OK after 3 years, Back to CPAP

[Pugsy]

How on earth do I determine how true that is and to what extent?

We start with looking at the actual software report graphs and not just looking at overall AHI.
We also look at flow limitation graphs from your machine because they aren't part of the AHI.

This thread has some examples
viewtopic/t103468/Need-help-with-screen-shots.html
and this has more of a how to do imgur (which I think is easier than some of the other photo hosting sites)
https://sleep.tnet.com/reference/tips/imgur
Be sure to follow the links for "how to organize your graphs" and when you post an image for us to look at you don't have to include all the graphs that are available.
This talks more about SleepyHead which works well with your machine and is easier to manage than ResScan but I can get you ResScan (Resmed's software) if you wish.
https://sleep.tnet.com/equipment
So let's get you some software and start evaluating your results. Sometimes it isn't all about just the AHI.
Let's start by looking to see if anything on the reports could stand improvement.

[FUQE3]

Thanks Pugsy, I have sleepyhead installed on my Mac and am going to allow a few days of data to accumulate to see if there is any pattern or trend.

I will post some screen shots in the next few days to get your insightful opinion. I also want to read up a bit more on some of the graphical components of Sleepyhead. I cannot believe how much data there is! Pretty cool really! I need to understand each graph!

[Pugsy]

Concentrate on understanding the basics first.
SleepyHead will give you a lot more graphs than you really need.
Basics....events and AHI and the components.
Flow rate
Pressure
Leak
and maybe flow limitation or snore graphs if your machine does them if they are showing much going on.

All those other graphs like minute volume or respiration or tidal volume, etc. Those values have a very wide range of norms and unless you have some sort of lung problem you will likely just see a wide variation in norms and the data isn't all that critical. If you do have some sort of lung issue you most likely will already know about it and can discuss what you see with your doctor.

[FUQE3]

This is weird! For the past couple of days, I have had no more than three total incidents of OAs through the night and a couple of Hypopneas. But 26 and 28 incidents of CAs, yet I had zero centrals in my sleep study.

There are virtually no leaks. I'll keep you posted.

[Pugsy]

Look at when the centrals are flagged...any chance that you might have been awake or semi awake when they happened?

[FUQE3]

Here's my first attempt at sharing some Sleepyhead data. Apologies if I am posting the wrong information.

CAs were lower last night at 14 but nonetheless my AHI would have been < 1.0 if not for the CA events which numbered 26 and 28 the last couple of days (in total not per hour)

Feeling a little unrested today

[FUQE3]

Look at when the centrals are flagged...any chance that you might have been awake or semi awake when they happened?

Pugsy, I have no idea, however they do tend to gather in the latter part of my sleep. During my sleep titration study back in 2012, I had none reported.

I also dropped the pressure down from 7 last night back to the original prescription of 6.

[Pugsy]

Couple of ideas.
First of all having a few centrals is actually normal and not usually a cause for alarm.
It's common to have what we call "sleep onset" centrals and they aren't usually a problem unless we see a large number of them and they cause serious desats or they keep waking a person up so they can't progress through the various sleep stages.
I suspect that the first 2 little cluster of centrals (CAs on SH) at roughly 12:30 and again at approx 3:45 are perhaps sleep onset centrals.

Secondly, our awake/semi awake breathing is much more irregular than our asleep breathing and these machines can't tell if we are awake or asleep...they just measure air flow and they can and will flag awake/semi awake breathing irregularities as some sort of apnea event and most commonly they flag them as centrals. Remember all it takes is a 10 sec pause or reduction and it gets a flag. We hold our breath and not know it for 10 seconds easily. We sometimes hold our breath when we turn over in bed.

Since the bulk of your centrals seem to occur in the time frame just preceding full awake...perhaps some semi awake breathing pauses and perhaps some sleep onset centrals as you fluctuate between awake and semi awake and that first sleep stage.

I doubt the centrals are anything to be concerned about and I doubt they are responsible for your not feeling as good as you like.
More likely the breaks in therapy (from whatever reason) played a more important part and I wonder if in addition to the 2 shown breaks in therapy if you had other times where you woke up and just went back to sleep without the therapy breaks. Fragmented sleep will totally trash our sleep quality no matter how perfect our "numbers" are.

Do you take any meds of any kind? If so, what?
Do you normally go to bed so late?
Do you wake often during the night? If so, any idea why?

[FUQE3]

I doubt the centrals are anything to be concerned about and I doubt they are responsible for your not feeling as good as you like.
More likely the breaks in therapy (from whatever reason) played a more important part and I wonder if in addition to the 2 shown breaks in therapy if you had other times where you woke up and just went back to sleep without the therapy breaks. Fragmented sleep will totally trash our sleep quality no matter how perfect our "numbers" are.

Do you take any meds of any kind? If so, what?
Do you normally go to bed so late?
Do you wake often during the night? If so, any idea why?

I take Ambien is tiny doses to help fall asleep and am not averse to doing so during an awakening to ensure I fall asleep again. Other than that I only take the occasional NSAID for headaches or back pain that I essentially have lived with my whole life.

Yeah I often go to bed around midnight and often have thought about how erratic and unstructured my sleep hygiene is. I also wonder if it really helps all that much to be more structured with bedtime in order to get a better night.

As far as waking during the night is concerned, I have done for years. The cursed BPH mid 50s male toilet trips have been a certainty for me now for over 7 years. It's always at least one trip to the bathroom and sometimes two or three. As you can see, last night was two and it's always a challenge to get back to sleep without a little pharmaceutical assistance.

My return to CPAP is not least in part because I am hoping that this therapy will allow me to sleep more deeply and keep me asleep other than having to run to the bathroom. But it's too early to tell if it's working. My charts look good but I am wondering how much of an influence having to get up a couple of times a night to pee has on my overall feeling of malaise and how much has been the breathing abnormalities. If it's more about sleep disturbance then, quite frankly I might be screwed!

[Pugsy]

More structured (and better) sleep hygiene might help and sure wouldn't hurt.
I doubt it is the whole problem. I suspect that you have a combination of things that are messing with overall sleep quality that most likely is the reason why you don't feel the good numbers.

The BPH thing...have you talked to the doctor about maybe trying (or have you tried) the common meds that might help?
Nocturia that is caused by sleep apnea usually will go away with effective treatment but unfortunately not all nocturia is caused solely by sleep apnea.

Sleep maintenance insomnia (that's where you have trouble staying asleep for any reason) is a tough problem to sort out and fix. The cause is not always readily apparent and even if it is apparent the fix is not always easy to find success with.

Frequent wake ups (whatever reason) totally messes with the normal progression of the sleep stages that we need for our sleep to be the best at doing its restorative magic. I have battled it for a different medical reason that took a lot of trial and error to get it to a manageable level. In my case it was pain...old severe injuries causing bad arthritis and if I lay too long in one position I hurt and if I move I hurt and I used to have 30 to 50 known wake ups and I felt like total crap despite some excellent "numbers" in terms of cpap therapy. Even if I didn't have sleep apnea in the mix I was still screwed.

To have the best chance of feeling the good numbers we simply have to have better sleep quality both in terms of reduced wake ups and good sleep hygiene. These cpap machines can't fix sleep issues that aren't related to sleep apnea no matter how much we wish they would or how much we want to put everything that ails us in the sleep apnea basket.

I rarely sleep through the night and it's just something that I have come to accept. I have worked with my doctor to find a combination of meds that help the nighttime pain and limit daytime grogginess from the pain. Ambien...I take it occasionally but it will leave a hangover effect for me that lasts a good chunk of the day but I have discovered that even with the hangover thing...that's not as bad as a 30 wake up night feeling the next day. I don't take it all the time...I sort of rotate my meds so that I don't build up a tolerance requiring more to get same results. So while I might take Ambien occasionally I have other meds that I take to help reduce the cause of the wake ups which is of course the pain. I am screwed in that my primary daytime pain med happens to cause insomnia despite the "may cause drowsiness" sticker. A small percentage of people experience insomnia with it and I drew the short straw on that one.

If you regularly take NSAIDs for pain you might talk to your doctor about amitryptiline in very low dosages..like 10 mg. My doctor and I discussed it because they have had good success with it in low doses at bedtime to help manage pain and it has a side effect of causing drowsiness which helps me "sleep a little deeper so the pain doesn't bother me as much"...and as long as I remember to take it by 9 PM I don't have much morning grogginess from it. In the big doses for depression it will knock an elephant on its ass but at the tiny doses it is much less of a "knock you on your ass" side effect.

I still don't wake up feeling like running a marathon...but at least I don't wake up feeling like I just ran one.

Talk to your doctor about what you can do to improve your sleep quality. Talk about the BPH thing to see if maybe you want to try some meds to help reduce the nocturia.
Google "sleep maintenance insomnia" and see if anything else is spotted that might be part of the problem or solution.

Think long and hard about what it is about your unwanted daytime symptoms actually might be...is it fatigue or excessive sleepiness? They aren't the same thing.

Google all your meds...including the over the counter NSAIDs and look for side effects that might be part of the problem....fatigue...drowsiness..insomnia..nervousness..sleep issues, etc.
And remember these meds have half lives and take a while to get totally out of our systems even if not repeating the dosage.

There's so much more to good sleep quality than just good cpap numbers. I wish it were that easy...good numbers are really fairly easy to get. Cpap machines can't fix bad sleep when the bad sleep is caused by something other than sleep apnea and there's a long list of potential culprits in the bad sleep causes list.

[FUQE3]

More structured (and better) sleep hygiene might help and sure wouldn't hurt.
I doubt it is the whole problem. I suspect that you have a combination of things that are messing with overall sleep quality that most likely is the reason why you don't feel the good numbers.

Undoubtedly true. It's also always been true for me that the last couple of hours of ideally an 8-hour night, are always the most important. Why? I have no idea. If I don't get those last couple of hours, I am left with a "lost day"; feeling lousy.

The BPH thing...have you talked to the doctor about maybe trying (or have you tried) the common meds that might help?
Nocturia that is caused by sleep apnea usually will go away with effective treatment but unfortunately not all nocturia is caused solely by sleep apnea.

For BPH there are alpha blockers (like Flomax) which have their own slew of side-effects. I have an ongoing prescription for Alfuzosin, however I prefer not to take meds and haven't taken them in a while. I am not sure that they necessarily help with frequency.

Sleep maintenance insomnia (that's where you have trouble staying asleep for any reason) is a tough problem to sort out and fix. The cause is not always readily apparent and even if it is apparent the fix is not always easy to find success with.

Frequent wake ups (whatever reason) totally messes with the normal progression of the sleep stages that we need for our sleep to be the best at doing its restorative magic. I have battled it for a different medical reason that took a lot of trial and error to get it to a manageable level. In my case it was pain...old severe injuries causing bad arthritis and if I lay too long in one position I hurt and if I move I hurt and I used to have 30 to 50 known wake ups and I felt like total crap despite some excellent "numbers" in terms of cpap therapy. Even if I didn't have sleep apnea in the mix I was still screwed.

To have the best chance of feeling the good numbers we simply have to have better sleep quality both in terms of reduced wake ups and good sleep hygiene. These cpap machines can't fix sleep issues that aren't related to sleep apnea no matter how much we wish they would or how much we want to put everything that ails us in the sleep apnea basket.

For me, not having used the CPAP for almost three years, I have lived with a cycle of feeling lousy for a few days and then sleeping wonderfully well (generally as a result of exhaustion), waking up like I could rule the world only for it to last a day or two and then subsequently wake up with yet another lost day. I was hoping that returning to CPAP and sticking with the program would help me break this vicious cycle. Alas, so far it doesn't seem to be the case. The restorative magic is still elusive.

So now I will concentrate on sleep hygiene. Going to bed earlier, avoiding caffeine after noon, avoiding alcohol and drink minimally in the evenings.

I rarely sleep through the night and it's just something that I have come to accept. I have worked with my doctor to find a combination of meds that help the nighttime pain and limit daytime grogginess from the pain. Ambien...I take it occasionally but it will leave a hangover effect for me that lasts a good chunk of the day but I have discovered that even with the hangover thing...that's not as bad as a 30 wake up night feeling the next day. I don't take it all the time...I sort of rotate my meds so that I don't build up a tolerance requiring more to get same results. So while I might take Ambien occasionally I have other meds that I take to help reduce the cause of the wake ups which is of course the pain. I am screwed in that my primary daytime pain med happens to cause insomnia despite the "may cause drowsiness" sticker. A small percentage of people experience insomnia with it and I drew the short straw on that one.

If you regularly take NSAIDs for pain you might talk to your doctor about amitryptiline in very low dosages..like 10 mg. My doctor and I discussed it because they have had good success with it in low doses at bedtime to help manage pain and it has a side effect of causing drowsiness which helps me "sleep a little deeper so the pain doesn't bother me as much"...and as long as I remember to take it by 9 PM I don't have much morning grogginess from it. In the big doses for depression it will knock an elephant on its ass but at the tiny doses it is much less of a "knock you on your ass" side effect.

I still don't wake up feeling like running a marathon...but at least I don't wake up feeling like I just ran one.

I have generally eschewed meds coming from the premise that they are all toxic. That being said, I most likely would take anything if it provided me help with staying asleep or achieving better quality sleep. I will read up on amitryptiline, but I am frankly intrigued that an SSRI has helped with your sleep quality. I will do some more research.

Talk to your doctor about what you can do to improve your sleep quality. Talk about the BPH thing to see if maybe you want to try some meds to help reduce the nocturia.
Google "sleep maintenance insomnia" and see if anything else is spotted that might be part of the problem or solution.

Think long and hard about what it is about your unwanted daytime symptoms actually might be...is it fatigue or excessive sleepiness? They aren't the same thing.

Google all your meds...including the over the counter NSAIDs and look for side effects that might be part of the problem....fatigue...drowsiness..insomnia..nervousness..sleep issues, etc.
And remember these meds have half lives and take a while to get totally out of our systems even if not repeating the dosage.

There's so much more to good sleep quality than just good cpap numbers. I wish it were that easy...good numbers are really fairly easy to get. Cpap machines can't fix bad sleep when the bad sleep is caused by something other than sleep apnea and there's a long list of potential culprits in the bad sleep causes list.

Pugsy, and all the other contributors, thank you so much for all the generous advice. Thank you for all the time and thought that has gone into helping me start thinking about this the right way. I have a feeling that this is going to be a battle and I will keep you posted with my progress.

[Pugsy]

I initially balked at the idea of taking a SSRI because I thought he was trying to sneak in an anti depressant on me. But he explained about the studies done with SSRIs in very, very low dose in helping with pain management. So I did some reading and elected to give it a try. I think I started it in Dec 2010 maybe.
Last summer 2014 I elected to stop taking it totally for 4 months. I wanted to see what impact (if any) not having it made in terms of my sleep. I discovered that my time asleep suffered the most. I went from averaging 7 to 8 hours a night to be doing good to get 6 hours and I need that extra hour or two to feel my "best". I used Ambien mainly or would supplement with a real pain pill (hydrocodone) for those 4 months.
The Ambien and the opiate helped with the fragmented sleep from the pain but I simply couldn't stay in bed as long as I wanted. So I am back on the Amitryptiline most nights but not every night. Sometimes it isn't possible to take it within the time frame it needs to be taken (like last night we went out of town yesterday and didn't get home until 2:30 AM and I simply don't take it that late because I would then be sleeping the day away and that means I can't go to sleep at night. Instead I just accept the short night and deal with it and be prepared to most likely go to bed earlier tonight. In most cases if I nap at all during the day I have trouble going to sleep at night no matter what pills I take.

Something to think about and talk about with your doctor.

I can't take any sort of NSAIDs for pain control..my stomach rebels very strongly so for my arthritis I am limited to aspirin or some other sort of pain med. I can't even take a small 200 mg dose of Motrin or similar med without having so much GI pain that I think I need to be taken to the ER and given morphine.
Either that or I have so much puking and pain in the gut that I am more than willing to just have the arthritis pain because the belly pain is so much worse.

[FUQE3]

I have written to my Sleep Dr and mentioned the SSRI. He's a neuro as well as a sleep doctor and is very open to any good ideas regarding treatment and finding ways to recovery.

I am including last night's Sleepyhead data as I think the number of CAs again are for me a little worrisome. I should add that I feel way better today irregardless of the sleep profile.



Your thoughts and comments would be very much appreciated.

[Pugsy]

You don't by chance have one of those overnight recording pulse oximeters to see if those centrals are causing desats do you?
You are going to need to ask your doctor about just how worrisome those centrals are.
If they are awake/semi awake breathing irregularities getting flagged...they aren't worrisome at all.
Only problem is that we can tell from the data we have here if they are awake/semi awake flags or something else.

Since it concerns you and bugs you...run it by your doctor. Normally if they were the real deal they aren't considered worrisome until 5 per hour average and while you are pushing that last night. I have no doubt that part of that average is from awake/semi awake flagging.

[FUQE3]

You don't by chance have one of those overnight recording pulse oximeters to see if those centrals are causing desats do you?

It's funny you say that. I was thinking about getting one of those just yesterday. I do remember in my sleep study, this was a major concern for my sleep Dr. that while my AHI was considered mild, I had a typical desat down into the 80s. It stated that the typical SaO2 during a respitory event was high 80s recording a low of 84%.

You are going to need to ask your doctor about just how worrisome those centrals are.
If they are awake/semi awake breathing irregularities getting flagged...they aren't worrisome at all.
Only problem is that we can tell from the data we have here if they are awake/semi awake flags or something else.

Since it concerns you and bugs you...run it by your doctor. Normally if they were the real deal they aren't considered worrisome until 5 per hour average and while you are pushing that last night. I have no doubt that part of that average is from awake/semi awake flagging.

Again thanks for the input Pugsy. You are a wealth of knowledge and your sharing of that knowledge is very much appreciated.

I do feel quite energized today