Apnea, insomnia, snoring and doctors

[stanps]

As you might guess from the subject, this will be a long and convoluted post. I apologize in advance for it and greatly appreciate anyone with the patience to read through it and give my any kind of advice.

I was diagnosed with severe obstructive sleep apnea this spring and have been on CPAP for almost three months. My current AHI for the month is 4.7, which I understand is considered successful treatment. My sleep lab AHI was 56 and I have a ResMed machine which over reports hyponias, so I feel like my sleep apnea is under control.

My problem is my inability get enough sleep. I fall asleep promptly at 10:00, sleep for four hours and then wake up. On a good night I roll over and sleep for another 3-4 hours. On a bad night I am up for the remainder of the night (and day). Most days fall somewhere in between. The bottom line is that although the quality of my sleep is very good, I just do not get enough of it to feel rested and functional throughout the day. I have developed the habit of reading when I am up in the middle of the night. I read until I am to exhausted to read any more, then put on the mask and try to fall asleep. Usually I can not fall asleep and try to read some more. After several rounds of this I eventually fall asleep. The problem with this routine is that it takes 8-9 hours to get 7 hours of sleep. I am typically in a deep sleep when my alarm goes of, making it harder to get up.

Another complicating factor is the fact I have been told that I still snore. Apparently, after falling asleep on my side, I roll over on my back and snore. I do not sleep with a partner regularly so I do not have a good feel for how much this happens. I am working on getting more consistent fedback.

I have asked my sleep doctor to prescribe something that will help me sleep through the night. She would not prescribe anything because I am still snoring. She wants me to try a chin strap to see if it prevents snoring. I do not have the chin strap yet but I do not have much confidence in it or my doctor. She is a perfectly nice person but I get the feeling she doesn’t have a clue about how to help me. I'm not sure any prescription sleep meds would help and I do not want to take them but at least in the short term, I will do anything that helps me get a good night's sleep.

An interesting thing I have noticed is that when I wake up at 2:00 am and check my numbers my AHI is just a little over 2. If I sleep for the rest of the night and check it in the morning, it us usually 4-6. There is something about the quality of that first four hours of sleep that I just can't reproduce in the second half of the night. I do not have ResScan software so I am just going by the numbers on the display.

So my questions include but are not limited to:

- What is the relationship between my good AHI number and my snoring? Does the snoring make the numbers invalid? Would they be even better if I didn’t snore?

- If my numbers are good and I feel good when I sleep, can I assume that my apnea is being treated and my insomnia has another cause?

- What conditions exist in the first half of the night that don’t exist in the second half?





Thanks again for any advice.

Stan

[WindFlyer]

From what I've been told, if CPAP is doing it's job you should not be snoring. You might choose to bump your pressure up and see if that helps. As for the sleeping half the night thing- you might want to talk to your sleep doctor about that. They might be able to tell from another PSG what's going on. That's my two cents on it, anyhow.

[stanps]

WindFlyer,

Good point and something I forgot to mention. She did have me bump it up from 6 to 7. Still quite low. I am new at this and still reluctant to change my pressure if not specifically told to do so. I wasn't sure if increased pressure would make my snoring better or worse. It is something I will definitely pursue.

Thanks

[jdm2857]

A small digital "tape" recorder could help you monitor your snoring. Or you could consider getting the software and card reader for your machine.

Speaking of your machine, which one do you have?

One reason that the later part of the night may include more apneas is that many people require a higher pressure to prevent them during REM sleep. And REM occurs only after stage I, II and possibly III sleep, so you do not have it right away.

[LSAT]

Interesting..."Quote...I was diagnosed with severe obstructive sleep apnea"

Your pressure is 6-7 with 'severe obstructive sleep apnia and are having problems. I was diagnosed with mild-moderate sleep apnia and have a pressure of 7 which is morking beautifully. I don't know the relationship, but it seems to me that you need your pressure increased.

[rested gal]

If the leak rate is low, I agree with the others that the pressure probably needs to be raised.

Another way to handle it might be to turn EPR down or off, if EPR is being used.
My thoughts (just opinion..I'm not a doctor) about EPR:

Nov 2008
viewtopic/t35923/viewtopic.php?p=310021#p310021

Aug 2008
viewtopic.php?p=289264#p289264

Oct 2006
viewtopic/t14479/viewtopic.php?p=121621#p121621

Oct 2006
viewtopic/t14479/viewtopic.php?p=121625#p121625

Dec 2007
viewtopic.php?p=231782#p231782


But, before I did anything, I'd check the leak rate. Since you're not using a Full Face mask, there's always the possiblity that mouth air leaks and/or mouth breathing during sleep might be letting an awful lot of treatment air escape out into the bedroom instead of going down where its needed to splint the airway open.

Ideal leak rate with a ResMed machine is zero. 0.0

If the leak rate is well under 0.4 L/s (liters per second) that's ok. Leaks hitting 0.4 or more are not good.

[jdm2857]

OSA severity is based on the number of apneas and hypopneas per hour (AHI), not on the pressure needed to prevent those events.

One person may have 75 events per hour (severe) and be well treated with a pressure of 7 cm H20, while another may have 20 events per hour (moderate) and require a pressure of 12. Severity and treatment pressure are independent of each other.

[stanps]

jdm,

Yes, I thought of the recorder too. The card reader and software is on my wish list but unfortunately not in my budget for the foreseeable future.

I have a ResMed S8 Elite II (the picture should show up below).

The part about needing higher pressure in REM sleep is interesting. I guess I don't know much about sleep architecture. I assumed I was getting REM sleep in the first 4 hours. Still it seem that raising my pressure may be the way to go.

[stanps]

rested gal,

Thanks for the wealth of info. My leak rate (if memory serves) is about 0.14 L/s. Good right? Another thing I don't get, if I am snoring shouldn't my leak rate be higher? Would it be even lower if I didn't snore?

I am using EPR set at 3. I will reduce it. There also is a setting to bring back full pressure more quickly at the end of an exhale. It is currently set to medium but can be set to fast. I would tweak the EPR and eliminate it if I need to.

Thanks so much for all of the help!

[Muse-Inc]

...Your pressure is 6-7 with 'severe obstructive sleep apnia...I was diagnosed with mild-moderate sleep apnia and have a pressure of 7...

There is no relationship between SDB severity and the pressure required to stent open the airways; the pressure is specific to the physical anatomy of each person's airways.

[rubymom]

If you think that rolling over onto your back is part of the problem, can you prevent that? I've read on this forum of people using different techniques to prevent that--you might want to do a search for them.

Also, I'm sure you've tried a million things. Is one of them going to sleep later? I used to regularly go to sleep around 9:30 or 10 and often woke up around 3 in the morning wide awake. I'd lie there for a few hours and then an hour or so before the alarm went off would fall soundly to sleep again. Now I regularly stay up til midnight or so and while I still wake up from time to time, I always fall right back to sleep and function pretty well on the 6-1/2 to 7 hours sleep I'm getting.

Good luck!!

[old64mb]

Thanks for the wealth of info. My leak rate (if memory serves) is about 0.14 L/s. Good right? Another thing I don't get, if I am snoring shouldn't my leak rate be higher? Would it be even lower if I didn't snore?

From your profile, you're using an F&P Zest. As such, the ResMed's displayed leak calculation is going to be somewhat off unless at 7 cm the Zest's vent flow rate is 24. (A helpful discussion explaining this in a bit more detail is here.) I tried to find the graph that would indicate what would be intentional for your mask but was unable to in a quick search.

However, the problem with overall leak rates is that they still don't tell you that much. I have a very good seal with my Swift LT, and on the surface both my sleep doc and DME were extremely impressed with an initial leak rate in the low 20s (using Respironics, which calculates things differently) and occasionally low teens. I later discovered, however, that since that was only an average of the entire night it was not reflecting my leak rate when I'd open my mouth and snore away on my back, causing major respiratory events and leak rates in the 50s. It was only for a few minutes at a time, but it was enough to basically render a large part of my therapy useless when it happened several times a night.

Hence - you're flying in the blind making assumptions on what your leak rate means unless you get an actual time-series leak chart versus an overall number. Only way to do that is with software, which while I know it's in the budget in the future becomes somewhat more urgent in a case such as yours.

However, let's go back to the larger picture. You believe you're snoring, you're waking up in the middle of the night, and you're in a deep sleep and feeling unrested when you wake up.

If snoring (which you still don't know, but I'd be willing to be that you are - what did the sleep study say?), you're having a partial obstruction of your airway. That can be offset by increasing pressure, but only if the pressure is available to get to it. If your mouth is wide open, chances are the pressure isn't going to do so.

Hence, you have three options to keep pressure in your mouth. You can try a full face mask, try mouth taping, or try...a chin strap. I don't know if your doctor has a clue or not, but her attempt to have you try to use a chin strap is not only the first step in step therapy, but also the cheapest overall for someone with financial constraints. If that doesn't work, then you take the next step in step therapy and try a full face mask. And if that doesn't work, then you move on to other things like tweaking pressure settings, and then you move on to a higher level step, which is sleep medications and perhaps another sleep study.

You want meds, but her refusal is perfectly reasonable: it's unwise to do if you haven't exhausted most of your other options. Occasional usage is one thing, but long term usage of them has some serious potential complications. Once you get past the generics they're also expensive, which in your case sounds like it's an issue - especially since your goal is to stay asleep, which the two generics don't do that well. Most important of all, despite all the marketing claims the quality of rest isn't as good as if you're able to sleep a full night without any meds whatsoever. (This is coming from someone who has all 4 of the non-benzodiazepines in his medicine cabinet and is coming off a Lunesta last night with an AHI of 1.4 and felt like garbage for the first hour up after over 8 hours of sleep.) Meds have their place and can be useful, but overall you've got to be working your problem first.

To answer your other questions briefly, later-night sleep cycles tend towards more REM sleep, which have a whole host of things going on with it - including potentially more respiratory arousals. Your insomnia could be a bunch of different things and may eventually require additional types of treatment if your therapy is working the way it's intended (which it clearly isn't), but one question - if you're reading if you can't get back to sleep, are you getting up out of bed into a different room to do so? That's one of the basic tenets of sleep discipline.

Anyway, I'd accept your doctor's suggestion to try a chin strap as a start, and really would recommend trying a full face mask if you could and getting software to see what you're really doing at night. Cheers.

[stanps]

rubymom,

I have done some reading here and I am going to give the "falcon" position a try to keep me off my back. As far I know my snoring is completely related to being on my back so I have some hope this will do the trick.

As far as going to sleep later, that simply delays the whole process and gives me less time to sleep before the alarm goes off. Besides, even at my healthiest I have always been an "early to bed and early to rise" kind of guy.

old64mb,

Thanks for your lengthy reply. You have given me much to think about.

However, let's go back to the larger picture. You believe you're snoring, you're waking up in the middle of the night, and you're in a deep sleep and feeling unrested when you wake up.

That's not completely accurate. When I am able to get 7-8 hours of sleep, I feel pretty darn good. It's only when I have been awake for a while in the middle of the night and the alarm goes off too soon after I have fallen back asleep, I feel pretty awful.

>>>, but one question - if you're reading if you can't get back to sleep, are you getting up out of bed into a different room to do so? That's one of the basic tenets of sleep discipline.

I'm propping myself up in bed to read. I assume the idea is that I should be in bed in bed only when I am ready to sleep. I stay in bed because there I am not temped to watch TV or eat which I know will keep me awake. I will try reading elsewhere.

Thanks to everyone who replied.

Stan

[old64mb]

I'd definitely talk to your doctor about 'sleep discipline', then, since many have a handout that has a bunch of pretty important tips that might help your insomnia. (I suspect you might be able to speed things up and find the whole range of things you're supposed to do by searching either here or Google for that term and seeing what you come up even before you have that chat.) Most good MDs will also insist you try the steps in there before pharmacological treatment.

And if you do feel good after 7 or 8 hours uninterrupted sleep, then I'd definitely work on the assumption you're mouth breathing before working the other problems. Apnea can do a number on your hormones, and some of them do tend to wake you up in the middle of the night.

You may also want to look up 'positional apnea'. Rough breakdown of those with apnea who are positional: mild 50%, moderate 20%, severe 10%. If your study indicated you were having the vast majority of events on your back, then staying off of it or at least minimizing it (tennis balls in your tshirt may not help you if your other problem is insomnia, because waking up from them isn't going to be better than waking up for other reasons) becomes paramount.

[stanps]

I increased my pressure from 7 to 8 cm/H2O with great results. I am no longer snoring and my AHI has gone from 4.7 to 1.5. Instead of only getting 4 hours of sleep each night I am getting 6. Not as much as I would like, but a very significant improvement.

Thanks for all the help!