Expiratory palatal obstruction

My DISE showed severe collapse at the soft palate, tongue, and epiglottis. “Expiratory palatal obstruction” is when the soft palate flaps back into the nose upon mid-nasal expiration, preventing CPAP from being effective. Does anyone know how it can be determined that this is occurring? If the breathing looks stable (according to my sleep doc) and the objective data is good — AHI of 1 or less — how does one know? Subjectively, I feel not much better on CPAP (severe fatigue and other symptoms) and I suspect I am still having many arousals.

I suspect your ENT doctor is just dying to operate, yes?

I would get another opinion if nothing else.

Btw, you said your 'DISE" (drug induced sleep endoscopy) showed severe collapse, etc... so why do you ask how to tell if the collapse is occurring?

DISE seems to be something used more overseas, maybe to a greater extent than here, as I had to look it up.

It’s more about my complaints to the ENT that CPAP is not resolving my fatigue and symptoms and that sleep quality is poor. I asked how to tell if the “expiratory palatal collapse” is occurring on PAP. That is, if PAP is ineffective when used to treat this. I suppose another “DISE” while ON CPAP would tell. But I’m in no position to do that.

Well, I don't know why you're only on straight Cpap at 7, didn't realize til now that you do have a history here in other threads (best to stick to the same ones so people don't have to look all over), but in any case, can you download Oscar (free) software and post according to instructions, so we can take a new look at what's what... it's on a stickie at the top of the page.

Okaythen wrote: ↑

Wed Jun 10, 2020 5:11 am

That is, if PAP is ineffective when used to treat this.

You don't mention anything about your AHI or your leak level. Are you keeping an eye on it using OSCAR or even just looking at the machine display? You can tell if CPAP is ineffective by looking at the data.

BiPap is set to CPAP straight 7 pressure

That's a low pressure. Some people only need a low pressure, but most need higher pressures. Check your data to see if CPAP is effective.

Julie, I’m on a pressure of 8 now. Gotta update that. I’ll try and do as you suggested.

Whale Road, I mentioned in the post that my AHI is 1 or less. The data looks fine. But I don’t feel fine, AT ALL. Could the type of obstruction described make cpap ineffective despite having perfectly fine data? It sounds like a dumb question. I am clearly still having a lot of arousals judging by my poor sleep quality.

Are you on any medications? If so, what?

Any other physical or mental health issues that might impact sleep quality and how you feel?

How many hours of sleep are you getting?

How many wake ups during the night do you remember?

Before any meds, my sleep quality was just as bad on PAP. Now I’m on Paxil and low-dose Ativan (not before bed).

Chronic Fatigue Syndrome was suggested. No psychiatric issues at present. I’m trying to rule out it being an unusual case of anatomical obstruction which can make PAP ineffective, like what I described. If I can do that, then the diagnosis is likely CFS.

9-11 hours of sleep per night.

1-3 awakenings per night

Paxil side effects....look them up....bad, bad nasty side effects in terms of what it does to sleep quality as well as how we feel during the day.
It's a SSRI class medication....google "SSRIs and sleep" and start reading. Well known to not only have those nasty side effects but they actually mess with the sleep cycles themselves. Well known to suppress REM stage sleep so you don't get the needed amount of REM sleep.
Meds may not be all your problem but they could very well be a significant factor in why you don't feel so great on cpap therapy.

As far as your original question...how to know if you are still experiencing expiratory palatal obstruction while on cpap...you already know the answer to that...you need another DISE while using cpap to document it.

You might take the time to learn to evaluate the flow rate and look for low level flow rate reductions that might cause arousals and the flow rate reductions might not be enough to earn a flag of some sort. It's about the only way the data from the machine might help and that's a big maybe.
http://freecpapadvice.com/sleepyhead-free-software

Remember cpap only fixes bad sleep when the bad sleep is related to airway issues. It doesn't fix bad sleep when the cause is from anything other than airway issues (like medication side effects or insomnia). The list for potential culprits for bad sleep is miles long and sleep apnea is but one item on that list.

The very reason you were put on Paxil in the first place is also well known to mess with sleep and how you feel.

Thanks very much for your feedback, Pugsy. I appreciate it. Regarding the Paxil, I am aware of the side effects, but my hunch is that this is not the case. You see, I’ve only been on Paxil for a year and my bad sleep has been going on for 5 years. It was even worse 3 years ago. Will look into the flow rate.

A hallmark feature of CFS is poor, nonrestorative sleep.

I’m in no shape to get that DISE done in order to solve the puzzle, unfortunately.

Thanks for your help.

Sounds like they put you on Paxil for CFS. It's unfortunate because the side effects actually mimic CFS symptoms AND are documented to mess with REM sleep which ends up causing the very symptoms you are trying to reduce. We really have no way to know if it helps or not.

Learn how to evaluate the flow rate and look for arousals. It can't always explain the why behind the arousals (we don't always remember arousals) but it can at least tell you if you had a lot of arousals which explains the non restorative sleep and then you have to do more detective work to try to figure out the why behind the arousals.
I have done this myself. I might remember a half a dozen arousals but I always have probably 20 to 25 and sometimes more but I know the cause of mine...pain in the back and pelvis.
A few arousals are normal. Like it's normal to awaken briefly after a REM cycle. Most of the time we don't remember them though because we aren't awake long enough to form a memory of the awakening.

Very helpful. Thank you, again!

I wish they had a better alternative for CFS issues than the mood meds because the mood meds all come with so much baggage it's almost always impossible to fix the problem with a medication that are so well know to have those kinds of side effects.
My doctor and I have had this same discussion when I complain of poor sleep and the back pain. I refused to even give them a try.
I did the Paxil thing some years ago when going through a painful divorce and it didn't take me long to realize that the side effects were a whole lot worse than my mental state at the time. I quickly abandoned it in favor of just bulling through the mental issues knowing I would eventually sort them out and heal and I didn't have OSA to mess with my sleep at that time.

I agree. While there are differing theories on CFS and there’s a way to go before the underlying pathology is discovered, the notion that nueroinflammation is present in patients with CFS warrants a potential medication that crosses the BBB (blood-brain barrier). Currently, there is no real drug that would be effective in reducing inflammation in that manner.

Nothing of the pain meds works for you, huh? At least you have a target, though. You’ve tried CBD oil and the like?

I have my own chronic pain issues (it's a fun issue, isn't it?). In my case the problem is my back. Paxil is one of many medications I take to help with this (for me, Paxil also helps by preventing severe anxiety attacks that I've had since my 20s ... aka a long time). Another medication I take is gabapentin (neurontin). It has off-label applications around nerve pain issues including CFS related pain. Gabapentin DOES have its own sleep-related issues, and is known to spike apnea indexes in some people, so approach with caution ... but those studies appear to be without regard to existing sleep apnea treatment (here's one article on the subject: https://onlinelibrary.wiley.com/doi/ful ... /jsr.12495).
Gabapentin also causes (for me) a bit of a mental fog, though a cup of coffee in the morning seems to alleviate it. I did choose to reduce my dosage because of this, but not eliminate it. It's all about choices. I could choose (and was at one point) to have a high-ish dose of morphine, but it has declining benefits over time. My doctor suggested the gabapentin and it has a definite, but not immediately obvious, benefit. I was able to greatly reduce other pain medications.
So it's not a perfect medication (no medication is), not by a long shot, but it might help.
I'm not a doctor, so I can't say if gabapentin is even an option for you, but I consulted Dr. Internet on this, and it appears to be...
(Yeah, I know Dr. Internet is a poor choice, but I don't have other options right now)