to look "spikey" like that? With a lot of bumps in between? It kinda ticks me off though. I thought they were supposed to be a bit more rounded according to the following image, they seem really weird to my noobie eyes.

Thanks a lot for your input.

ChicagoGranny · Post by **ChicagoGranny** » Sat Jul 10, 2021 8:22 am

Malib wrote: ↑
Sat Jul 10, 2021 6:34 am
Malib

For your future reference, there is an Attachment tab at the bottom of the post box. You can attach screenshots directly and avoid an outside hosting service (Imgur in this case).

Malib · Post by **Malib** » Sat Jul 10, 2021 9:00 am

ChicagoGranny wrote: ↑
Sat Jul 10, 2021 8:22 am

Malib wrote: ↑
Sat Jul 10, 2021 6:34 am
Malib
For your future reference, there is an Attachment tab at the bottom of the post box. You can attach screenshots directly and avoid an outside hosting service (Imgur in this case).

My bad, thanks!

Pugsy · Post by **Pugsy** » Sat Jul 10, 2021 9:38 am

It hurts nothing to use imgur if you want to. I use both imgur and the forum attachment feature.
Especially if your image is large because the forum attachment has a 1 MB file size limitation.

So you don't have to use the attachment thing if it works out to use imgur. Just have to sort through imgur BS a bit and take a wee bit longer to get your image up.

So you weren't bad...and it hurts nothing but using the attachment feature is less work and we are all about less work.

Also...when a lot of people use a lot of attachments....eventually the forum storage gets full and we have to have a house cleaning.
We have had this happen once.

If you are comfortable with imgur...use it...if you want a quick attachment you can do that as well.
Like I said...I actually will use both.

Malib · Post by **Malib** » Sat Jul 10, 2021 1:48 pm

Pugsy wrote: ↑
Sat Jul 10, 2021 9:38 am
It hurts nothing to use imgur if you want to. I use both imgur and the forum attachment feature.
Especially if your image is large because the forum attachment has a 1 MB file size limitation.

So you don't have to use the attachment thing if it works out to use imgur. Just have to sort through imgur BS a bit and take a wee bit longer to get your image up.

So you weren't bad...and it hurts nothing but using the attachment feature is less work and we are all about less work.

Also...when a lot of people use a lot of attachments....eventually the forum storage gets full and we have to have a house cleaning.
We have had this happen once.

If you are comfortable with imgur...use it...if you want a quick attachment you can do that as well.
Like I said...I actually will use both.

All good!

I saw you a lot on this forum when lurking, you seem like you know a lot about OSA/UARS. Could I ask you what you think about the whole situation? I also have little above average nasal congestion I think, Dr said I had slightly large turbinates, if that helps.

I've been on APAP for more than a week and I still feel awful... I feel very little difference. My expiratory flow seems really weird.

Pugsy · Post by **Pugsy** » Sat Jul 10, 2021 3:04 pm

Do you take any medications of any kind?
How many hours of sleep are you averaging? Real sleep and not just laying in bed.
Are those hours of sleep fragmented by very many wake ups?
Any other physical or mental health issues going on???

UARS is a hard diagnosis to make and it is mainly a rule out diagnosis unless someone has a sleep study done in a lab with a Pes device.
The data these machines gather really weren't ever designed for UARS.
Your expiratory flow rate looks okay to me but then I don't it is not an area that I have much experience in.

It's only been a week. While overnight miracles do happen on occasion most of the time it takes much, much longer and is a very gradual process. You didn't get this way overnight and it's going to take some time for your body to heal and get adjusted to just sleeping with all this stuff.

SleepGeek · Post by **SleepGeek** » Sat Jul 10, 2021 3:59 pm

Malib wrote: ↑
Fri Jul 09, 2021 8:45 am
So I started to really suspect UARS

My sleep doc once told me that anyone with sleep apnea has UARS.

Pugsy · Post by **Pugsy** » Sat Jul 10, 2021 4:37 pm

SleepGeek wrote: ↑
Sat Jul 10, 2021 3:59 pm

Malib wrote: ↑
Fri Jul 09, 2021 8:45 am
So I started to really suspect UARS
My sleep doc once told me that anyone with sleep apnea has UARS.

That's what I have read as well but the kicker is how bad is it and is it the cause of unwanted symptoms.

Malib · Post by **Malib** » Sun Jul 11, 2021 3:05 am

Pugsy wrote: ↑
Sat Jul 10, 2021 3:04 pm
Do you take any medications of any kind?
How many hours of sleep are you averaging? Real sleep and not just laying in bed.
Are those hours of sleep fragmented by very many wake ups?
Any other physical or mental health issues going on???

UARS is a hard diagnosis to make and it is mainly a rule out diagnosis unless someone has a sleep study done in a lab with a Pes device.
The data these machines gather really weren't ever designed for UARS.
Your expiratory flow rate looks okay to me but then I don't it is not an area that I have much experience in.

It's only been a week. While overnight miracles do happen on occasion most of the time it takes much, much longer and is a very gradual process. You didn't get this way overnight and it's going to take some time for your body to heal and get adjusted to just sleeping with all this stuff.

I take lamotrigine (Lamictal) for my Bipolar disorder which is an anti-epileptic, but I'm perfectly stabilized so I don't think it plays a big role. I also take Concerta (extended release form of ritalin/methylphenidate) but never have insomnia issues because of it, I take it early enough in the day.

I sleep on average 7-8hours a night.

Yes, before CPAP I would wake up often (also urinating at least once in the night) and I also had 15 micro-arousals per hour according to my sleep study. I think micro-arousals are what I should be focusing on but I have no way to measure them, it would be interesting to see how many I have now.

No physical issues except maybe congested nose? I plan on maybe getting a turbinate reduction. Bipolar and ADHD as for mental health issues, but those are under control.

That's true, I need to have some patience. It's just frustrating to expect a miracle to happen based on all those success stories, and see little improvement on my end.

Pugsy · Post by **Pugsy** » Sun Jul 11, 2021 6:21 am

Malib wrote: ↑
Sun Jul 11, 2021 3:05 am
I think micro-arousals are what I should be focusing on but I have no way to measure them, it would be interesting to see how many I have now.

Actually you do sort of have a way to look for micro arousals. Manually count them. Fairly easy to spot on the flow rate. Don't zoom in quite so much on each breath though.
Watch the videos here
http://freecpapadvice.com/sleepyhead-free-software
Learn to spot awake/arousal breathing flow rate from asleep flow rate.
Remember we don't necessarily remember arousals...just depends on how long we were awake or half awake.

Your meds potentially could be a factor if you look at the possible side effects. I am not saying we can blame all your problems on meds but they sure could be a factor.

If (big IF) there is some sort of UARS component to your sleep disordered breathing there really isn't anything that is going to be of much value on the data gathered from the cpap/apap machine. They just weren't designed for that level of detail.
The RERAs...maybe a little help but to be honest it's of limited value IMHO because to know for sure if we have a RERA we have to know for sure if we are asleep first of all and the machine doesn't know if you are asleep or awake. It only measures air flow....doesn't measure sleep status. At best when we see a RERA flag it just means the machine thinks your breathing LOOKS LIKE the breathing that is normally seen with people who are having respiratory event related arousals. It's something but not the end all be all marker.
My own personal opinion...FWIW.

UARS is a difficult diagnosis to make without a Pes device in place in a sleep lab sleep study.
From what I have read about for sure UARS diagnosed patients they tend to need more pressure than what apap machines will want to give. So while their software reports show a nice low AHI at so and so pressure in real life (and in sleep studies with the Pes device) they end up needing more pressure than the machine will feel the need to deliver so people have to start out with higher minimums than it looks like that might "need" per what the machine is doing. Sometimes a lot more. I know of one woman whose cpap machine said she was doing quite well at 8 cm pressure in terms of AHI but in terms of UARS needed 13 cm to deal with things when she had an in lab sleep cpap titration study with the Pes device.

You will have to go on more subjective feelings than data points offered on the software reports. It's hard because we like numbers to validate things but sometimes we just don't have numbers to back us up.

You do need to take a big dose of patience though. Most of the time when you see people talking about the overnight miracle thing with cpap treating OSA their OSA was a LOT worse than yours. The more severe the OSA the more likely to see marked changes and even then sometimes it takes a while. It does seem like the ones with the "mild" category diagnosis do seem to take longer to see results for some reason or other.

It takes a while of the body and brain to adjust to sleeping with the alien plastered on the face blowing air up the nose. I know in my case it was about 3 months before my brain quit waking me up just to tell me there was an alien on my face and I had zero problems with masks or stuff like that.

Having a lot of arousals going on ...no matter what the cause...messes with sleep quality and when you mess with sleep quality and don't get the normal cycles of sleep in the required normal percentages...we just feel like crap.
Right now it is entirely possible you are having arousals just from cpap and the alien on your face thing.
It is also possible that you have some UARS component going on.
It is also possible that medication side effects are playing a part in things...and don't tell me that you didn't have these side effects before cpap so it can't be the meds. When you deal with OSA things change and medication side effects can change because your body has changed. It's all a complicated mix of things. Mood meds can cause people to be more easily aroused and when we add in the new alien on the face thing...we just don't sleep as soundly as we need to.

If you want to pursue the UARS thing you are going to have to maybe try more minimum pressure for a period of time and experiment....and keep very detailed logs as to how you feel. Those subjective feelings are critical because the data from the machine isn't going to help all that much.
Big dose of patience...at least 2 weeks at a pressure setting with detailed logs as to how you slept and felt before trying a different pressure.

Good luck to you. I wish I had some miracle idea that I could pull out of my bag of tricks but I just don't and especially since you have been on cpap for just a week. It's really too soon to expect much change.

Malib · Post by **Malib** » Sun Jul 11, 2021 7:25 am

Pugsy wrote: ↑
Sun Jul 11, 2021 6:21 am

Malib wrote: ↑
Sun Jul 11, 2021 3:05 am
I think micro-arousals are what I should be focusing on but I have no way to measure them, it would be interesting to see how many I have now.
Actually you do sort of have a way to look for micro arousals. Manually count them. Fairly easy to spot on the flow rate. Don't zoom in quite so much on each breath though.
Watch the videos here
http://freecpapadvice.com/sleepyhead-free-software
Learn to spot awake/arousal breathing flow rate from asleep flow rate.
Remember we don't necessarily remember arousals...just depends on how long we were awake or half awake.

Your meds potentially could be a factor if you look at the possible side effects. I am not saying we can blame all your problems on meds but they sure could be a factor.

If (big IF) there is some sort of UARS component to your sleep disordered breathing there really isn't anything that is going to be of much value on the data gathered from the cpap/apap machine. They just weren't designed for that level of detail.
The RERAs...maybe a little help but to be honest it's of limited value IMHO because to know for sure if we have a RERA we have to know for sure if we are asleep first of all and the machine doesn't know if you are asleep or awake. It only measures air flow....doesn't measure sleep status. At best when we see a RERA flag it just means the machine thinks your breathing LOOKS LIKE the breathing that is normally seen with people who are having respiratory event related arousals. It's something but not the end all be all marker.
My own personal opinion...FWIW.

UARS is a difficult diagnosis to make without a Pes device in place in a sleep lab sleep study.
From what I have read about for sure UARS diagnosed patients they tend to need more pressure than what apap machines will want to give. So while their software reports show a nice low AHI at so and so pressure in real life (and in sleep studies with the Pes device) they end up needing more pressure than the machine will feel the need to deliver so people have to start out with higher minimums than it looks like that might "need" per what the machine is doing. Sometimes a lot more. I know of one woman whose cpap machine said she was doing quite well at 8 cm pressure in terms of AHI but in terms of UARS needed 13 cm to deal with things when she had an in lab sleep cpap titration study with the Pes device.

You will have to go on more subjective feelings than data points offered on the software reports. It's hard because we like numbers to validate things but sometimes we just don't have numbers to back us up.

You do need to take a big dose of patience though. Most of the time when you see people talking about the overnight miracle thing with cpap treating OSA their OSA was a LOT worse than yours. The more severe the OSA the more likely to see marked changes and even then sometimes it takes a while. It does seem like the ones with the "mild" category diagnosis do seem to take longer to see results for some reason or other.

It takes a while of the body and brain to adjust to sleeping with the alien plastered on the face blowing air up the nose. I know in my case it was about 3 months before my brain quit waking me up just to tell me there was an alien on my face and I had zero problems with masks or stuff like that.

Having a lot of arousals going on ...no matter what the cause...messes with sleep quality and when you mess with sleep quality and don't get the normal cycles of sleep in the required normal percentages...we just feel like crap.
Right now it is entirely possible you are having arousals just from cpap and the alien on your face thing.
It is also possible that you have some UARS component going on.
It is also possible that medication side effects are playing a part in things...and don't tell me that you didn't have these side effects before cpap so it can't be the meds. When you deal with OSA things change and medication side effects can change because your body has changed. It's all a complicated mix of things. Mood meds can cause people to be more easily aroused and when we add in the new alien on the face thing...we just don't sleep as soundly as we need to.

If you want to pursue the UARS thing you are going to have to maybe try more minimum pressure for a period of time and experiment....and keep very detailed logs as to how you feel. Those subjective feelings are critical because the data from the machine isn't going to help all that much.
Big dose of patience...at least 2 weeks at a pressure setting with detailed logs as to how you slept and felt before trying a different pressure.

Good luck to you. I wish I had some miracle idea that I could pull out of my bag of tricks but I just don't and especially since you have been on cpap for just a week. It's really too soon to expect much change.

Thanks a lot. I will learn about spotting arousal breathing.
Yes, I'm sure my Bipolar meds have a bit of a role but I can't afford to go off them, they quite literally saved my life so I must adapt and overcome whatever side effects they have on sleep.

About the arousals, I had 15 arousals/hour even before CPAP so it can't be only the mask thing.
I'm going to keep my minimum pressure at 8 (instead of the 5 prescribed) and see where this goes. I really really think, after ready dozens and dozens of stuff about UARS, that I have it for whatever reason. I'll keep detailed logs and report back soon if need be.

Help with OSCAR flow rate/limitation

Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation

Re: Help with OSCAR flow rate/limitation