Advice please--I can't stop waking even with very low AHI

[Jeanne Ellen]

After three years, I just can't seem to figure this out. I probably shouldn't complain because I have very low AHI numbers--I frequently have 0 events per night. I don't get classic apneas but I' often get flow limitations, RERA's and hypopneas which cause me to wake up multiple times per night. I've decided that I must be super-sensitive to such things, and while some people can sleep through them, I can't. Even though my experience with cpap has some problems, I know I feel better with it than without it, so I keep trying. I generally feel pretty good during the day and don't have the headaches and sleepiness I had in the bad old days.

Ove the years, I've experimented with different pressures. I've had the greatest success using straight cpap at a pressure setting of 10, but still get several wake-ups during the night and have difficulty going back to sleep. I tried raising the pressure to 11, but that gave me gas, bloating, and hiccoughs. I tried auto set from 7-15, but the wake-ups were worse, I think maybe the pressure changes disturb me. The only way I could get a reliable good night's sleep was to take benedryl, but that would only work for a few days. My doctor prescribed a short-acting sleep aid, but I don't like to use that often--only when I wake up at 3 am and can't get back to sleep. When I do use sleep aids, my AHI's increase, but never more than to .5 or so. I'm obviously sleeping through the events that normally cause me to wake up. I also feel great the next day.
Recently, I tried 3 mg. melatonin before bed and thought I'd found my solution. However, after a week or so, I started getting stomach issues and diarrhea (yuck), so had to stop.

Now I'm trying out a Bleep mask, which I like a lot. I felt like I was getting more air up my nose and was waking up with a dry mouth, so I lowered the pressure to 8. That was a bad idea because it increased the wakefulness. Last night I went up to 9 and still had arousals. In the middle of the night, I set it back up to 10, but continued having RERAS. This morning I feel the opposite of refreshed. download/file.php?mode=view&id=14219d.

[ChicagoGranny]

wake-ups during the night and have difficulty going back to sleep.

CPAP improves breathing. What about the other aspects that affect sleep? Here is an old checklist.

Good Sleep for CPAPers

- Practice good sleep hygiene (Google it and read several sources; ignore extreme advice.)
- Eat a good diet
- Have a regular, moderate exercise program
- Try to avoid daytime naps
- Practice total abstinence of caffeine including sources like chocolate (sigh)
- Review all medicines, vitamins and supplements you are taking to make sure none are interfering with sleep
- Use the bedroom for sleeping (and sex) only, and make sure the bedroom and bed are comfortable.
- Learn to appropriately handle emotional stress in your life
- Do not listen to your breathing or the sound of the machine as you are falling asleep. (Some people, including me, actually find listening to their breathing and the sound of the machine to be relaxing.)
- Distract your mind by thinking of a pleasant, relaxing activity that you enjoy.
- If you are awakening at night, do not be too concerned. It is actually a normal part of sleep. (It does become a problem though for people who, when they awaken, become frustrated and have difficulty returning to sleep.)
- Use CPAP software, such as the free OSCAR (or the free SleepyHead), to make sure your therapy is optimized
- If you still don't feel or sleep well, make sure you have regular medical checkups to confirm there are no other medical problems

This is a checklist. Some of the things you already do. Some are easy and can be done right away. Others you can work at over time.

CG

[Jeanne Ellen]

Thanks, CG. I do a pretty good job of following all this advice except the caffeine and chocolate part. I do enjoy my two cups of coffee a day, but gee, it's only two cups, half-full, and I drink the last one about 2 pm. I could try eliminating coffee--it wouldn't kill me. I'm not going to give up chocolate so that's that (I usually have one piece a day). I don't consider myself overweight. I weigh about 130 lbs and I'm 5'7". The weight part has stayed the same for the last five years. I've gone to bed at the same time every night since I can remember. I walk the dog twice a day for at least an hour each time. I do all the housework around here. I don't take daytime naps. I do have a very small glass of wine before dinner--I suppose I could give that up, but I don't think I will. I could stop checking the clock when I wake up. I know that doesn't help. Other than that, I think my sleep hygiene's about as good as it's going to get.

Here's a question: Is it just my imagination or does the Bleep send more air up the nose than a medium size set of P10 nasal pillows? It seems like it to me because my nasal passages feel more open (a good thing.) However, all that air blowing up my nose, at the same pressure I used with the P10, feels sort of disturbing. I turned the hose humidity up from 1 to 2 because my mouth and throat felt dry. Then I started adjusting the pressure. I can't seem to find the best setting. Tonight, I'm going back to my old setting with the P10 and maybe take a benedryl.

[AmSleepnBetta]

First, a top of head reaction to your perceptive reports:

• 1.I too interpret your mentions of wakings and of having many flow limits with few apnea as indication your breathing is significantly flow limited and that you waken from doing the work of sucking air through a straw that is too small or too pliable and prone to partial collapsing.
  
  2. From my fairly empathetic POV (but greater reluctance to change), the first things I see as needed from you now are a couple of 2-minute views of your flow rate curve at an enlarged vertical scale of about a 1.25 inch amplitude (the overall screen height of the breathing cycle, top to bottom). If many of the tops of the curve are not smooth, choose at least one 2-minute view of those along with one view that is most representative of typical nights. Include the overall view for the night.
  
  3. I don't think you or others have addressed blue (and green) light from our computer screens, smart phones, TV's, flourescent or LED lights. (As below, I am reluctantly evaluating a major habit change: a trial of shutting those screen sources down about 90 to 120 minutes before sleep time. I have Windows (or is it IRIS?) turn on its blue blocking earlier and have ordered the highest rated blue blocking glasses I could find .)
  
  4. You see possible need to cut some coffee, another tool. (I could not stand decaf until I began using Peet's and found it--via a new-to-us Keurig--tolerable, so in my trial period, I have cut caffeinated coffee to 2 cups before 3pm and one cup of decaf with 6 PM meal.)
  
  5. I've read that the Respironics is not as effective as the ResMed in responding to flow limits. I used the ResMed Autoset to cut OSA, but got a ResMed AirCurve VAuto for flow limits. The latter's fast responding BIPAP feature is known to be (and has proved for me) superior in reducing flow limits dramatically. I believe it is possible you might be able to use the VAuto's APAP, feature, even though your Respironics experience of it raises doubt.

As one who reduced his AHI from the 50s (primarily OSA) I still see a lot of coinciding, sudden bursts of motion (accelerometer motions and repositionings) and of flow rate amplitude--those apart from continuing but vastly reduced flow limits and much improved sleep quality--thanks to good titration afforded by non-MD forum advice/lurkings and by the ResMed VAuto. Longtime sleep deprived but now treated and hopeful of further improvement, I began focusing on often continual irregularities in the peaks of inspiratory airflow and rate curve. Eventually, I gambled and bought the Dreem D2 headband with its simplified set of EEG and other sensors, wanting to drill down and assess arousals. The idea was to see if the D2's enhancement of my sleep data (as reflected in sleep-stage graphs in OSCAR) would help identify any regularity in disturbance patterns at changes from REM or DEEP to WAKE or LIGHT sleep.

I knew the D2 with low sampling rate had poor resolution (with its low sampling rate) but expected that some disturbance pattern might stand out in that time interval from, say, one minute before to 30-seconds after those sleep stage "declines" to WAKE or LIGHT. The effort was and still is to try to discover a way to meaningfully score patterns signifying arousals that are not currently flagged by our PAP devices. Score in hand, I/we would have a tool to use to measure, over a shorter period of time, a limited change of life style habit/diet/exercise/prayer/meditation/news-abstinence (for me just now, e.g., cutting caffeine and late night screens for a few weeks.)

I too use both the P10 and bleep, mainly the P10 because insensitive fingers make getting a leak free connection to the ports difficult. I do believe your dry mouth indicates some breathing through your mouth. As can be found elsewhere, I, a mouth breather, seal-up by using a cervical collar as well as a piece of Siiipos' Gel-E-Roll. It's kind of like a mineral backed ACE bandage, but, lacking adhesive, it requires an overlaying (DIY) retainer.

Good luck. I hope you will post the recommended views.

[UARS_BE_GONE]

Totally sounds like me. I have UARS as well, curious what CPAP machine you have? Very cool that it shows RERAS as well. Perhpas mine does too and I just haven't figured it out. I have the Resmed myair 10. I also haven't found a solution that really works according to my definition (not waking up so many times).

Sorry I don't really have an answer for how you can stop waking up because I have the same problem. There are people for whom CPAP does not solve the problem (not sure if you or I fall into this category though).

https://doctorstevenpark.com/2things

[ChicagoGranny]

I have the Resmed myair 10.

There is no such model in ResMed's line.

have UARS as well, curious what CPAP machine you have? Very cool that it shows RERAS as well. Perhpas mine does too and I just haven't figured it out.

If you have a ResMed AirSense 10 (hopefully AutoSet), the RERA data is there. Just start using OSCAR to see it.

[ChicagoGranny]

I do enjoy my two cups of coffee a day, but gee, it's only two cups, half-full, and I drink the last one about 2 pm

You might try tapering down to zero. This is the only way to know if it helps.

Hopefully, you eat the chocolate by midday.

[Jeanne Ellen]

CG, I’ve given up coffee before so I can try it again, also chocolate and alcohol. I’ll do a two week experiment and see what happens.

SMB, I tape my mouth so I’m not doing any mouth-breathing. thanks for the reminder about blue screens.

UBG, I use the Phillips Dreamstation.

For the meantime, I’ve gone back to my P10 mask. It seems to me that the Bleep, with the large nasal openings, is shooting more air up my nose than the medium size nasal pillows I’m used to.

[ChicagoGranny]

I use the Phillips Dreamstation.

According to your OSCAR screenshot, you have the Auto model.

Why are you using a straight CPAP pressure settingg?

[ElusiveSleep]

* I also awake early (~4 or 5 am) since starting APAP. But after removing my mask (for at least 6 hours on the machine), I doze back to sleep. This usually results in a prolonged period of sleep inertia (being in a daze after awaking) until I've had 1 or 2 cups of coffee. Despite all this, my daily function is pretty good.

* To investigate the issue further, I consulted with a neurology sleep doc with expertise for insomnia (my regular sleep doc is a pulmonologist). He made some good suggestions, one of which was to eliminate ambient noise from a pedestal fan (after some resistance, my wife agreed to remove it).

* I also sought the help of a well regarded clinical psychologist who specializes in cognitive behavior therapy for insomnia (CBT-I). She acknowledged that something was going on but we both agreed that it was not true insomnia since my daily function was not impaired.

* Now my thoughts on what is happening:
- I believe that as a person with close to normal BMI, my arousal threshold is too low. This is based on the research of Prof. Eckert in Australia, who found that compliance of CPAP use was lowest in patients with normal BMI, and as a group, they had the lowest arousal thresholds (LAT).
- LAT means that a person is more susceptible to being aroused ie, woke up by various stimuli. This could be due to pressure changes in the PAP machine, or environmental factors (noise, light, bed partner movements, etc.).
- Some medicines have been tested for raising arousal threshold, and one of these is trazodone, which I take before bedtime. My first use of this was 12 years ago when I first developed insomnia (and 7 years before my diagnosis of sleep apnea).

However, the most important practice is to follow NASA Rules of Sleep: dark room using blackout shades, minimize sounds, and keep cool temperatures (<68 degrees).

[Miss Emerita]

Jeanne Ellen, one experiment you might try is to introduce some flex. This lowers the pressure when you exhale, then raises it again when you inhale. Having the pressure rise when you inhale sometimes helps to resolve flow limitations, hypopneas, and RERAs. It can also feel more comfortable. Normally you'd want to raise your minimum pressure to keep your expiratory pressure the same, but you have so few events I think it'd be worth leaving your minimum alone. Try flex of 1 and see how it goes, if you're in the mood for experimentation.

When I started using the Bleep, it felt like more air was blowing around in my nose than with my nasal pillow masks. Now it just feels normal. I think maybe because the air isn't channeled, it creates a little more turbulence -- though that's just a guess.

[Jeanne Ellen]

DG, well, since you asked..... I've tried auto settings before but I've never got it right. When I first started using cpap, the machine was set on APAP at pressures of 8-14, but I couldn't tolerate it for more than an hour, so, thinking that the pressure changes were waking me up, we (the sleep doctor) changed it to straight cpap at 8, which wasn't fantastic, but at least I could sleep well enough to keep going. I struggled with aerophagia and air kept blowing out of my mouth, which led to a big chinstrap and taping my mouth, but since that time, my AHI has always been under .05.

Over time, I've increased the fixed settings from 8 to 11, trying to eliminate arousals, which are almost always from flow limitations, RERAs, or the occasional hypopnea and trying to prevent aerophagia and hiccouphs, which also wake me up. I sometimes get leaks from the P10 because the straps move around on my head. Thinking that the Bleep would solve that problem, I wanted to try it.

When it seemed like more air was blowing in my nose from the same setting I'd used with the P10 (causing more arousals), I thought I'd see if I'd get better results from an auto setting. I found that with auto setting at 7.5-14, plus a 3 mg melatonin, I got a good night's sleep and AHI of 0.00. So, this was wonderful until the melatonin started to give me diarrhea after six nights! When I stopped the melatonin, I ended up with a horrible night's sleep, for me, anyway, which was the screen shot at the top of this message. I went back to straight cpap, this time set at 8, but still lots of arousals, upped it to 9, then 10, but still lots of arousals, due, I think, to the amount of air that's coming from the Bleep as compared to the P10.

I went back to the P10 last night at my former fixed setting, took a Benedryl, and had a decent night's sleep. I'd like to use the Bleep because I think I get superior treatment, but my sensitivity to pressure makes it hard for me to figure out how to set my machine.

[Jeanne Ellen]

Miss Emerita,
I tried flex in the past but turned it off because I decided that the changing pressures woke me up. I can give it a try with the Bleep. Thanks for the suggestion. I'd forgotten about that.

[UARS_BE_GONE]

My bad the name is airsense 10