AHI below 5 but still feeling tired

kiri wrote: I take antidepressants (escilatopram).

Unfortunately most of the antidepressant medication come with the fatigue/lack of energy side effect.
Unfortunately the depression itself often comes with fatigue/lack of energy side effect. Let's face it...that's part of the depression symptoms.

https://en.wikipedia.org/wiki/Escitalopram

http://www.emedicinehealth.com/drug-esc ... cle_em.htm

drowsiness, dizziness;
sleep problems (insomnia);

and more at the link

Google "Escitalopram side effects" and start reading...and read from multiple sources

It's in the class of medications called SSRI and pretty much all SSRI meds will also affect sleep architecture (messes with the sleep stages you need for the restorative powers of sleep to work their magic).

You can google "SSRI and sleep stages" and do some reading...there's lots out there.

The best cpap therapy in the world can't fix a problem unrelated to sleep apnea and there's a real good chance that the bulk of your lack of energy and tired feeling is caused by not only your depression but the medication for treating depression.
It's a damned if you do and damned if you don't situation. I understand the reason for taking the medications and unfortunately even if you changed meds the replacement stands a good chance of being a trouble maker too. It's the nature of those types of medications unfortunately.

You might talk to your doctor about altering dosage or time of dosage to see if it helps with how you feel during the day.
Worth checking into.
Might also talk about changing meds but if you do then you need to research the medication thoroughly to see how likely it is to either cause fatigue/lack of energy or mess with your sleep quality in general.

Sometimes just knowing that our unwanted symptoms are caused by medications will help us deal with the unwanted symptoms a little better. Sort of be able to come to grips with the reality of the situation and it's nice to know that there is a known cause for the unwanted symptom and we can accept it more easily and not worry so much about it...which is counter productive and causes stress which can cause even more depression.

I am faced with a similar situation with some medications that I take...I have some pretty bad arthritis issues so I take a pain pill which does help (not an opiate either) but unfortunately one of the known side effects is insomnia despite the "may cause drowsiness" sticker on the bottle. It doesn't really make me drowsy at all...it wires me up a bit and that's why I don't sleep well if I take it in the evening. So my doctor and I had to do some experimenting to find something to help with the night time pain (because if I didn't take something to help with the pain I wouldn't sleep well because of the pain) that didn't cause insomnia. We finally came to a workable compromise for night time pain management which involved not only meds but some changes in the bed itself.
It's frustrating that my usual pain meds causes poor sleep quality but knowing that it can do that relieves my brain a bit and I know there is a real reason for it and it's not "just in my head" or menopause (one doctor blamed everything on menopause).
Knowing allows me to move on and try to fix the problem and one has to know what the problem is before it can ever be fixed.

The answers to your unwanted symptoms are unlikely to be found in the cpap reports because cpap can't fix problems that aren't related to sleep apnea.
If your software reports don't show anything that just screams out "fix me"...maybe time to look at other culprits besides sleep apnea and/or cpap therapy.

I know we all want to have cpap fix all that ails us but it simply can't do that. It doesn't/can't fix my poor sleep caused by pain and it can't fix the insomnia caused by the pain meds...no matter how much I wish it could.

kiri wrote:Thanks for all the advice.

@Pugsy, I'm on CPAP the whole 9-10 hours.

I take antidepressants (escilatopram).

See what Pugsy has written about the escilatopram.

@Robysue, thanks for the moral support

That's part of what we're here for.

Aerophagia is medium-level bad I guess. Discomfort from it wakes me up while on CPAP. Makes me fart a lot, and during the day constant feeling of needing to burp but unable to get the air to come out. I'm also sometimes waking up with reflux.

Given that the aerophagia is waking you up, along with the reflux, I'd be cautious about raising the pressure, at least for now. What I mean is this: You may have to work out a compromise: A bit higher treated AHI in exchange for less aerophagia. In other words, in the long run, you may feel better with an AHI in the 2-4 range with less aerophagia than an AHI < 1 but more aerophagia.

What do you do for the reflux? Just ignore it? The self-help guidelines for dealing with reflux may also help with the aerophagia. Have you considered raising the head of your bed slightly?

I do tend to eat just before bed, which has been a lifelong habit, which I need to try kicking. I'll try to avoid that for a few days and then report back on the results.

Do try it for a few days track whether it makes a difference in terms of the aerophagia.

Not sure if I should turn EPR on because it seems to make the apnea worse, but I'll try it some day.

How much worse does the apnea get when EPR is turned on? If we're talking about the AHI going from 1 to 2 or 3, then base your decision on comfort: In the long run you will sleep better with an AHI between 2 and 3 and little or no aerophagia instead of an AHI < 1 with enough aerophagia to wake you up.

Having said that, let me also add: Change ONE thing at a time. That's the only way you can track whether a change is positive, negative, or neutral in terms of making you feel better.

So for the next 4 or 5 days, eliminate the just before bedtime snacking and see if that makes any difference.

After you know whether bedtime snacking is/is not aggravating the aerophagia, then turn on EPR and see if that helps the aerophagia issues.

Drooling/rainout problem: Drooling wasn't a big problem before CPAP. However I'm not sure if I wasn't drooling, or whether the drool just dried in the morning. I'll reduce humidity tonight and see if it drops the water in the mask problem. Hopefully less humidity won't mean dry sinus again.

You'll know almost immediately if your nose requires a lot of humidity. Pugsy and I both have noses that love excess humidity and our noses let us know immediately if they're not getting enough for some reason. Others find that their nose actually does better with less humidity.

Also: Do you have a heated hose? If so, what temperature setting are you using? If you can tolerate a bit more heat in the hose, that can help with the condensation problem.

Since you are using a FFM, you might also want to look at using a mask liner.

Depression is quite bad. I've been depressed for 7 years or so (i'm 25). It used to be much worse, I felt very negative each day, but with the medicine I usually only feel neutral or slightly negative. Actually I was hoping CPAP would give me the energy to make a change to my depression, but it hasn't happened yet. I'll need to get rid of all these problems with CPAP I guess.

In the long run, using the CPAP may indeed help with depressive symptoms. But it's a process, not an instant fix. In other words, you need to keep these points in mind:

1) CPAP doesn't fix bad sleep. It fixes sleep apnea and nothing else. If there are other things in addition to the sleep apnea that are causing the quality of your sleep to be bad, then those other things have to be addressed as well. And that's a process, but if you fix the other things that are wrong and allow the CPAP to fix the apnea, then you will gradually start to feel better.

2) If sleep apnea is the only cause for the bad sleep, then once you are sleeping well with the machine, you will (gradually) start to feel better.

3) You are still a new CPAPer and you are still learning how to sleep well with the machine. You've made some real progress, but the aerophagia may be bothering your sleep than you realize. That's why I think we need to start there as far as the CPAP stuff is concerned.

4) Major depression can adversely affect the quality of sleep and, as you well know, the quality of sleep can adversely affect the depression. CPAP is one tool that you are using to try to break the feedback loop that exists between your depression and your sleep issues. But you also need to consider whether there are things that you can do to tackle the depression part of the loop as well. Other than taking the escilatopram, what kinds of things do you do to try to manage the depression? How long has it been since you talked to the doctor who prescribed the escilatopram? Have you had a discussion about the fact that you feel only marginally better (in terms of mood) with the escilatopram? Have you talked about the potential side effects of the escilatopram? If I were you, that's where I would start on trying to attack the "depression aggravates sleep issues" part of the puzzle.

Heres the graph for last night. Some things I can point out with my rudimentry knowledge: pressure seems to be hitting the ceiling so I need to raise the max again. Leak rate seems to spike several times a night. I believe the cause of this, if I'm not mistaken, was when I was wiping the saliva away from the sides of the mask. If this is true then I must have woken up several times in the night too. Again not sure why central apneas are so much higher than obstructive apneas.

change your pressure to 10 min 14 max tonight and see where it lands. Did you have centrals in the sleep study, ot have they started since cpap, if the latter they should resolve within 12 weeks. You have the epr off and that's a good idea.

google about valdoxan, it's not on PBS and is $60 a month. I think it works well.

Look closely at when some of those centrals are flagged. Several appear at the same time as a big leak spike where you likely were wiping the mask...awake or semi awake at least. I suspect that some of them are SWJ centrals and don't count.
If some are SWJ and some are normal sleep onset centrals and we remove the SWJ centrals from the evaluation process I think the numbers will be less alarming (though even right now if that were all real centrals there's not enough to be alarming).

I don't know that I would jump from an 8 minimum to a 10 minimum in one big jump but I would maybe raise the minimum maybe 0.5 to 1.0 and open the max up a bit. I tend to be real conservative with increases unless there is an obvious huge need for a bigger jump and I don't see it here. The centrals we can't do anything about with your machine and there's not enough of them to need to do anything about them at this time...so all we can do with this machine is try stuff that can be fixed with this machine...your AHI is mainly hyponeas if we remove the centrals from the evaluation and usually hyponeas take very little more pressure to get them killed.

In your situation with such a tight range I would open up the max before I ever changed the minimum if it were me. I like to keep any changes made to 1....remember science 101...keep your variables to a minimum so that you can best evaluate which change caused what result. If you make 2 changes at one time and something changes you won't know which change in setting brought about the change in results.

How come you are using such a tight range? Is it the aerophagia??? If so, I for sure wouldn't increase that minimum from 8 unless I absolutely had to.
There's nothing wrong with using a tight range but unless you have problems with a larger range there is no reason to run such a restrictive range.
If the aerophagia is why you are using such a restrictive range....change the maximum first if you are going to change anything and then only make a small change in the max at a time...like maybe 1.0 cm more.

There's no urgent need to change anything though...yes you are maxing out the pressure at times but your obstructive AHI (the OAs and hyponeas) is only around 2 and that's still pretty darn good. Sometimes just because the machine wants to go higher doesn't mean that we have to let it go higher if going higher creates bigger problems than what it might fix.

when you are titrated in a sleep study. They send you home with the correct treating pressure to be put into your machine. You start off on day one with the right number, be it 5,15 or more.

t's up you you how you do it, some like to play for a month doing it. For a conservative pressure range. Your median number is 10, your max should be around 14 and see where the 95% pressure lands. I would need a really good reason to do otherwise.

ajack wrote:Your median number is 10, your max should be around 14 and see where the 95% pressure lands

Median is close to 10...but we have no idea where the max might be. It might be 10.6 for all we know if looking at last night's report.
Heck, it might be 18....we just don't know about the max until the machine is allowed to go where it wants to go.

All well and good as long as a person doesn't have a problem with more pressure and letting the machine go to where it wants to go but if the higher pressures cause significant problems (like aerophagia) then a person has to sit back and regroup and decide at what point the aerophagia becomes more of a problem than a couple of apnea events slipping past the defenses by limiting the pressure so that the aerophagia is kept away.

95% numbers are just numbers and not the holy grail of anything.

I am thinking your 10 min and 14 range recommendation is going to cause significant aerophagia issues with this particular cpap user.
He already has complained about aerophagia in prior posts.
Why use more pressure when it clearly isn't urgently needed and there's a history of problems with aerophagia...all you are doing is changing one maybe very tiny problem into a much bigger problem that can make a person sick all day.

Yeah the machine wants to go higher but there's no urgent need to allow it to go higher if going higher causes more problems than it fixes and it might just end up doing that. Sometimes we have to make compromises.

ajack wrote:when you are titrated in a sleep study. They send you home with the correct treating pressure to be put into your machine.

Maybe in a perfect world an in lab titration study will get you the correct pressure but often it's not a perfect world.
I had an in lab titration sleep study and it was the entire night and not half the night and they still got it wrong by at least 2 cm.

you advise what you think, I'll advise what I think. The median, 95% and max pressure are very significant in the titration of an auto cpap. The 95% is often used as the fixed pressure cpap pressure, but if you don't know this, it's fine.

The resmart is a self titrating auto cpap. *Pmean is the average pressure number
http://www.multidoctorshop.com/image/da ... nual-2.pdf
Significance of Auto and Titrate Mode
The Titrate Mode is based on manual titration and its algorithm is sensitive to respiratory
events. Advantages: it can decrease AHI effectively and compute the P95 pressure
accurately. Disadvantages: it has large pressure range, the pressure changing is easy to
cause the patient discomfort.
The APAP combines the Titrate Mode with new Auto Mode to effectively adjust the
pressure for maximum comfort, with the premise of effective treatment. To get a accurate
P95 pressure, Titrate Mode is applicable for the first 1-2 weeks during the use. Based on
the P95 pressure, MAX APAP is determined. It is suggested to set the MAX APAP little
higher(1or 2 cm H2O) than P95 pressure. And based on the Pmean pressure, Treat P is
determined. It is suggested to set the Treat P little lower(1or 2 cm H2O) than Pmean
pressure. It can improve patient’s compliance with more accurate and humane pressure
range.

ajack wrote:you advise what you think, I'll advise what I think. The median, 95% and max pressure are very significant in the titration of an auto cpap. The 95% is often used as the fixed pressure cpap pressure, but if you don't know this, it's fine.

Yeah, I do know this but that doesn't make the 90/95% numbers the holy grail people think it is. I have a perfect example of why it isn't in another thread but photobucket has messed me up with my images and I need to redo them for people to see why 90/95% numbers are easily skewed or misleading. Maybe I can get it redone this weekend.

Plus you are forgetting one very important factor complicating the situation....aerophagia. What do you propose to do about that little complication?
It's kinda important for a lot of people and what you are advising is pretty much going to cause major belly issues. Maybe you don't care about that but I never want anything that I offer to make any situation worse and what you are offer almost certainly will make the problem worse and there simply is no urgent reason to do it in the first place.
Maybe you haven't ever experienced the joys of major aerophagia issues but I have and it's a lot more than some belching and farting.

Hell, if he wasn't already complaining of belly issues I would suggest opening the machine wide open and let the machine sort it out.

So go ahead and advise what you think and I will come right behind you and explain why it might not be the best option in some situations for some people if that is what I think needs to be said.

Your ideas have merit except for the one complication that we already know is going to be a factor....aerophagia...and that's pretty important.

Now if the AHI was high...and primarily obstructive and there was an obvious need for more baseline pressure I would advise going higher but go up slowly and see where the trigger point for the aerophagia might be and then decide the best options at that time.

Kiri,

The data from last night looks pretty good.

You write:

Heres the graph for last night. Some things I can point out with my rudimentry knowledge: pressure seems to be hitting the ceiling so I need to raise the max again.

Maybe, maybe not. There's nothing wrong with running at max pressure for extended periods of time if all of the following are true:

• The treated obstructive part of the AHI is consistently below 5.0
• The events that do get through are not tightly clustered together
• You feel rested when you wake up

Your data clearly shows the first two are true. The title of the thread shows the third is not. But you're still in the process of figuring things out and it could just take a while before you are sleeping well. You've complained of two cpap-related problems (aerophagia and rain-out and/or drool) that can cause problems with the quality of your sleep, and arbitrarily increasing the max pressure is not going to help with either of those issues. More on this in a bit.

Leak rate seems to spike several times a night. I believe the cause of this, if I'm not mistaken, was when I was wiping the saliva away from the sides of the mask. If this is true then I must have woken up several times in the night too.

My guess is that you have identified the cause of the leak spikes. That means the leaks themselves are not a serious problem: Even the one official Large Leak is not really long enough to worry about.

There are three things to keep in mind about wakes/arousals to wipe up the drool:

• Increasing the max pressure is unlikely to decrease the drooling, and hence unlikely to decrease the wakes/arousals for dealing with the drooling.
• Minimizing the time you are awake dealing with the drool will do more for the quality of your sleep than a pressure increase would.
• A few short wakes (to turn over, to make sure everything's ok in the sleep environment, to pull the covers on, to throw the covers off, etc) are normal even for folks with NO sleep disorders. So it may be unreasonable to think that you need to eliminate every last "wipe up the drool" wake. Eventually you should be able to do this "in your sleep", meaning you arouse just enough to do it, but you're awake for such a short period that it doesn't really disrupt the overall quality of your sleep.
  

  Again not sure why central apneas are so much higher than obstructive apneas.

  Read pugsy's theory about the centrals. I agree with her.
  
  And keep in mind that a higher max pressure is not going to eliminate the CAs.
  
  Now your real question is where to go from here. So I'm going to chime in with my two cents. First an observation. Earlier in the thread you wrote this

  kiri wrote:Still getting aerophagia.

  and this

  kiri wrote:Aerophagia is medium-level bad I guess. Discomfort from it wakes me up while on CPAP. Makes me fart a lot, and during the day constant feeling of needing to burp but unable to get the air to come out. I'm also sometimes waking up with reflux.

  Given your ongoing problems with aerophagia, I would NOT increase either the min or the max pressure right now. You already did an experiment with increasing the max pressure to 12, and it increased your problems with aerophagia. That was why you backed off the max pressure to 10.
  
  Your obstructive AHI = OAI + HI = 2.17 which is low enough to not really matter. Yes, you might be able to lower this number a bit by increasing either the max or min pressure, but the cost will likely be much more discomfort from aerophagia and many more aerophagia/reflux wakes and arousals. They'll be more disruptive to your overall sleep than the small number of OAs and Hs you are getting with the max pressure set to 10.
  
  Now a middle-to-long term plan for addressing the obstructive AHI is this: Once you are comfortably sleeping at 8-10 and getting little or no aerophagia, then very gradually bump the pressures up. First try bumping to 8-11. (My guess is that you'll find that you spend a signficant amount of time running at 11cm.) If the aerophagia does not return in a week or so and the obstructive AHI is still higher than you want, then bump the pressures up to 9-11. As long as the aerophagia does not return after 4 or 5 days, you can keep bumping either the max or min pressure up by 1cm until you find settings that work for you.
  
  But with aerophagia problems, you may eventually have to decide between
  • using pressures your stomach can tolerate and a slightly higher AHI than you'd like, or
  • using pressures high enough to let you have a near zero obstructive AHI and continuing to have problems with aerophagia

In my case, I found that using pressures my stomach can tolerate and a slightly higher AHI leads to much better overall sleep quality. Your mileage may vary, however.

Kiri,

First of, all ten hours is probably not an issue that needs to be addressed directly. In most cases, the problem is the underlying need to sleep so much, not the excess sleep itself. For instance, you may be paying back a chronic sleep debt.

Secondly, I would try turning up the max to as high as the machine goes. If you experience worse aerophagia and/or more or longer central (or "clear airway") events, then you can turn it back down. Also, the ramp serves no medical purpose, so use it only if it makes you more comfortable. Ditto for exhalation relief.

Last, note than an AHI of 5 is an arbitrary cutoff for diagnosing sleep apnea. If you're still tired at 4.7, you need to work on lowering it. There's no such thing as too low. I would not be surprised if the doctors decide that the cutoff needs to be lower!

The ineffectiveness of CPAP coupled with rampant aerophagia and depression makes me want to hang myself. I've managed to get past most of the roadblocks so far (blocked noses, drooling and mask leaks) but the only thing stopping CPAP from being effective now is the aerophagia. I get it even at very low pressures like 5 cm during the ramp up. I tried sleeping at an incline, not eating etc. Getting ridiculous levels of aerophagia which make be constantly burp and feel uncomfortable in the night. I didn't even use to get it earlier on when I was doing CPAP. What the hell changed which causes it to keep forcing air down my gullet? I feel like killing myself for how hopeless my situation is, I was counting on CPAP to give me energy and lift me out of depression but the past 3 months i've spent a lot of money and effort doing mostly nothing, being unemployed and shouted at by my parents all the time.

G'Day Kiri,

Please, please don't give up - the answer(s) will be somewhere and everyone here will try and help you as much as we can.

I understand your situation, it sounds quite similar to mine. I was taking escitalopram for a while, and it took the edge of the depression/anxiety but that was about it. When I was initially diagnosed with sleep apnoea it was a relief and I was briefly happy. Suddenly, lack of energy, inability to concentrate, random bouts of feeling stressed or anxious for no reason - well, it kind of made sense.

But then the reality of CPAP hit home. I wasn't lucky enough to be one of those few who find the therapy miraculous, an overnight cure. In fact, I got worse. Much worse. My tiredness became extreme. I was feeling very stressed. I was exhausted. I could barely manage work. I was living in a foreign country with minimal knowledge of the language and my exhaustion making it impossible to learn/improve. I spent several nights in the sleep lab with no real help (or so it felt). This was very difficult. I found some solace here on this forum but even then I became a little stressed - so many people with very low numbers and mine were increasing! But the support here, the fact that many people gave their time to try and help me (the very same people on this thread trying to help you), and the knowledge that it took time for some people to feel better kept me going.

Unfortunately, CPAP is not the panacea for all ills - but it can certainly help. But you must keep the faith that you will find the answer. For me it was the discovery that my sleep apnoea is hugely affected by sleep position. Pugsy had recommended to me to try and sleep on my side. I tried - a bit half-heartedly if I am being honest with myself - and failed. But when I was having a 'less bad day' I tried again - and it worked! It's not perfect but the improvement has given me hope. I'm tired but the anxiety has gone. I no longer need medication.

Kiri - my CPAP results are similar to yours, my OA+HA being only slightly lower. My centrals are sometimes similar but sometimes as high as 3.5. However, doing some research and being assisted by some of the people trying to help you, I am fairly certain these centrals are not real. Of course, sometimes when the number is high it is reflective of a bad night's sleep, being awake and turning non-stop - but every human being has these nights. I am finally beginning to feel better but it has taken time. Your centrals may be different but the people here can help you to try and determine if they are real. I don't even think the numbers are that troublesome if they were all real.

And here's the thing: with similar numbers to you I feel much better than I did, but it took time. I think, especially for you, it is a false and dangerous route to concentrate solely on that AHI number - unless it is really high. If we dismiss the centrals I'd be happy with your number. If we add the centrals then I still think it is ok, can be worked on but is possibly not the reason why you are still tired.

This will sound odd but I think your apnoea therapy is working. It may be too early for you to feel the benefit or it may be that there are other things that are causing the fatigue, but we can try and find out and help you.

The meds, the stressful situation with your parents, the adjustment to CPAP period, possible other sleep disorders, insomnia etc.,the fact that you are not feeling better and, of course, the depression itself. I'd forget about the AHI for a time and concentrate on the other stuff. Do you have good medical support over there? Maybe talk to the doctor who prescribes you the meds to reduce/stop/switch - it's worth a try.

But please, please seek help - we will support you here as much as we can. It is tough and difficult -but it is worth it. There are so many people here who share similar experiences - we will all try and help. It will get better.

Best wishes from Germany - keep us updated.

(Edit: opening part retyped due to unfortunate choice of words)