2 Weeks on CPAP, Also Have Insomnia Issues. Seeking Input.

[Miss Emerita]

Try a mixture of caf and decaf, changing the mix slowly week by week.

[ozij]

Speaking of caffeine: There are slow caffeine metabolizers, and fast ones. The fast metabloizers get it out of their body much faster than the slow metabloizers. I'm a coffee loving slow metabolizer - and have discovered that 4 cups before 11 AM are simply too much for my body.

And yes, caffeine withdrawal should be avoided.

[Rubicon]

And the type of coffee as well. I like Starbucks French Roast, it's got like double the "normal" amount.

And the Moka or French Press?

Fuhgeddaboudit!!

[robysue1]

The arousal total is the sum of PLM, respiratory and spontaneous arousals.

Need the maff lady to figure out how those guys are doing their rithmotick.

The computation of that arousal total is indeed mysterious looking and it certainly doesn't follow the standard rules of arithmetic for our universe. But maybe it is caused by some kind of a transcription error.

If we look at the respiratory analysis section plus the movement arousal analysis sections together we see:

That 108 figure listed as the number of total arousals also appears as the total number of hypopneas scored under the AASM Recommended standard.

So a good question would be how many of those so-called Hypopnea2's scored under AASM Recommended got scored because there was an associated arousal and how many of them got scored in spite of not having an arousal. If most or all of them had associated arousals, you would expect the number listed as Respiratory arousals to be close to 108, and so there's some kind of transcription error on that line: Perhaps this is the line that should have 108 and that would make the total arousal total greater than 108?

A second good questions to ask would be whether it's a reasonable idea to suppose that only 10 of the 108 Hypopnea2's that were scored had an associated arousal and the remaining 98 were all scored because there were associated desats that were >= 3%. And in that case, the total number of arousals ought to be listed as 23.

So here's a question for Rubicon: Do most hypopneas scored under the AASM Recommended standard have associated arousals? Or is it reasonably common for hypopneas to have a >= 3% desat without an arousal?

And a second question for Rubicon: Would every hypopnea scored under the AASM Alternate standard (i.e. the Hypopnea1's in this data), also be scored under the AASM Recommended standard? It seems like the answer ought to be "yes" since a desat that is >= 4% clearly meets a guideline that is satisfied by a desat of >= 3%. But if I recall correctly, the required decrease in airflow on the two standards is also subtly different, and that could mean that some hypopneas scored under the Alternate standard might not be scored under the Recommended standard. Is that correct? Or am I missing something?

[robysue1]

I'm also like "Say what?" in the HST where they claim "Significant Obstructive Sleep Apnea" with an AHI of 5.93.

Yeah, I noticed that too.

The home sleep study says:

An overall total of 47 respiratory events yields an Apnea Hypopnea Index (AHI) of 5.9

and it also states "Significant Obstructive Sleep Apnea" under the assessments. (Possibly worth mentioning: This AHI is correctly computed based on a total of 47 events and 475.5 minutes of "monitoring time" if we assume "monitoring time" means "sleep time".)

Also worth noting: The hypopneas on this home sleep study were scored using the AASM Alternative standard, which requires a 4% O2 desat.

But if we look at the respiratory data from the in-lab NPSG, we have the following:



While the numbers in the arousal section of this study don't make sense, the numbers in the respiratory section do seem to be accurate.

Of interest (in my opinion) is that under the AASM Recommended standard, the AHI is correctly computed as 16.9, which puts the OSA into the moderate category. Using the AASM Alternate standard, the AHI is correctly computed as 2.9, which would mean the OP doesn't even have OSA at all.

So what gives here?

We have a home sleep study scored using the AASM Alternate standard, and the patient has mild OSA (which is then called "Significant" on the assessment part of the report).

We have an in-lab study scored both ways, and with the AASM Alternate standard, the patient doesn't have OSA at all. But under the AASM Recommended standard, the patient has moderate OSA.

So based on the given data, what's the best, most accurate diagnosis for the OP? No OSA? Mild OSA? Moderate OSA? Should the diagnosis take into account what kind of OSA symptoms the OP is having?

In any case, I think we can conclude a couple of rather obvious things:

1) We really don't sleep the same every night, and the severity of our apnea can vary a bit from night to night. And if we get tested on a "good" night our apnea might not appear to be as significant as it is if we get tested on a 'bad" night.

2) The standard used for scoring hypopneas matters and matters a lot when it comes to diagnosing OSA: It is possible to have "no apnea" under one standard while having "moderate apnea" under another---even when it's the same night's data that is being scored. And that begs the question: Why are there still two standards for scoring hypopneas? Is it just because Medicare insists on the older AASM Alternate standard that requires a 4% desat? Or is there really no consensus among sleep medicine professionals about whether "hypopneas with arousal" are or are not "real hypopneas" in the sense of being an accepted part of obstructive sleep apnea?

[Rubicon]

The HST has a low number of arousals (zero actually) and consequently no arousal-only hypopneas because it can't measure arousals:

The Philips Alice NightOne has three sensors that monitor seven data points to help detect sleep apnea. A nasal cannula, pulse oximeter, and effort belt

The idea of 2 separate hypopneas didn't come from the "sleep medicine professionals", it came from Medicare. And (IMO anyway) there shouldn't be any confusion because the NPSG Report, according to Da Rules, must clearly define all the data including how it was scored, and we're looking at hard data (OK, there is that "% Agreement Among Scorers Thing", but for arguments sake let's call all the data on the NPSG Report fact).

So the discrepancy. NPSG Reports are automatically generated, so I don't think it's transcription error, it's a calculation error. The text looks like Sandman, and in an early version of Sandman the same type of thing occurred but with PLMs. That was fixed a long time ago tho. IIWM I'd call up the guys who did the study and get an explanation from them, including what system they use and what version of software they got.

[Rubicon]

So based on the given data, what's the best, most accurate diagnosis for the OP?

Chronic Insomnia.

[Rdea]

My “mild” apnea began during an extremely stressful period of my life. It was accompanied by nightmares, insomnia. I don’t know which upset me more; going to bed or getting up in the morning. I feel there is a environmental link, probably requiring some mental health intervention, exacerbating the apnea if not the entire reason for it.
I went 4 months of experimenting with cpap but so far, leaks and facial changes have been discouraging. I tried a custom mandibular device ($900.) but as weeks passed, I realized the occasional relief it brought was coincidental and abandoned it. Then came prescriptions for armodafinil and Aderrall to buy me a couple of hours of alertness, before losing their effectiveness and leaving me nauseated and anxious. Im back online, investigating cpap machines again, hoping the technology has improved in the past 2 years.

Meanwhile- and this may be of tremendous help with your insomnia- before I go to bed I inhale once ,from a pipe, a measured amount of a mild cannabis prescribed for sleeping or relaxing, followed by 1mg of lorazepam. Marijuana alone doesn’t work as a sleeping pill but neither I found was Ambien, at least for me. At any rate, sleep arrives sooner AND deeper, with less events of waking after I smoke.

I’ve never been a fan of pot, even during my young years. I could neither drive or carry on socially after I smoked it, without having to put more effort into either activity than it was worth. I finally found a use for it.

[SDBud]

Night - THC most nights as it relaxes me,

You may think it relaxes you, but THC is a psychoactive drug that stimulates your brain, it does NOT relax it.

Try skipping that, and see if it helps.

[Rubicon]

Night - THC most nights as it relaxes me,

You may think it relaxes you, but THC is a psychoactive drug that stimulates your brain, it does NOT relax it.

Try skipping that, and see if it helps.

Too many references demonstrating otherwise:

https://www.google.com/search?q=thc+as+ ... e&ie=UTF-8

Best advice--

"YMMV"

[robjones1985]

Hello again. Wanted to check in with you all, as my sleep problems have continued unfortunately. I’m in the process of finding a third sleep doctor to get someone else’s input on my situation, but wanted to get your input as well. I'd say the graph at the bottom is a typical night for me at this point. The gap in the middle is my typical 90 minute wake up time.

A typical night now, I fall asleep for about 1.5 hour, then wake, sometimes pee. Usually, can fall back asleep within an hour. Then, I’ll sleep for a few hours until 3-4AM. Once I wake the second time it’s like I have enough energy/wakefulness there is no hope of falling back asleep. Just lay in bed. Reading a book, moving to another room, etc does not help. I’m currently getting 4-5 hours of sleep and feel low on energy, moody/irritable most days.

I tried a lot of what you all recommend (thanks again for the suggestions). Over the last few months here are some things I’ve tried:

Exercise- Still strength train 3x per week, do some low impact cardio twice a week. Average 10,000 steps per day. Can be hard to do all this with low energy, but I find a way to do it.

Caffeine- did a small taper for two weeks then got off it for 6 straight weeks. Didn’t notice any change to my sleep during this time. I’m currently back on caffeine, about 2 cups before 8AM most days.

Saw another ENT specialist to get a second take on my nasal problems. Diagnosed with “chronic pansinusitis” and “hypertrophy of nasal turbinate”. Declined surgery as I have concerns over empty nose syndrome. I already had a turbinate reduction when I was a teenager and don’t want to risk making things worse.

Due to recurring nasal congestion and poor air flow, I’ve landed on the AirTouch F20 Memory Foam mask. This has proven to be the best mask for me. I was actually off my cpap for about 2 months while I worked through my nasal problems and trialing/failing to find a mask that worked. I like the memory foam full face now.

Night routine- I’m pretty consistent getting to bed at 9:30PM, lay in bed read a book for a while, then lights out at 10PM. Some nights are harder than others, my mind does wander even after trying to relax and read to take my mind off things.

THC- Dropped it cold turkey little over a month ago, bad withdraw symptoms first 8 days but now fine. Was relying on it too much and I think it made my sleep onset worse. Since ditching it, I fall asleep faster.

Asked my Dr. about Olmesartan and Rosuvastin, he said they won’t cause insomnia.

Got off testosterone 2.5 months ago – no impact on sleep. Considering going back on as I feel worse without it. But wanted to rule it out as a source of insomnia.

Did a 4 point saliva cortisol test, no signs of high cortisol, no signs of adrenal fatigue.

Experimented with lots of supplements. Magnesium, melatonin, tryptophan, taurine, glycine, valerian root, zma. Nothing helped more than a few days, if that.

Drastically cut back on alcohol, I drink twice a month now at most. No effect on sleep.

Last two weeks I've totally given up on supplements and sleep meds, as none have worked. I simply try to relax, go to bed and read, pee right before bed then cpap on and lights out.