Great AHI but more tired with CPAP than without?

[haughki]

Hi,

I'm hoping for feedback on this question: given everything below, is it worth it for me to keep trying to use the CPAP?

In short: I'm more tired when I use the CPAP than when I don't. My current theory: I have relatively mild sleep apnea, and, just because of "who I am" ("sleep type", genetics, mental health), my sleep is more disrupted than is usual by wearing the CPAP mask. Therefore, even though the CPAP is handling my sleep apnea events, I'm more tired with than without it.

See two Oscar screenshots images of recent nights; these are representative of my data over the last 1.5 months.
https://i.imgur.com/hXY2Vew.png
https://i.imgur.com/3mkqQgn.png

Details:
After many years of false starts, leaky masks, exhaustion, I finally was able to get a setup where I could get through most of a night wearing the mask, with a consistent AHI of between .5 and 1.5, usually below 1.

For a month and a half (aug, sept), I did the following: lights out at 10:00 PM, wear the mask until 6:00 AM or so, then get another ~hour of sleep without the mask. I just wanted to wear the mask as much as possible while still being able to function somewhat during the day. But, often on the weekends, I just had to sleep for a night or two w/out the CPAP. I would just get progressively more and more tired during the week. Not subtle at all, but still, I've been tracking my sleep closely, esp. my 'subjective tiredness' on a scale of 1-10, and it's very, very clear that I'm more tired when I wear the CPAP.

My goal was to get comfortable with the mask, and then go for wearing all night, every night. I recently did 6 nights straight: lights out at 10:00, out of bed at 7:15, pushing that until ~8:30 on the weekend. Again, I'm just exhausted, significantly more so than without the CPAP, even though my AHI is great, and the CPAP seems to be functioning well (see Oscar screens). I wanted to go for 2 weeks, but I got very sick, all bets off.

During both of these "experiments", there were no significant stress events, etc., that I think negatively affected my sleep; at least nothing more than is usual for me.

I have other issues that affect my sleep/sleep quality. Esp., pretty severe generalized anxiety disorder, for which I take both celexa and lamotrigine. I've struggled with insomnia (esp. maintenance insomnia) most of my adult life. I have developed great behavioral techniques for going to sleep and getting back to sleep, and the medication helps a lot with my anxiety, so that is all well managed. Overall, I seem to just "need a lot of sleep" -- this has been true since my teens: these days, 9 hours in bed with lights out seems a minimum. On a good night, that means 8-8.5 hrs of time when I don't know that I'm awake (i.e., subjectively asleep). I also recently started wearing a Whoop strap; I'm not %100 convinced on the accuracy of the data, but it seems like I get less deep and REM sleep than average.

So. Many people seem to say that you just have to keep sticking with the CPAP, and eventually, it will pay off. But, are there cases where, for whatever reason, using the CPAP is just too "disruptive" to a person's sleep, so that, even though the CPAP is doing its job and handling the apnea events, overall, it's just not worth it? How long do I have to stick with this before I know? I'm guessing there's not hard and fast rule/answer here, but I'd love any guidance.

Lastly, I haven't checked in with my sleep doctor about this yet, because he's hard to schedule with, and I don't want to go back to him and have him just say, "You need to wear the CPAP more", which is essentially what he's been saying for a long time. I want enough data so that, if the CPAP is just not working for me, he will believe me and we can move on.

Thanks in advance,
Hawkeye Parker

[Pugsy]

I have relatively mild sleep apnea,

What exactly was your "relatively mild sleep apnea" diagnosis based on?
What was the diagnostic AHI?
Did you have any desats in terms of drops in blood oxygen levels?
Google "SSRIs and sleep" and start reading...your celexa is a SSRI...you should read up on its side effects as well.
Now I know you have probably been on it a long time but it messes with sleep quality and cpap can also mess with sleep quality so you are most likely getting a double whammy of potential negative side effects.

Is being tired the only reason you are using cpap in the hopes it will fix the fatigue issues?

Are you experiencing any nasal congestion at night?

[haughki]

I have relatively mild sleep apnea,

What exactly was your "relatively mild sleep apnea" diagnosis based on?
What was the diagnostic AHI?
Did you have any desats in terms of drops in blood oxygen levels?

My most recent "in lab" sleep study is from 4/2015. A summary of that study follows, with a link to the complete report below. I had an at home test in 2019, small black wrist device with a pulse ox? Result was: AHI 2, RDI 5, Oxygen level "Normal", "You have tested negative for sleep apnea". I had two other in lab sleep studies before 2015. As I recall, the result was "mild to moderate sleep apnea". I can probably dig up more details on these if you want.
2015 Report
DISTURBANCES OF SLEEP:
The minimum oxygen saturation during the study was 92 percent.
Snoring was present. The Apnea Hypopnea Index (AHI) was 1.6 events per hour of sleep (2.1 while
supine and 5.4 in REM sleep). The Respiratory Disturbance Index (RDI) was 14.0 events per hour of
sleep, and included respiratory effort related arousals (RERA) in addition to AHI. Periodic limb
movements of sleep (PLMS) did not occur. Cardiac rhythm was sinus.
IMPRESSION:
This study demonstrates snoring and mild sleep disordered breathing /mild obstructive sleep apnea
(OSA).
Oxygen Saturation:
Lowest Oxygen Saturation 92 90 – 99%
Lowest Oxygen Saturation in REM 96

https://drive.google.com/file/d/1NACHr- ... sp=sharing

Is being tired the only reason you are using cpap in the hopes it will fix the fatigue issues?

Yes, for sure, but also the many "side effects"/negative impacts of chronic poor sleep/fatigue, esp. in my case worsening cognitive/memory issues and mental health issues.

Are you experiencing any nasal congestion at night?

Yes. Chronic vasomotor rhinitis is one diagnosis. I've been allergy tested many, many times over the years, with positive results for dust, which I've tried and tried to mitigate, but ultimately unsuccessfully. I've taken flonase (fluticasone) and a handful of other drugs, with no relief. Related: my current CPAP setup is the DreamWear nasal pillow with mouth tape and chin strap, which is what finally worked to stop mask leaking for me, but given my nasal congestion, it's feels like a "weird" way to go. I often can only breathe through one nostril at night. But, it "works" in that the CPAP numbers are great, and I can see on the pressure graphs that the CPAP is able to ramp up "properly", which I assume happens when I have apneas. I've certainly wondered whether or not it optimal or even "valid" (in terms of the CPAP therapy) to be using a nasal pillow, given my congestion, but I tried so many (more than 10) different full face and hybrid masks, and I could just never get through a night without leaks that woke me up.

Google "SSRIs and sleep" and start reading...your celexa is a SSRI...you should read up on its side effects as well.

Thanks very much for this. I've certainly wondered about this and thought it must have an effect; I've talked with my psychiatrist about it, but he never really "red flagged" the medications with respect to sleep. That said, he's certainly very biased; I haven't researched this, and I will. I think my "sleep issues" predate my use of SSRI's, but I have been taking them now for 20 years, and I take a pretty significant dose, 30mg/day, plus the lamotragine which definitely has a sedative effect. The balance and interplay between my mental health issues and sleep issues...tightly intertwined, so complicated, and I want to be _really_ careful about "messing wtih" my mental health. But, I want to know.

[Pugsy]

The balance and interplay between my mental health issues and sleep issues...tightly intertwined, so complicated, and I want to be _really_ careful about "messing wtih" my mental health. But, I want to know.

Understood and agree completely.

I am NOT suggesting discontinuing the meds but offering up the idea that they could be playing a part in your unwanted symptoms. When it comes to mood medications they almost all have some rather nasty side effects but we have to measure those effects against the problem that those meds are meant to address. Talk about the proverbial rock and hard place to get stuck in. Something to be thinking about.

Your flow limitation graph looks like someone who might be having some congestion and you confirmed that with your comment about your battles with Chronic vasomotor rhinitis. That said it wouldn't be impossible for the congestion to also be impacting overall sleep quality.
Question....do you think the rhinitis has worsened with the cpap use? Or improved?
Are you using the humidifier? If so, at what setting? Have you experimented with more or less humidity? If so..what were the results?

Snoring... even without a boat load of apnea events forming can also disrupt sleep...so that's a potential factor and a good reason to try cpap.

IMHO you have to weigh the results with cpap against the results of not using it. That old proverbial rock and a hard place again to be in.
Your OSA seems to be very mild indeed and you are the one who has to weigh the old risk vs rewards thing that comes with all this stuff be it cpap use or medication use or whatever.

We can't make that decision for you.
BUT if it were me and cpap use made my sleep quality a whole lot worse and I also had very mild OSA without significant desats....I am leaning towards not using cpap in this situation but only after I had exhausted all other options.
Is sleeping position a factor at all? If it is one could try sleeping in the position that minimizes the apnea issues.
While we don't expect cpap use to fix all our problems we certainly don't expect cpap use to make matters markedly worse.