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General Discussion on any topic relating to CPAP and/or Sleep Apnea.
tedtomato
 
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OSA resolved, but still poor quality sleeping

Postby tedtomato on Mon Dec 04, 2017 6:46 am

Hi,

I have been on CPAP for a year, and I have been fairly compliant (using the machine each night, for at least 5 hours).

The daily AHI number achieved with CPAP/APAP is now typically below 1.5.

A full sleep study was done in July of this year, and showed that OSA was accounting for one third of arousals (when not using the CPAP machine, in the first part of the night).

However, many spontaneous arousals (about 20 events per hour, in addition to OSA-related ones) are still not explained, so still feeling tired in the morning, despite a low AHI.

I don't have restless leg syndrome, and OSA seems to be controlled, so what else could it be?

Thanks,
T.

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Last edited by tedtomato on Mon Dec 04, 2017 12:21 pm, edited 1 time in total.

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Re: OSA resolved, but still sleeping badly

Postby coconur on Mon Dec 04, 2017 9:34 am

tedtomato wrote:I don't have restless leg syndrome, and OSA seems to be controlled, so what else could it be?

Thanks,
T.

Many things can contribute to sleep problems, for example, hypothyroidism. Have you talked to your primary Dr recently about not sleeping well? You may need more than one solution.

Also, you say you're only using the machine about 5 hours per night on average. Is that because you're only in bed that much, or are you spending some of your sleeping hours each night without your machine?

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Re: OSA resolved, but still sleeping badly

Postby jnk... on Mon Dec 04, 2017 10:05 am

tedtomato wrote: . . . fairly compliant (using the machine each night, for at least 5 hours). . . .


Not to pick on your wording, but just to clarify one aspect of PAP that is often confused by doctors and thus confusing to patients, "compliant" by one definition (the do-we-pay-for-the-machine-for-someone-starting-out? definition) is not the same as "compliant" by the most useful and significant medical definition (the always-using-optimized-pressures-100%-of-the-time-asleep definition). In other words, . . .

Although someone may meet the definition of "compliance" that is used by payers to decide whether to pay for a PAP machine for someone just starting out who is trying to figure out how to use it, that does NOT mean the person is getting full benefit of PAP. FULL benefit of PAP therapy occurs ONLY when a person eventually is using it at optimized pressures during ALL times of sleep, even brief naps. In that sense, there is no such thing as "fairly" compliant. A person either uses fully optimized pressures at all times or does not.

Why is that confusion particularly damaging to some patients? Here is one viewpoint/theory on the reasons.

OSA trains some brains to become very touchy and jumpy during sleep, resulting in many arousals. If a person like that occasionally sleeps without PAP, even if only for a few minutes once in awhile, and some bad breathing occurs, that tells the brain that it still needs to be jumpy--watchful throughout the night for bad breathing. But if a person with that problem gets his pressure(s) fully optimized and then NEVER sleeps without PAP, the brain can sometimes eventually start to relax and trust that breathing during sleep is no longer an issue, since it has been months/years since significantly bad breathing has occurred.

If many months go by of optimized pressure used at all sleep times but sleepiness remains, there is likely something beyond sleep-breathing causing the ineffective sleep. But in my book, sleep-breathing as the root cause of the problem has not been ruled out until optimized pressure all night every night, no exceptions, has been used for many months.

I wish more doctors took the time to explain that meeting the payers' initial definition of compliance is not the same thing as getting full benefit from PAP for eliminating the many complicated results of a history of bad breathing during sleep.
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rick blaine
 
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Re: OSA resolved, but still sleeping badly

Postby rick blaine on Mon Dec 04, 2017 11:03 am

Hi tedtomato,

I looked back over your previous correspondence - and there was some question then of events other than OSA and HYP.

And - if I read your previous posts correctly - you were diagnosed via an 'at-home' sleep study. If so, the next step might be to have a full-on 'sleep lab' examination.

At the moment, fewer than 10 pc of sleep studies in the NHS are done in a sleep lab (and not every sleep medicine unit has one). But there are a number of sleep labs in the private sector. And if you're still seeing your comsultant on a private basis, he (or she) should be able to book you in to one of them.

It may be that you have quite a lot of centrals - and for that, you would need to be prescribed an ASV machine.

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Re: OSA resolved, but still sleeping badly

Postby jnk... on Mon Dec 04, 2017 11:11 am

ASV is but one of many possible approaches for the treatment of CSA.

https://www.mayoclinic.org/diseases-con ... c-20352114
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Re: OSA resolved, but still sleeping badly

Postby tedtomato on Mon Dec 04, 2017 12:13 pm

rick blaine wrote:Hi tedtomato,

And - if I read your previous posts correctly - you were diagnosed via an 'at-home' sleep study. If so, the next step might be to have a full-on 'sleep lab' examination.


I initially had a home sleep study about a year ago, but then a full PSG sleep study a few months ago, at a proper private sleep clinic.

Conclusion was that:

* OSA was worse than originally envisaged. Initially, I was diagnosed with mild OSA (AHI of 7), whereas it was closer to 15 when properly measured
* Events were mainly hypopneas. A few obstructive apneas, and no central apnea measured
* However, a lot of arousals were not related to respiratory events or limb movements (spontaneous arousals), so still around 20 arousals per hour with unknown causes, according to the PSG sleep study report
* OSA seems to be properly treated with CPAP. Second part of the sleep study demonstrated so, while using my CPAP machine. Snoring also stopped, as well as bruxism

Therefore, I have been focusing over the last year on CPAP therapy, but it does not seem to be the primary reason for poor quality sleeping. I do sleep 7 or 8 hours per night, but feeling tired in the morning.

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Re: OSA resolved, but still sleeping badly

Postby kteague on Mon Dec 04, 2017 1:15 pm

[quote="tedtomato" Conclusion was that:
* However, a lot of arousals were not related to respiratory events or limb movements (spontaneous arousals), so still around 20 arousals per hour with unknown causes [/quote]
Were any of the arousals related to limb movements? What was the eaxct wording in the report regarding limb movements? Did you have both a diagnostic and titration study in the lab?

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Re: OSA resolved, but still sleeping badly

Postby tedtomato on Mon Dec 04, 2017 2:21 pm

kteague wrote:Were any of the arousals related to limb movements? What was the eaxct wording in the report regarding limb movements? Did you have both a diagnostic and titration study in the lab?


PLM index: 1.2 (per hour)
PLMs with micro-arousals: 0

PLM is not an issue.

First part of the PSG sleep study was done without my APAP machine. Second part was done with my own APAP machine, on my normal settings (8.5 to 12.5 pressure).
AHI without the machine was 15, and down to 1.5 with the machine.

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Re: OSA resolved, but still poor quality sleeping

Postby jnk... on Mon Dec 04, 2017 2:58 pm

-jeff, a user, not a pro.

'Attack the message if you want to; just don't attack the messenger.'--Pugsy.

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Re: OSA resolved, but still poor quality sleeping

Postby tedtomato on Mon Dec 04, 2017 3:27 pm



Thanks. I don't have chronic pain, and there is absolutely no noise during the night where I live (and I sleep with earplugs anyway, as the place is so quiet that the CPAP machine can be heard).
GERD: TBC (but not feeling sick or acid reflux, and CPAP would improve this as well, apparently)

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Re: OSA resolved, but still poor quality sleeping

Postby Jay Aitchsee on Mon Dec 04, 2017 4:13 pm

Trying to chase down the cause of spontaneous arousals may not prove to be helpful. A certain number of arousals are normal and an AI of 20 may not be significant. See this paper where some "normal" patients exhibited higher indexes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564772/ Apparently, your doctor was not concerned about your AI.

For an in depth discussion of arousals see: http://www.sciencesleep.org/ziliao/The% ... 0sleep.pdf

I suggest you review Sleep Hygiene and ensure you are doing your best to follow its precepts.

Five hours sleep (or cpap use) was mentioned earlier. Very few people can get by satisfactorily with five hours sleep, even with a satisfactory AHI.

Edit: Rereading your posts, I see you say you get 7-8 hours sleep nightly, but that seems to be at odds with your statement of 5 hours per night average use.

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Re: OSA resolved, but still poor quality sleeping

Postby kteague on Mon Dec 04, 2017 5:46 pm

Was the info you provided on PLMs from the diagnostic or titration part of your study?

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Re: OSA resolved, but still poor quality sleeping

Postby tedtomato on Tue Dec 05, 2017 12:01 am

kteague wrote:Was the info you provided on PLMs from the diagnostic or titration part of your study?


There was no titration part in the sleep study.

I was already on APAP for 8 months before doing the full sleep study, so the machine was already set up with an optimum pressure range for achieving a low AHI. First part of the sleep study was without the machine (to check again OSA and other issues), and second part of the night was with the machine (to check the difference).

PLM was measured for the whole night, and didn't appear to create arousals.

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Re: OSA resolved, but still poor quality sleeping

Postby Mogy on Tue Dec 05, 2017 1:33 am

Hi Jnk,
You state in your response to OP:

"Not to pick on your wording, but just to clarify one aspect of PAP that is often confused by doctors and thus confusing to patients, "compliant" by one definition (the do-we-pay-for-the-machine-for-someone-starting-out? definition) is not the same as "compliant" by the most useful and significant medical definition (the always-using-optimized-pressures-100%-of-the-time-asleep definition). "

I have seen this position stated by posters here but have never seen it stated by anyone in medicine or scientific studies. Do you know where it comes from other than comments from forum members? Link?
Don't know much, but willing to learn.

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Re: OSA resolved, but still poor quality sleeping

Postby jnk... on Tue Dec 05, 2017 3:28 am

Mogy wrote:. . . medicine or scientific studies. Do you know where it comes from . . . ? Link?


Compliance/adherence has the same basic medical definition in all medical therapies and can be expressed as a percentage when discussing how closely a prescription is being followed by a patient. I am unaware of any doc specifying PAP use for a percentage less than 100 percent of total sleep time on the Rx. It is not an "as needed" Rx.

Did someone say links? Oops, I feel a link-flurry coming on . . .

Even the most effective medical devices are only effective when they are used. The effect may be 100% when always used, nil when never used, and partial when used sometimes but not always. This is particularly true for CPAP use in OSA. -- Sleep. 2011 Jan 1; 34(1): 105–110. Published online 2011 Jan 1. PMCID: PMC3001787 M.J.L. Ravesloot, MD and N. de Vries, MD, PhD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001787/


Although the expectation for CPAP use is during all hours of sleep, few OSA patients achieve that lofty goal. . . . The Centers for Medicare and Medicaid Services adopted the 4 hours of use on 70% of nights as their measure of acceptable adherence. . . . More recent publications have established that increased hours of use are likely to further improve symptoms, depending on the clinical outcome measure. -- RESPIRATORY CARE • SEPTEMBER 2010 VOL 55 NO 9 http://rc.rcjournal.com/content/respcar ... 0.full.pdf


Better outcomes occur, for the most part, with more hours of nightly CPAP use . . . Increased use was associated with longer survival. . . . This study shows a clear relationship between effectiveness of CPAP therapy and hours of use of CPAP in routine clinical practice, adding to the growing evidence that increased nightly use leads to better clinical outcomes. . . . More CPAP use is associated with greater relief of sleepiness (no matter how it is measured). . . . Although continuous gains are achieved for objective and subjective daytime sleepiness with greater use, it appears no further benefit in functional status is realized with use beyond 7 hours. -- Sleep. 2007 Jun 1; 30(6): 711–719. PMCID: PMC1978355 "Relationship Between Hours of CPAP Use and Achieving Normal Levels of Sleepiness and Daily Functioning," Terri E. Weaver, PhD, RN, FAAN, et al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978355/


The best practice is to put the CPAP on at lights out each night and to make every attempt to put it back on after nighttime awakenings. -- http://surgicalsleep.org/treatment-of-sleep-apnoea/


To maximize treatment benefits for all important health outcomes, CPAP needs to be consistently used for the majority, if not all, of the sleep period. -- https://sleepcenterofcny.com/wp-content ... of-OSA.pdf


Always use CPAP when you sleep. Even if you’re just putting your head down at your desk for a quick power nap, you’re likely experiencing disruptive, harmful apneas if you’re not using CPAP. -- https://www.resmed.com/us/en/blog/thera ... rders.html


If your doctor prescribes a CPAP, you should wear it whenever you sleep, even for naps. -- https://familydoctor.org/cpap-devices-for-sleep-apnea/


CPAP should be used whenever you are asleep, including naps. -- http://www.sleepmanagement.md/sleepdiso ... /CPAP.aspx


We recommend that you wear your device whenever you sleep[;] your airway can become obstructed anytime you relax enough to fall asleep, such as after meals or watching TV. . . . Every time you sleep your airway is obstructed and your oxygen drops your heart, brain, lungs, and other bodily systems are strained. That’s why it’s vitally important that you use continue your therapy whenever – and wherever – you sleep. -- http://www.feelinggreatsleepcenter.com/ ... d-answers/


Train yourself to use CPAP. Start with 2 hours per night. Add another 30 minutes per week until you are sleeping with it all night long. -- https://sleepfoundation.org/ask-the-exp ... e/page/0/1

And my personal fave source (WARNING: Shameless plug for forum sponsors) :wink: :

Do I have to use CPAP every time I sleep? Yes. Using CPAP therapy every night and during naps will increase the effectiveness of therapy, which will lead to an improvement in your mood and energy levels. Remember that even during a short rest your air passage is obstructed and being without oxygen is harmful to your health both short and long term. To avoid the side effects of untreated Sleep Apnea use your CPAP each time you sleep. -- https://www.cpap.com/cpap-faq/New-CPAP-User.html


Bad sleep is bad sleep. Bad breathing is bad breathing. Choosing to experience either one or both, even just occasionally during part of the night by removing PAP, is not a choice that is likely to improve one's health, which depends on breathing and sleep. This is especially true for moderate-to-severe OSA. For very mild OSA with no symptoms, full adherence may not be as critical. On the other hand, for very severe OSA, a person could be taking his life into his own pillow if he sleeps even a moment without PAP. So all the above are merely general rules of thumb. Nothing said on this forum trumps what a patient hears from his or her doctor, but docs tend to focus on minimum adherence as defined by the payers and do not stress enough, in my opinion, that all medical therapies are dependent on consistent, and in the case of PAP continuous, use for full benefit. It is a patient's choice whether to solve a sleep-breathing problem only part of the time or to solve it all the time. But I would never move on to other approaches to address residual sleepiness without optimizing the treatment already being used.

Hey, just me.

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