SleepyHead interpretation please

Okay, so here are some screenshots from last night. IPAP of 12 and EPAP of 7. My 2 sleep study results are also pasted below. AHI has always been very low. But I still feel I sleep like ****. I think perhaps there are issues at play that are not captured by a sleep study. Diagnosis was mild OSA. I think he must have based this off of my RDI and not my AHI, in combination with my self-reported poor sleep quality.

General description of my own sleep problems, as I understand them: I have a chronic infectious disease. I believe 100% of my sleep issues are caused by it, as I have seen them all wax and wane in conjunction with how my overall infectious disease is waxing and waning. The sleep issues are 4 fold, I would say. One is that my sinuses have a lot of resistance. Two is mild OSA with the throat/tongue. Three is generally weak breathing apparatus which makes my breaths very shallow. Four is that I have something of a muscular problem where I have trouble spontaneously triggering the next inhalation, even without any obstruction.

Sleep study 1 (normal sleep):
Arousals: 7.5/hr
Respiratory-related arousals: 7.5/hr
Total apneas: 8, of which 7 were obstructive and one was central.
AI = 1.5 apneas/hr
Hypoapnea index = 0.9/hr.
AHI =2.4/hr
RERA (respiratory effect-related arousals) index = 2.1/hr
RDI (respiratory disturbance index) = 8.3/hr
mean SpO2 = 95.3%
min SpO2 = 91%
periodic limb movements: 39/hr

Sleep study 2: (titration study, ranging from 5cm to 8cm, with 8cm being concluded as optimal. I don't know what kind of EPR was used.):
[It should be noted that in the first study, I was in a very hot room with a broken thermostat. In my general ill health, a hot room is the worst thing for my sleep quality. In this second study, I got the room with the working thermostat, and cranked it WAY down. That is a major reason for the improvements seen, I believe. Hot nights also make my sinus restriction worse.].

Arousals: 0.9/hr
Respiratory-related arousals: 0.9/hr
Total apneas: 6, of which 1 was obstructive and 5 were central.
AI = 1.1 apneas/hr
Hypoapnea index = 0.5/hr.
AHI =1.6/hr
RERA (respiratory effect-related arousals) index = 0/hr
RDI (respiratory disturbance index) = 2.6/hr
mean SpO2 = 96.1%
min SpO2 = 84%
periodic limb movements: 1.8/hr

In my opinion, most (if not all) of the improvements from CPAP in the second study are really due to the room being colder and me just having a better night in general. You can see how much I was tossing and turning from my limb movement score in the first study. Central apneas went up with CPAP.

So here are screenshots with my new BPAP. I chose 12 IPAP and 7 EPAP last night. Best AHI I have had to date (1.0), but still not refreshing sleep. My rationale for choosing bilevel is that my very shallow breathing needs a larger pressure support to increase tidal volume. As for choosing EPAP of 7, this so far is my best guess for managing my described issue of difficulty triggering inhalations. With nasal pillows, for example, I feel that trying to trigger an inhalation from an EPAP of say 4 is more difficult than not having a CPAP at all, because the pillows themselves are providing resistance. I use large pillows. Medium pillows have smaller holes and make this effect even worse. I just played around while still awake and felt 7 was where I had the easiest time triggering inhalations. Lower than that there is that "resistance" effect I just described. Higher than that I think my muscular problems play out if a different way that is hard to describe that also makes triggering inhalation harder. I have trigger sensitivity set to the highest, which is a great feature my AirSense 10 did not have.

I suspect I need to try a full face mask, which would bypass the sinuses completely. I would have to be a mouth breather. I also find it easier to spontaneously trigger inhalations through my mouth in general, and think I may be able to get away with lower pressures all around. It's getting close to time for insurance to replace my mask, and I am thinking of asking for an AirFit F20. One concern is dry mouth and oral health, but I guess increasing humidity could manage this?

One strange thing you will notice in the screenshots below is that whenever I have long blocks of large leaks, my flow rate graph seems to look good, in contrast to every other time. Why is it that leaks seem to help me? Answering this question would require me to understand how these machines auto-adjust to handle leaks. I have an idea, but I probably don't know what I'm talking about.

Screenshot #1: (Note that no events occured during any of the long leak periods)


Screenshots #2 through 6: Examples of flow rate during nonleak times. Funny stuff happening. I don't know how to interpret these graphs yet, but I would describe the whole night as being "very erratic".






Screenshots # 7 to 10: Examples of flow rate during leak times. It looks so much more uniform. And I tried to pick the worst looking periods.





Thanks!!!

Your flow rate when in large leak...nothing more than normal sleep breathing IMHO.
Nice normal boring asleep breathing.

Now the others where things are more ragged looking..like #3...that looks like arousal/awake breathing to me.
So does the bulk of the others where you see nice normal asleep breathing and then you see irregular breathing.

So if you see a LOT of the irregular breathing pattern then that could mean (notice I said could) arousal/semi awake/awake breathing and that points to a lot of arousals (you may or may not remember an arousal) which points to crappy sleep in general.
Now why it is crappy...that's an unknown. If OSA is the cause of the arousals then we would expect cpap therapy to help but as you well know there are a lot of other potential culprits causing arousals and/or crappy sleep quality in general.

Here is an example that is a bit easier to see the flow rate and compare asleep to arousal breathing.
Note this is a Respironics report and Encore software and there's no easy way to get this type of graph from a ResMed machine.
The top 3 lines...asleep breathing....nice and boring and smooth
4th line...arousal breathing...maybe awake, maybe not but not totally sound asleep
then it starts to settle back down a bit with the irregular breathing more sporadic and not as prolonged
Some apnea flags are involved so could be related to OSA itself.

The irregular breathing is practically all night long. I am very confident I am having a lot of arousals.

If I understand your comment correctly, a face value interpretation of the leak periods perhaps suggests I do better without any CPAP at all, and that maybe CPAP is causing my arousals. But I am very confident I always got a lot of arousals without using CPAP. That is what makes me think there may be more to that nice boring breathing during the leak periods than meets the eye.

Strange my sleep study did not say I was having tons of RERAs. Perhaps sleep studies don't really detect all my problems? Or maybe I need to go back and try just sleeping with the titrated pressure of 8, with no pressure support? I am pretty sure that would lead to horrible shallow breaths, but might be worth trying again.

I think I will give a full face mask a try.

Arousals don't necessarily have to be respiratory related...they can also be spontaneous with no known specific cause.
RERAs are related to respiratory events that cause arousals...doesn't take into account arousals from something else.

Did your sleep studies mention spontaneous arousals?
A drawback or limitation to a sleep study....it can spot the arousal and if no respiratory events are there to blame it on then it will probably get called spontaneous but we don't have anyway to know what actually caused it.
Sleep studies can tell us we have crappy sleep but they can't always tell us why that sleep is crappy. The idea with cpap therapy is to hopefully fix the airway potential issues that could be causing the crappy sleep but if the airway isn't the issue then cpap can't fix it.

First sleep study says 40 arousals, all respiratory related. Second sleep study (titration study) says 5 arousals, all respiratory related. I wonder if the devil is in the details of how they define a respiratory related arousal. Maybe I am having a lot more than 5 with CPAP (if some threshold was lowered perhaps), but definitions just hide that fact from me.

I also note in my flow rate a lot of events were the flow rate is flatlined to zero for some seconds, but not enough to get flagged as an event. Clear airway events for example seem to not get flagged unless they last at least 10 seconds. I don't see anyway to change this parameter. Do you know of one?

metallikat36 wrote:Okay, so here are some screenshots from last night. IPAP of 12 and EPAP of 7. My 2 sleep study results are also pasted below. AHI has always been very low. But I still feel I sleep like ****. I think perhaps there are issues at play that are not captured by a sleep study. Diagnosis was mild OSA. I think he must have based this off of my RDI and not my AHI, in combination with my self-reported poor sleep quality.

General description of my own sleep problems, as I understand them: I have a chronic infectious disease. I believe 100% of my sleep issues are caused by it, as I have seen them all wax and wane in conjunction with how my overall infectious disease is waxing and waning. The sleep issues are 4 fold, I would say. One is that my sinuses have a lot of resistance. Two is mild OSA with the throat/tongue. Three is generally weak breathing apparatus which makes my breaths very shallow. Four is that I have something of a muscular problem where I have trouble spontaneously triggering the next inhalation, even without any obstruction.

Sleep study 1 (normal sleep):
Arousals: 7.5/hr
Respiratory-related arousals: 7.5/hr
Total apneas: 8, of which 7 were obstructive and one was central.
AI = 1.5 apneas/hr
Hypoapnea index = 0.9/hr.
AHI =2.4/hr
RERA (respiratory effect-related arousals) index = 2.1/hr
RDI (respiratory disturbance index) = 8.3/hr
mean SpO2 = 95.3%
min SpO2 = 91%
periodic limb movements: 39/hr

Sleep study 2: (titration study, ranging from 5cm to 8cm, with 8cm being concluded as optimal. I don't know what kind of EPR was used.):
[It should be noted that in the first study, I was in a very hot room with a broken thermostat. In my general ill health, a hot room is the worst thing for my sleep quality. In this second study, I got the room with the working thermostat, and cranked it WAY down. That is a major reason for the improvements seen, I believe. Hot nights also make my sinus restriction worse.].

Arousals: 0.9/hr
Respiratory-related arousals: 0.9/hr
Total apneas: 6, of which 1 was obstructive and 5 were central.
AI = 1.1 apneas/hr
Hypoapnea index = 0.5/hr.
AHI =1.6/hr
RERA (respiratory effect-related arousals) index = 0/hr
RDI (respiratory disturbance index) = 2.6/hr
mean SpO2 = 96.1%
min SpO2 = 84%
periodic limb movements: 1.8/hr

In my opinion, most (if not all) of the improvements from CPAP in the second study are really due to the room being colder and me just having a better night in general. You can see how much I was tossing and turning from my limb movement score in the first study. Central apneas went up with CPAP.

So here are screenshots with my new BPAP. I chose 12 IPAP and 7 EPAP last night. Best AHI I have had to date (1.0), but still not refreshing sleep. My rationale for choosing bilevel is that my very shallow breathing needs a larger pressure support to increase tidal volume. As for choosing EPAP of 7, this so far is my best guess for managing my described issue of difficulty triggering inhalations. With nasal pillows, for example, I feel that trying to trigger an inhalation from an EPAP of say 4 is more difficult than not having a CPAP at all, because the pillows themselves are providing resistance. I use large pillows. Medium pillows have smaller holes and make this effect even worse. I just played around while still awake and felt 7 was where I had the easiest time triggering inhalations. Lower than that there is that "resistance" effect I just described. Higher than that I think my muscular problems play out if a different way that is hard to describe that also makes triggering inhalation harder. I have trigger sensitivity set to the highest, which is a great feature my AirSense 10 did not have.

I suspect I need to try a full face mask, which would bypass the sinuses completely. I would have to be a mouth breather. I also find it easier to spontaneously trigger inhalations through my mouth in general, and think I may be able to get away with lower pressures all around. It's getting close to time for insurance to replace my mask, and I am thinking of asking for an AirFit F20. One concern is dry mouth and oral health, but I guess increasing humidity could manage this?

One strange thing you will notice in the screenshots below is that whenever I have long blocks of large leaks, my flow rate graph seems to look good, in contrast to every other time. Why is it that leaks seem to help me? Answering this question would require me to understand how these machines auto-adjust to handle leaks. I have an idea, but I probably don't know what I'm talking about.

Screenshot #1: (Note that no events occured during any of the long leak periods)


Screenshots #2 through 6: Examples of flow rate during nonleak times. Funny stuff happening. I don't know how to interpret these graphs yet, but I would describe the whole night as being "very erratic".






Screenshots # 7 to 10: Examples of flow rate during leak times. It looks so much more uniform. And I tried to pick the worst looking periods.





Thanks!!!

I did not read the post as I know nothing about O2.
It looks like all your AHIs are low enough that you are considered adequately treated by the medical community so the cause of your dissatisfaction may have nothing to do with AHI.
The chart you posted shows leak rate that is greatly fluctuating. I do not like to see this. A change in leak rate is either due to the patient refitting the mask, or it is due to the patient changing their state of sleep. In your case it sure looks like your sleep is reacting - which is not good.