Easy arousability on PAP

[Okaythen]

My doctor says that while CPAP is taking care of the airway obstructions, my sleep is still fragile and “easily bothered.” I am on straight CPAP with a pressure of 7. My AHI is lower than 2 and at times close to zero. I was diagnosed with mainly “increased upper airway resistance,” (UARs) though I do have some apneas. Needless to say, I awake severely exhausted and experience severe daytime fatigue and other symptoms.

Anyone experience arousals from PAP despite being properly titrated and treated?

Any thoughts on how to improve this tricky situation?

[Julie]

Any reason you're using machine in Cpap mode (fixed pressure of 7), vs Auto?

[Okaythen]

Yes, because my numbers were a bit worse on auto.

[Pugsy]

There are 2 kinds of arousals.

Respiratory related arousals....OSA or UARS kind of arousals and cpap can potentially help with those arousals.

Spontaneous arousals....no known cause except not airway related and cpap can't help with those. Not always so easy to figure out why much less fix them.

Example....I have a lot of spontaneous arousals...wake up often because of pain and needing to change position in bed. I know the cause and it's still hard to fix and the nights I have a bunch of arousals I feel like crap during the day. OSA is well treated though. I just have other stuff going on that messes with my sleep and it will thus mess with how I feel.

Do you take any medications of any kind? If so, what?
Any other physical or mental health issues going on?

[Okaythen]

I think I must have a lot of microarousals. I take Ativan twice per day and low dose Seroquel at night before bed, which in the beginning seemed to help a little bit with sleep quality. No mental health issues or things going on other than the stress of suffering from severe fatigue and daytime symptoms.

[DreamDiver]

My doctor says that while CPAP is taking care of the airway obstructions, my sleep is still fragile and “easily bothered.” I am on straight CPAP with a pressure of 7. My AHI is lower than 2 and at times close to zero. I was diagnosed with mainly “increased upper airway resistance,” (UARs) though I do have some apneas. Needless to say, I awake severely exhausted and experience severe daytime fatigue and other symptoms.

Anyone experience arousals from PAP despite being properly titrated and treated?

Any thoughts on how to improve this tricky situation?

Clearly there's more involved here than what machine you're using with regards to wake triggers, but I'd like to offer a perspective on Respironics vs. ResMed that may help.

You're on straight CPAP because Auto induces a wake trigger? It may be the Respironics air patency algorithm. Air patency is whether or not your windpipe is obstructed, perhaps by your larynx or your soft palate or a stuffy nose. If the windpipe is obstructed (obstructive apnea) the pressure may be increased.

I prefer not to use Respironics for this reason. When the machine checks for air patency, it sends 2cm pressure pulses back at your lungs every second. It wakes me up every time. Someone may as well be poking me with a pencil eraser. The Respironics Auto algorithm also tends to ramp pressure changes faster than ResMed, which can be an additional wake trigger.

ResMed's machines use a different air patency algorithm that pushes only .5cm pressure pulse back at your lungs every few milliseconds. It's only really noticeable if you're already awake. It feels more like a purr and isn't a wake trigger for me. The ResMed auto raises and lowers pressure on a smoother ramp, so it's also less of a wake trigger.

I wonder if the same is true for you. If you're a bit frustrated and wondering... looking for something... anything... last-ditch ways to reduce wake triggers, it may be worth trying out a ResMed machine.

Just a thought.

Chris

[Okaythen]

Thanks for the feedback, Chris. Very interesting. I actually have a new ResMed Autosense in my closet. I tried it a few times but never for a full night. Might be worth pursuing.

Oddly, too, I sometimes feel like the nasal mask and air is “attacking me,” and I’ll have to rip it off. Mask is sealed fine and pressure is only a 7. Maybe my brain is just highly reactive to it. It’s perplexing.

[DreamDiver]

Oddly, too, I sometimes feel like the nasal mask and air is “attacking me,” and I’ll have to rip it off. Mask is sealed fine and pressure is only a 7. Maybe my brain is just highly reactive to it. It’s perplexing.

2cm pulse concentrated right at the nose... Yeah... Could be. Good luck!

[Miss Emerita]

Do try the Resmed machine, for the reasons DreamDiver gives. But on your current machine, what level of pressure support are you using?

[Julie]

And Ativan's not something you want to take long term... look up the side effects and/or just the 'regular' ones, and some pts are known to develop depression on it.

[Okaythen]

Can anyone comment on having a sensitive ventilatory control system or a low arousal threshold? What, if anything, can be done about such an issue?

[DreamDiver]

Can anyone comment on having a sensitive ventilatory control system or a low arousal threshold? What, if anything, can be done about such an issue?

Could you clarify what you mean by "sensitive ventilatory control system"? Are you just referring to your machine or your own pulmonary system? I too wake up at the drop of a pin. I sometimes wonder if I ever get sleep some nights, but I'm not to the point where I am taking prescription meds to sleep. I tried a few of these and found them more disturbing than nothing at all. Non-prescription things like melatonin don't work well for me either. The only thing I'm taking right now is 5HTP. It's a precursor of seratonin which can be a precursor for melatonin, so it's a little more gentle. That and not eating for several hours before bed time seem okay for me. I hope that if there is someone else in a similar position on this forum that they'll come forward with better advice.

[Okaythen]

Yes, I’m referring to my own pulmonary system. It sounds like you’re functioning better than me, however, not to compare. Your sleep must not be as severely disturbed as mine, though I’m sure you still struggle. I’ve tried a lot of meds, to no avail. Seroquel helped mildly.

Have you tried Valerian root? I’m nervous to try it for some reason, and although I have low expectations, I think I should give it a try so I can cross it off my list.

[Julie]

Just don't let it near cats - drives them nuts, like catnip!

[DreamDiver]

Yes, I’m referring to my own pulmonary system. It sounds like you’re functioning better than me, however, not to compare. Your sleep must not be as severely disturbed as mine, though I’m sure you still struggle. I’ve tried a lot of meds, to no avail. Seroquel helped mildly.

Have you tried Valerian root? I’m nervous to try it for some reason, and although I have low expectations, I think I should give it a try so I can cross it off my list.

I've tried Valerian. It actually works for a while, but like many teas used as herbal medicinals, it loses impact with continued use. It also leaves stains on teeth and smells gawdawful. You get used to it, but after a while, I just had to stop. It's not going to konk you out immediately or anything, but it's probably best not to drive if you're taking valerian. Chamomile tea is delicious and can be use to carry and cover the taste of Valerian. Sometimes people like taking Chamomile alone as a sleep tea, but I find it's less about sleep and more about being a comforting hot tea that has no caffeine before bed. Celestial Seasonings carries a tea called "Sleepytime extra". The "extra" is valerian. It's a good starter tea. If you think you might enjoy more potent valerian, you could order it in bulk and make your own tea bags.

I hope this helps!

Chris