UARS suspected, Optimizing CPAP treatment

Hi,
My doctors initially diagnosed OSA and now suspect UARS. You will see an AHI of zero, but my sleep quality is still bad. I'd like to discuss 2 topics:
1. Do you also suspect I have UARS?
2. What are your thoughts for treatment (ie pressure settings, EPR and type of machine)?

CPAP and Sleep Study Background
CPAP Treatment Duration: started about a year ago, originally diagnosed with OSA though that was due to sleeping on back. Very slow adaption to CPAP ~9 months. Now side sleeping 99% of night.
Intolerant of higher pressures which causes sinus, jaw and neck pain above 8.5cm.
O2 levels - monitored overnight, not an issue, over 90%

Recent Pressure history, AHI & FL averaged over a min of 7 days
Date AHI, FL, Min, Max (cmH20)
3/7, 1.4, .58, 8,0 10,
3/27, 0.48, 0.44, 8.5, 10,0
5/25, 0.31, 1.11, 9, 10.0
Note that AHI trends down, FL (Flow Limitation) going up with pressure

Symptoms
Chronic sinusitis, chronic coughing during waking hours, caused by chronic post nasal drip
Allergies - allergy tests show no major issue, but react strongly to any pollen all yearound.
Lungs - irritated due to coughing up mucus and irritation from pollen, etc
Essentially my sinus and lungs are hypersensitive and this has worsened over the years. Classic UARS symptoms.
Sleep quality- still wake up groggy. Bad sleep quality. perhaps 5% improvement from CPAP so far which is not too encouraging.

Questions
Do I likely have UARS and could micro-arousals (which are Flow Limitations and/or "unflagged" Flow Limitations) which could be a major part of my sleep quality?
From reading about micro-arousals they may only be detectable from an EEG or nasal canula. Note that Flow LImitation events have increased with pressure. Seems like min pressure should continue being set higher in small steps. 

Next possible steps?
Slowly increase min pressure by 0.5cm every 2 weeks and observe results by how rested I feel. The problem is that I cannot tolerate higher pressures. Perhaps I will tolerate higher pressures better using a machine with improved exhalation pressure relief. Such as a BiPAP machine, or a different Auto CPAP machine like Resmed which provides more EPR relief (ie greater than 2.5cm of exhalation pressure relief)?

Attached Screen shots
1. Zoom into an unknown event that is not flagged - I have about 1 of these events every 10 to 15 minutes.
2. Zoom into a Flow Limitation event
3. Full night of data, I don't have OSA so it seems like AHI of zero is not relevant.

What are your thoughts and/or questions?

Thanks!

jaygeils wrote: ↑

Mon Jun 08, 2020 12:07 pm

Chronic sinusitis, chronic coughing during waking hours, caused by chronic post nasal drip
Allergies - allergy tests show no major issue, but react strongly to any pollen all yearound.
Lungs - irritated due to coughing up mucus and irritation from pollen, etc
Essentially my sinus and lungs are hypersensitive and this has worsened over the years. Classic UARS symptoms.

How long has it been since you were tested for allergies? Have you discussed all these symptoms with your ENT?

jaygeils,

Your thread topic is in a present area of my study.

Please consider adding the FL graph below the FR graph in another post to this thread. I snipped and slightly enlarged a bit from your 3' 48" FR graphic as below. It shows the wrinkled trace of the FR curve a bit more; I refer to that below.

Others more knowledgeable than I may want more graphs to respond to you (if they haven't responded while I type this). They might ask for a redacted copy of your sleep study. Personally, I'd like to see typical 30 second and 2 minute duration images that have the FR curve stretched to about a 1.5-2 inch height, both with and without FL and including leak.

I've recently begun focusing on the question of what bodily breathing impairments, other than those scored in AHI, disturb our sleep. I have no answers and may never have more of them. However, there has been a lot of interesting research probing the factors in RERA and UARS. With the little I think I have learned, the irregular, never smooth flows throughout one of your breath cycles would cause me to believe I have something close to UARS, if not actually UARS. My understanding is that RERA must be present to some extent, for a diagnosis of UARS, just as a certain number of apneas must be present to diagnose SA. I know little to nothing about RERA and UARS, though I suspect I have some (Vauto) non-scoreable RERA and UARS. I don't know what can be done about it, but if applicable to me want to understand it. A few RERA were (mis-?)scored by my Autoset during the rough first month of my treatment in 2011.

I'm trying to learn about those breathing disturbances and am using an accelerometer to get a feel for how much physical activity (that is, the motions of my trunk as sensed at the lower back) coincides with FR, FL and leak disturbances and changes. I expect that the frequency, length and intensity level of that activity would correlate with RERA. Of course, an EEG is the tool for such determinations, but is beyond our reach at home. Nevertheless, something useful may be found from motion data that is synced with usual sleep metrics.

I see you found you must side-sleep to cut OSA, just as I did, but only after the accelerometer's data convinced me of my supine sleep I was in denial about. Further, the device gave feedback to indicate when I had stopped the habit. OSCAR will import and present motion data along with its other graphics. Anyone who has succeeded in greatly lowering AHI but has continuing poor sleep should also find out how much they move and what their positions are in sleep.

We know we are "medically treated" for SA when we get below an AHI of 5.0. But we also know that this and other sleep forums take exception with any claim that the SA affected should consider that the best that can be done to get more restful sleep. My thought is that once we have AHI down near zero, the main question still is how restful is our sleep. We got our near zero AHI. If we once knew and can remember and recognize good sleep and have it, then let's rest in it. Otherwise, some of us whose sleep is vastly improved, had bad sleep for so many years, we may not remember what good sleep feels like. Just as we weren't satisfied with our 5.0 "treatment", we want to dig a bit deeper into the topic, below the 0.0 grail, and make some effort to see how much better it can be.

ASB

Any chance you could swap this machine for the ResMed AirSense 10 AutoSet for Her model?

ChicagoGranny, AmSleepnBetta & Pugsy,

Thank you for your quick feedback and questions! I have responded to each of you further below.

Update: This morning my sleep doctor thought my numbers and data look good. The Doctor did not feel I had UARS. I am not convinced and will seek a second opinion.
Btw, I have other classic UARS symptom - cold hands and feet. My body type is thin. I have had many tests for diseases and syndrome by specialists and my primary care which ruled out other weird factors. They say I am fundamentally healthy except for my obviously heightened immune response in my upper and lower respiratory system.

ChicagoGrany> How long has it been since you were tested for allergies? Have you discussed all these symptoms with your ENT?
>> Countless allergy tests and multiple sinus surgeries. Allergist and ENT strategies have not resulted in improvement. I am now focusing on sleep quality.

AmSleepnBetta> Please consider adding the FL graph below the FR graph...
>> Sorry, a FL graph is not possible, I don't have a Resmed machine.
>> My sleep study was over a year ago and showed a dominance of OSA from back sleeping. It's now out of date and not much use as my events have evolved from OSA. Restless limbs are not likely. I recorded myself for 2 nights using night-vision camera and saw minimal limb movement. RERAs also not present as you can see.

Pugsy> Any chance you could swap this machine for the ResMed AirSense 10 AutoSet for Her model?
>> I noticed you suggested this machine previously for UARS. I am asking about evaluating "ResMed..for Her". I am arleady finding that it's more tricky to swap or loan during the pandemic. I will explore further. Worst case I will consider renting or buying a different machine, but should it be "ResMed AirSense 10 Autoset for Her" or ResMed BiPAP? The "ResMed .. for Her" algorithm may respond to FL events better. But suppose it turns it turns out I need much higher min pressure - then the Bi-level may help me tolerate higher pressures better since it supports an exhalation pressure relief greater than 3cm below Inhalation. But the Bi-level is much more expensive - so I guess start with "..for Her".

jaygeils wrote: ↑

Tue Jun 09, 2020 3:32 pm

But suppose it turns it turns out I need much higher min pressure - then the Bi-level may help me tolerate higher pressures better since it supports an exhalation pressure relief greater than 3cm below Inhalation. But the Bi-level is much more expensive - so I guess start with "..for Her".

The answer depends in part on how you are funding.

If out of pocket, you could always get a bilevel like the Resmed Aircurve VAuto, which would give you more flexibility.

On the new market, it's true it (much) more expensive.

But there are options, including used, where you can find them at substantial discounts.

If insurance is paying, it's more complicated, and you need to start with the ABPAP (like the autoset) typically.

I bought a low hour Vauto at and see more of those Resmed AirCurve VPAP machines at OfferUp. They claim to have (good?, I don't , know) buyer protections like ebay. Just checked and saw more such low prices in a search of "ResMed" at OfferUp.com. You need to create a free account to interact.

I used their seller a question feature to set up conditions my subsequent offer would be conditioned on: actual lifetime run hours , their response timeliness (expiration of my offer), non-smoking history, etc.

...that was supposed to read "ask the seller a question feature"