Looking for the right "recipe" for good sleep

Hello all,
In October 2014 I went to a sleep clinic with chief complaints of very unrefreshing sleep, daytime fatigue, 8-15+ wakings/night, middle insomnia, morning headaches and snoring. (Other things like thyroid, Lyme, etc. had been ruled out by primary care doc.) I had an at home sleep test (insurance reasons) that showed an AHI of 8. I started using the machine with a pressure of 6-12 and adapted pretty well to both machine and the P10 mask.
In December I changed doctors because the first place seemed like an apnea factory. New doc changed rage to 5-10 cmH20. By holiday time I was without headaches, no snoring, no middle insomnia, fewer bathroom trips, and AHI in the 1.8 to 3.8 range. Frequency of waking improved a bit to maybe 10 wakings per night. Energy level and feeling of unrefreshed sleep did not change at all.posting.php?mode=post&f=1&sid=770778f1f ... 785c2f9c7d#
I saw sleep doctor again at beginning of February. I suggested we try a straight 9 to see if changing pressure is causing wakings. I ran like that for over a week and it made no difference to either AHI or # of wakings. So recently I bumped it up to 10-17 cmH20. Still no improvements in perceived sleep quality. The main difference is the leak and the number of CAs went up. CAs now represents 40-60% of total.
I have had the notion that decreasing the number of times I wake up will help me feel better/more energy, but I don’t really know if this is true. Actually I would like to wake feeling refreshed however that could happen.
Does anyone have any ideas for me?
Thank you for your help.

Attached are two nights. One is from when pressure was 5-10, and the second 10-17.

elizabeth25 wrote:Hello all,
In October 2014 I went to a sleep clinic with chief complaints of very unrefreshing sleep, daytime fatigue, 8-15+ wakings/night, middle insomnia, morning headaches and snoring. (Other things like thyroid, Lyme, etc. had been ruled out by primary care doc.) I had an at home sleep test (insurance reasons) that showed an AHI of 8. I started using the machine with a pressure of 6-12 and adapted pretty well to both machine and the P10 mask.
In December I changed doctors because the first place seemed like an apnea factory. New doc changed rage to 5-10 cmH20. By holiday time I was without headaches, no snoring, no middle insomnia, fewer bathroom trips, and AHI in the 1.8 to 3.8 range. Frequency of waking improved a bit to maybe 10 wakings per night. Energy level and feeling of unrefreshed sleep did not change at all.posting.php?mode=post&f=1&sid=770778f1f ... 785c2f9c7d#
I saw sleep doctor again at beginning of February. I suggested we try a straight 9 to see if changing pressure is causing wakings. I ran like that for over a week and it made no difference to either AHI or # of wakings. So recently I bumped it up to 10-17 cmH20. Still no improvements in perceived sleep quality. The main difference is the leak and the number of CAs went up. CAs now represents 40-60% of total.
I have had the notion that decreasing the number of times I wake up will help me feel better/more energy, but I don’t really know if this is true. Actually I would like to wake feeling refreshed however that could happen.
Does anyone have any ideas for me?
Thank you for your help.

Attached are two nights. One is from when pressure was 5-10, and the second 10-17.

So, why only one week with one fixed pressure setting? The ranges are definitely NOT working for you. And, the pressure ranges you're using seem to be radically different.
From the flow limitations you have, the machine is going to predominantly chase them.


Den

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I hadn't included a day from the straight 9. Here it is. AHI in the same range.

Maybe a straight 10 cm. for a week........
There's more to this than AHI numbers.
But, the night of 9 you posted did have slightly lower AHI than the ones on Auto.

And, if you're using EPR, it's dropping your "effective" therapy pressure at the point of the end of exhale and the beginning of inhale by the centimeters of the setting.


Den

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If you work through getting your therapy optimized and still have many wakings, I'd be curious about if you have any problems with limb movements. I don't think the home study checks for limb movements. Is your sleep restless - how much do you move about at night? Oh, and have you already assessed any meds you might be on for possibly contributing to your poor sleep?

Wulfman... wrote:
And, if you're using EPR, it's dropping your "effective" therapy pressure at the point of the end of exhale and the beginning of inhale by the centimeters of the setting.


Den

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Den, could you explain that part in another way? I'm not sure what you mean, and I have wonder how EPR fits into the picture. I have it set at 2

kteague wrote:If you work through getting your therapy optimized and still have many wakings, I'd be curious about if you have any problems with limb movements. I don't think the home study checks for limb movements. Is your sleep restless - how much do you move about at night? Oh, and have you already assessed any meds you might be on for possibly contributing to your poor sleep?

According to my husband I don't have limb movements, but I'll look back and see if sleep study mentions this.
I don't move around while sleeping. Although when I do wake I usually roll to other side then. I use Flonase at night and take meds for hypothyroid in the morning.

elizabeth25 wrote:

kteague wrote:If you work through getting your therapy optimized and still have many wakings, I'd be curious about if you have any problems with limb movements. I don't think the home study checks for limb movements. Is your sleep restless - how much do you move about at night? Oh, and have you already assessed any meds you might be on for possibly contributing to your poor sleep?

According to my husband I don't have limb movements, but I'll look back and see if sleep study mentions this.
I don't move around while sleeping. Although when I do wake I usually roll to other side then. I use Flonase at night and take meds for hypothyroid in the morning.

Hi Elizabeth,

Many people have reported that taking a nasal steroid causes insomnia at night. You might want to try taking the Flonase earlier in the day to see if that makes a difference. It might not have anything to do with your problems but certainly worth a try to switch the time you take it.

49er

elizabeth25 wrote:

Wulfman... wrote:
And, if you're using EPR, it's dropping your "effective" therapy pressure at the point of the end of exhale and the beginning of inhale by the centimeters of the setting.


Den

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Den, could you explain that part in another way? I'm not sure what you mean, and I have wonder how EPR fits into the picture. I have it set at 2

I'll try.
ResMed uses "EPR" as an exhale relief and Philips/Respironics uses "Flex" as exhale relief. EPR uses settings of 1, 2 and 3. Each of those settings drops the pressure in whole centimeters. P/R drops the pressure in relation to the person's exhale effort......and at the highest relief level of 3, would only be approximately 2 cm.
OK. If, for example, a person is using a ResMed machine with a fixed (or also in auto mode) pressure of 10 cm. and an EPR setting of "2", on exhale, the pressure is going to drop by 2 centimeters through the end of the exhale and at the point where the person's exhale ends and they begin to inhale, the "effective" pressure is only going to be 8 centimeters. If, at a titration, they determined that the person NEEDS 10 centimeters to eliminate their apneas, then that person is probably going to have apneas occur as they have dropped below the "effective" (needed) pressure. Not everyone HAS them at that point, but it's possible/probable depending on the person.
Over the years, we've discussed on the forum what the two possible options are to achieve the "effective" pressure.
One is to increase the set pressure (like in this instance) to 12 while leaving the EPR at the same setting. That would then drop the "effective" pressure to 10 cm. which is where the sleep study determined it needed to be.
The other option is to reduce the EPR setting. In this example, the user would turn off EPR and leave the fixed setting of 10 cm. That would keep the "effective" pressure at 10 cm. all the way through the breathing cycle. The user wouldn't have any exhale relief (if they actually needed it), but their "effective" pressure would remain where the titration found it needed to be.
And, in the vast majority of sleep study titrations, they don't use exhale relief.

Does that help?


Den

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Thank you Den, for explaining that. Now I get it. I had seen EPR referred to as a "comfort feature" and I couldn't quite square that with what effect that has on the therapy.
E25