Help with CPAP Titration (OSA, PLM, TMJ, ABC123)

[tiredpanda]

Hello. Please help! I am new to this forum and relatively new to using a CPAP. I have been using my CPAP machine since February 2023 and am still feeling quite fatigued, tired, anxious, etc. My first sleep study was done in-lab in December 2022 and my first titration study was done in-lab in July 2023.

Diagnosis: Moderate OSA, AHI of 17 (diagnosed in Dec 2022 from an in-lab sleep study in Nov 2022). Also, non-REM parasomnia was noticed (movement while not in REM).
CPAP machine: Resmed Airsense 11 with a heated tube and heated humidifier. Originally on Auto-pap, pressure set between 5 and 15 from Feb 2023 to July 2023. See below for further pressures tried.
Mask: Full face mask (F&P Evora, Small/medium) because I am a mouth breather. I was using the F&P Vitera Large up until July 2023, but it was causing leaks.
AHI since using CPAP: 1 to 3. But I'm still tired.

I had a titration study done in July of this year (2023). The study noted the following:
“SLEEP: Normal sleep efficiency, short sleep latency, increased N1, increased N2, decreased N3, decreased REM. REM latency is prolonged.
RESPIRATORY: CPAP titration started from CPAP 5 cm H2O to 10 cm H20. Events were controlled with all
pressures. Patient was observed in supine and REM sleep with CPAP pressure of 10 cwp with good control of respiratory events.
The AHI at the recommended pressure is 0.6.
Snoring was eliminated with CPAP.
Position: 27.8%
PAP tolerance was acceptable
EMG: Normal. PLMI 8.0. There was a short period of leg movement which lasted less than 5 seconds as patient appears to be walking, at the epoch 719. Please correlate clinically.”
Recommendations: CPAP 10 cm H20 is recommended. Pressure change will be ordered.”

The sleep tech mentioned that my two main concerns were periodic limb movement and RERAs. He said the limb movements went away after the pressure was increased to around 8. The tech and doctor said that a fixed pressure of 10 should fix my issues.

I tried CPAP at 10 (EPR 2/aka EPAP 8 ) for 2 months and CPAP at 10 (EPR 3/aka EPAP 7) for one month and I didn’t really notice any improvement. I met with my sleep doctor one month ago and she recommended that I increase the pressure to CPAP 11 (EPR 3/aka EPAP 8 ). I brought it up to that one month ago and still haven’t noticed really any improvements in the past month. I’m still tired during the day and fatigued. I also still wake up with sore legs and lower back muscles like I have been moving my legs all night.

Medications: I currently take an SSRI and anti-depressant, which may affect my sleep. There are studies showing SSRIs affect Periodic Limb Movement, so I'm curious about that.
Other medical conditions: I have mild asthma, moderate anxiety, and mild depression. I have pretty bad TMJ issues, and I see a TMJ specialist for it. This includes: a quality acrylic grind guard, weekly physical therapy (including dry needling), and local anesthetic shots (every 4-6 weeks). My jaw still hurts a lot when I wake up, and I think that teeth clenching and grinding are either causing bad sleep or a symptom of it.
Blood tests: My blood results were pretty normal earlier this year, but I’m going to get them taken again to make sure I’m not anemic or anything.
Cardiology: The titration study noticed some bradychardia and PVCs. I did an EKG, Holter Monitor, and echocardiogram, and all turned out to be normal, so I should have a pretty healthy heart.

I attached a screenshot of my sleep titration study and some OSCAR results from this past Friday, December 1.

In terms of possible solutions, I'm curious if I should consider upping the CPAP pressure, switching back to APAP with a higher minimum than before, coming off of some medications, considering Bipap, or something esle.

Please let me know what you think. Any thoughts would be much appreciated. I'm happy to zoom in on any OSCAR data to give details. Thanks!

Titration Study Screenshot July 20, 2023.JPG (110.89 KiB) Viewed 6342 times

Daily Screenshot 12.1.23.JPG (416.88 KiB) Viewed 6342 times

Specific Screenshot 12.1.23 - Large peak and trough of flow rate.JPG (346.75 KiB) Viewed 6342 times

[Pugsy]

Research the potential side effects for the medications you take. They are well known to mess with sleep quality and sleep stages as well as causing some rather nasty daytime side effects.

The best cpap therapy in the world can't fix problems that aren't airway/apnea related no matter how much we hoped it would.

[tiredpanda]

Research the potential side effects for the medications you take. They are well known to mess with sleep quality and sleep stages as well as causing some rather nasty daytime side effects.

The best cpap therapy in the world can't fix problems that aren't airway/apnea related no matter how much we hoped it would.

Thanks, Pugsy. I am working on lowering the dosage of the SSRI. Do you know if the anti-depressant, Wellbutrin, has been known to cause sleep issues as well? The sleep doc said it shouldn't affect sleep too much, but I'm curious if you've heard different.

[Pugsy]

Do you know if the anti-depressant, Wellbutrin, has been known to cause sleep issues as well? The sleep doc said it shouldn't affect sleep too much, but I'm curious if you've heard different.

Indeed...I have heard a much different statement about Wellbutrin.
From my own personal experience some years ago, when I used it to help quit smoking, was that it totally trashed my sleep.
Horrid little pill. I tossed them in just a couple of weeks.

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

The common adverse effects of bupropion with the greatest difference from placebo are dry mouth, nausea, constipation, insomnia, anxiety, tremor, and excessive sweating.[21] Bupropion has the highest incidence of insomnia of all second-generation antidepressants, apart from desvenlafaxine.

Pretty much all those mood altering drugs will mess with sleep in some form or fashion.
Now I realize that sometimes those meds are needed and then people have to decide which is worse...the sleep problems they cause or the problems that caused that medication to be prescribed in the first place. That old risk vs rewards thing.

[kteague]

Been discussing PLMD with another poster called gohoos1998. You might want to check out our conversation if you think limb movements might still be a problem. I am not familiar with if any med you are on could contribute to a limb movement issue. Might be worth asking your doctor or maybe someone here knows. When I was having trouble figuring out if cpap was helping my sleep or not and what my legs were doing while on cpap, I finally saw a doctor who ordered a sleep study while using cpap at my prescribed pressure for the entire night, with my legs wired. That was my first realization of how bad my legs were. Unfortunately with limb movements, the usual testing of without cpap then with cpap being titrated will not answer the question of what a usual night looks like. Knowing what you're working with would better help you and your doctor going forward.

[Miss Emerita]

A few footnotes to the comments above.

In your place, I'd want to figure out whether the meds are contributing to ongoing fatigue and tiredness. If you want to pursue this path, it would be important to talk with your doctor about exactly how to go off one or both meds (gradually? cold turkey?) and whether to try going off both at the same time or just one at first.

I agree with you that some additional blood work would make sense. See whether you can get tested for all of the following: iron (an iron panel, not just one test), thyroid, testosterone if you are a man, vitamin B12, vitamin B6, vitamin D, and maybe C and E too, Lyme disease, autoimmune disease (especially in the connective-tissue-disease family).

[gohoos1998]

Hey! Looks like you know a lot about your condition(s) and are doing what you need to do to get better. Like you, I have been recently diagnosed with OSA (AHI = 9) and PLMD (my PLM index was 67/hr - severe).

I am not as well-versed in OSA as others, but I think I have a good understanding of PLMD triggers. As kteague alluded to, I have learned a lot of her experience with PLMD and possible treatments.

Absolutely, SSRI’s/SNRI’s will cause PLMs. I think tapering down relatively slowly would be the intelligent thing to do here. Don’t let your psych (unless you like him/her) tell you to get off of it quicker than possible. I’m very sensitive to meds, so take with a grain of salt. Do not go too fast! I am actually going off of cymbalta at the moment. I’m going down 2.5 percent every 3 weeks to start (extra careful) and will go from there.

Wellbutrin absolutely made by anxiety 100x worse. I have been on many SSRIs and SNRIs for anxiety - stopped Wellbutrin after a few weeks. It definitely can keep you up and trash sleep architecture, but should NOT make your PLMD worse.

Your PLMs resolving with your CPAP sounds a bit strange to me as any arousals coming from those should have been counted separately from your apnea events. Thus, I wouldn’t expect them to go away with CPAP, but it looks like I may be wrong here!

As for PLMD treatment, see if you can wean yourself slowly off of the SSRI. If not, you may need to taking another pill (gabapentin perhaps). Do not take dopamine agonists as those only make the problem worse in the long run. Lastly, as others suggest, get a blood test. Ask for a comprehensive iron panel - ferritin should be around 100 in people with PLMD. If you are at 50 or so, the lab will say you are in range, but this is for someone without PLMD. I would say to avoid pharmaceuticals at this point as your PLMD is still relatively mild (however, I don’t want to downplay it - I get how debilitating this is).

We’re all in this fight together. Hope this helps!