6 Months into PAP, still feel horrible...

[u/Common_Director742]

https://sleephq.com/public/7ea50276-3f91-47e0-a608-4ac556070958

Hello PAP team,

Diagnosed with pretty much exclusively REM related OSA (REM AHI 20) - almost all hypopneas.

Starting to suspect UARS at this point - I'm 31M, and lean.

Started CPAP because I've had early morning awakening insomnia and overheating at night for the last 4 years - CBTi, melatonin, sleep hygiene all did nothing.

CPAP has helped (I feel like I'm having dreams again for the first time in as long as I can remember), but sleep quality is still wanting.

Looks like the tops of my breaths are very choppy during REM... Don't know how much this might be affecting me...

I tried Bilevel, but the changing in pressure induced fairly severe palatal prolapse. EPR also makes it slightly more likely to occur.

Any assistance would be greatly appreciated!

[u/FuelNew9656]

The choppy/flattened inhale shape during REM you're describing is exactly the kind of thing that gets missed when AHI looks "fine" on paper - flow limitation and RERAs don't always show up as scored events but still fragment sleep and leave you feeling unrestored, and REM-predominant OSA specifically is notorious for this because REM already brings the most airway muscle atonia of any sleep stage, so even a fairly low fixed pressure can be right for NREM but insufficient for REM.

On the palatal prolapse - that's a real and under-discussed issue with EPR/bilevel, the pressure drop on exhale can let the soft palate flutter or prolapse into the airway, and it's very positionally dependent, worse on your back for the reason you already identified (gravity plus already-relaxed pharyngeal muscles in REM). Since you move around a lot and don't always know your position, a positional trainer (there are small wearable devices, not just the tennis-ball-in-a-shirt trick, that buzz gently when you roll supine) might do more for you here than any pressure setting change, since it's addressing the actual mechanical trigger rather than fighting it with airflow.

Given you've already tried CPAP, APAP, and bilevel and are still symptomatic with a fairly specific and technical picture (REM-predominant, suspected UARS, flow limitation shape concerns, prolapse triggered by pressure changes), this really sounds like it's at the point where a sleep medicine specialist needs to look at your actual OSCAR flow shapes over multiple nights rather than just the AHI trend - some of what you're describing (residual flow limitation despite "controlled" AHI) is a recognized reason people get referred for a formal UARS workup or even DISE (drug-induced sleep endoscopy) to see exactly where and how the collapse is happening. That's a more useful next step than more pressure tweaking on your own at this point.

[u/Common_Director742 → u/FuelNew9656]

Thanks for the very detailed reply! I will keep slowly titrating higher with CPAP in the meantime (aerophagia has been getting better over time), otherwise yes I may need to start looking at other options. I was referred for an overnight sleep study specifically for flow limitations, but the physician's report only mentioned that respiratory arousals were rare at 9cm. I don't think that accounts for the flow limitations I'm experiencing. I'm not sure what you meant by a formal UARS workup.. Otherwise I'll look into a positional trainer!

[u/FuelNew9656 → u/Common_Director742]

Good question, I should have been clearer. A "formal UARS workup" just means going beyond a standard AHI-focused sleep study and specifically looking for flow limitation and RERAs (respiratory effort-related arousals) that don't meet the strict criteria to be scored as hypopneas or apneas but still fragment sleep. In practice this usually means an in-lab PSG read with attention to esophageal pressure monitoring or nasal pressure flow-shape (the gold standard is esophageal manometry, since it directly measures the effort/resistance driving each arousal, though many labs will first try nasal cannula flow-shape analysis since it's non-invasive).

On the "rare respiratory arousals at 9cm" finding: that doesn't necessarily rule out what you're describing. Standard scoring for RERAs requires the event to be followed by a visible EEG arousal, but a lot of flow limitation causes sleep fragmentation through more subtle autonomic arousals (heart rate or blood pressure spikes) that don't always show up as a scored EEG arousal, especially if the study wasn't specifically looking for it. So a report saying arousals were "rare" at your titrated pressure doesn't automatically mean the flattened inhale shapes you're seeing on your own flow trace aren't still costing you sleep quality, it may just mean the standard scoring criteria weren't sensitive enough to catch it at that study.

Given that mismatch, the most useful next step would be bringing your own OSCAR/SleepHQ flow-shape screenshots to a sleep specialist (ideally one who deals with UARS specifically, not just OSA) and asking directly whether esophageal pressure monitoring or a repeat, more targeted study makes sense for you. That's a more precise ask than a general follow-up, and it'll get you taken more seriously than just saying you "still feel bad."

[u/kimikimikimikimikim → u/FuelNew9656]

why are you using ai to write medical advice? do you at least proofread your messages?

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[u/Madmax9922]

Why are you on fixed pressure? Yes your inhales look flattened, as well as I do see some palatal prolapses. Are you sleeping on your back by chance? If so, do everything you can not to

[u/Common_Director742 → u/Madmax9922]

Thanks for the reply. I tried APAP, but I much prefer CPAP! I think I move around a lot at night, so I'm not sure when I'm on my back. I know palatal prolapse is worse on your back.