avi123 wrote:I am surprised that you're still using the term "insomnia" instead the more defined medical terms such as fragmentation of sleep, latency of ....., delay or absent of REM etc. Also, why don't you set it on straight CPAP and see what's happening. What if you set inspiration at 7 cm and the Flex to reduce it to 5 or 4, what then?
Since you have no problems falling asleep initially, also after going to BR, and you sleep thru the stages (what about REM = dreams?) for a total of 6 t 7 hrs, what other problems left?
Avi123, my PA calls it "insomnia" as well as fragmentation of sleep cycles. It has involved problems with latency to sleep, problems with maintaining sleep, problems with getting into Stage 3/4 sleep, problems with feeling unrested, unrestored, unrefreshed upon waking for the morning. And while I'm in bed for a
maximum of
six hours every night, my total sleep time is consistently running between 4 1/2 and 5 1/2 hours. My ongoing insomnia/sleep fragmentation problems have manifested themselves with typical insomnia symptoms of daytime sleepiness, but being too alert at bedtime to fall asleep in a normal fashion and waking up frequently at night with much difficulty returning to sleep. But even at its worst, my insomnia monster has NOT involved problems with getting into REM. My previous bouts with insomnia have never involved any problems with getting into REM either. And quite frankly, my OSA never caused problems with getting into REM. [On my diagnostic sleep test, my REM AHI was better than my non-REM AHI.]
Now that I am several WEEKS into the sleep restriction therapy, some (not all) of my insomnia symptoms and problems are
beginning to improve or be eliminated. For example, I am having no problems falling asleep when I go to bed on most nights----because I'm going to bed no earlier than 1:30 AM and I'm getting up at 7:30 AM every morning---with no daytime naps. So the body is tired and sleepy enough to prevent the brain from yakking away to keep me awake for 30 minutes or more. But even now about 2 or 3 out of every 7 nights, I am not
sleepy enough at my PA-dictated bedtime of 1:30 to go to bed and I actually am up until 2:00 or 2:30 am when I do get sleepy enough to go to bed---because my PA's bedtime rule is technically that I am to go to bed at the LATER of the following:
- 1:30 AM if I am feeling sleepy OR when I am feeling sleepy enough to fall asleep within 20 minutes of going to bed
And I if I am not asleep within 30 minutes of getting into bed I am to get OUT of bed and LEAVE my bedroom and do something in a different room until I am feeling sleepy enough to return to bed and try again. During the first four weeks of working on the sleep restriction therapy, this was happening on an all too frequent basis. And I am not naive enough to believe that it will never happen again. But I am overjoyed that it has NOT happened in the last two weeks.
Likewise, the sleep restriction therapy is
slowly teaching my body how to sleep more soundly for longer periods of time. So instead of waking up five to seven times a night like I was doing back in December and early January, I'm now usually waking up two to four times a night. [But do the math: Six hours in bed divided by an average of three wake ups per night means that there are plenty of nights that I'm averaging only two hours of sleep at a time---at most.] And with the aid of the sleep restriction therapy,
slowly my body is forcing my brain to not become so alert at those wake ups. So instead of being awake for 15 or 20 minutes (or even longer) for EVERY wake up, on some of the wakes, I am able to get back to sleep much more quickly---like a normal non-insomniac person. But even so, there are several nights a week that I have at least one awakening where I'm awake long enough were I have to start thinking seriously about whether it's time to get out of bed to do something else until I get sleepy enough to come back to bed. It's been two weeks now since I've had to actually get out of bed---except for the sleep study when I used "I need to go to the bathroom" as an excuse to get out of the bed because I was DESPERATE to get out of the bed to regroup my thoughts and settle myself down enough to try to get back to sleep after the second wake up when I was extremely anxious and lying there getting more and more alert instead of getting back to sleep. But again I am not naive enough to believe that I'll never have to get out of bed because I can't get back to sleep again.
So fine---if you don't think
insomnia is the right word, call it what you will. But right now, I'd describe my problem as
insomnia on the mend or maybe myself as a
recovering insomniac. It's not as bad as it was back in October, November, December, and most of January---because I've put six weeks of HARD, HARD work into fixing this problem through cognitive behavior therapy: Hard work involving sleep restriction, caffeine restriction, even more attention than normal to good sleep hygiene (and at the start of this process, my PA said I had extremely good sleep hygiene practices in most respects), getting back into an exercise routine, and a far more rigid wake up time seven days a week than I have ever been willing to live with in the past. But my sleep remains a delicate problem. And there is (at this point) the constant knowledge that my sleep cycles are not yet well consolidated---my body still cannot reliably sleep as long as two or three hours at one time without waking up, let alone six (or seven or eight hours). The progress I've made is not yet on so firm a foundation as to be regarded as permanent. There's the real risk of a major backwards slide into the chaos of last fall if I don't consciously continue to work HARD on dealing with the insomnia monster---even as it looks like he is finally beginning to die.
As for why I don't set my BiPAP on straight CPAP? Been there, done that and that is what TRIGGERED the insomnia in the first place. As well as a severe, sudden and alarming decrease in my daytime functioning. Some four months ago. Although by the end of December the insomnia monster was feeding on issues far and wide in my life beyond the mere need to put a hose on my nose at night. You probably came in late to the story.
Flex? I cannot stand flex---there's been more than one thread on that too: When I'm awake I can feel the pressure come back up before I'm done exhaling and it KEEPS ME AWAKE and MAKES ME MORE ALERT. WAY MORE ALERT. And it causes more problems for the stomach than it solves---for me.
The sleep doctor and PA decided to recommend the BiPAP titration back in November because of the on-going aerophagia problems at relatively LOW pressure settings combined with my total collapse in daytime functioning when I started CPAP. Yes, I know it doesn't make sense to lots of folks that I could have aerophagia on a Resmed S9 APAP running at 4--8 cm with EPR set to 3. And I know that to some folks it makes no sense that the doctor's decision to switch me to a BiPAP was based on nothing more than my continued problems with aerophagia and the fact that I was crashing and burning in terms of daytime functioning on both CPAP and APAP during the first two months of xPAP therapy. And by crashing and burning ---I mean just that: I went from being a normal, functioning adult pre-CPAP to a completely non-functioning basket case with severe, excessive daytime sleepiness issues and exhaustion of the sort that I have never felt before---even when pregnant. And it seems to make no sense to some folks that my current setup of a Resprionics BiPAP with IPAP = 8 and EPAP = 6 with Bi-Flex = OFF (and Rise = 3) has given some relief to the aerophagia problems on the one hand, but not solved them completely on the other hand.
I'm an outlier: On paper there was no reason to suspect that I should have had any problems adjusting to xPAP therapy. Or so my sleep doctor told me back before I got the S9 AutoSet---he said I'd be feeling better than ever two weeks after starting therapy. Instead I was crashing and burning and hanging on by my fingernails desperately wondering how I'd ever survive a therapy that was making me feel worse than I'd ever felt in my entire life.
The sleep doctor's PA literally saved me from tossing the S9 into the closet back in October or November and has worked with me throughout a difficult transition period. She has been most patient with me and has genuinely listened to me in a way the doctor did not. And she has respected my wishes to deal with the insomnia with a minimum reliance on sleep meds in the short term and ideally with no reliance on sleep meds in the long term. The sleep restriction and cognitive behavior therapy approach to treating insomnia is not for the faint of heart. Nor is for those looking for a quick fix to insomnia. But it is the right approach
for me and I am lucky to have a PA who has both the knowledge and patience to guide me through it. The fact that she took the time to read my massive notes about the various night time wakenings and noticed the ongoing theme of "hit ramp because of air in stomach" and made the recommendation for yet another titration to see if a pressure adjustment could be done on the EPAP indicates the quality of her work: She is not one of those medical folks who just reviews the chart five minutes before you walk into the examining room; rather she takes the time to actually read and study the info in her patients' medical records and digests that info, and then is willing to look at the whole picture (the insomnia AND the apnea in my case) rather than just the pieces.
