Please help. Low AHI but still wake up all the time.

[Personxyz]

I consistently have an AHI below 2, sometimes even under 1 but I wake up 5-6 times every single night. I thought when I had my sleep apnea under control these frequent awakenings would stop but that hasn't happened.

Is there any part of the sleepyhead data that may give more insight into why I wake up so often? Could I zoom in on a time period where I know I woke up to try to see what triggered it? Which charts would be worth looking at in more detail if I did this?

I feel I'm within touching distance of getting really great sleep. My AHI numbers are really low, if I can stop the frequent awakenings I will be in a truly great position.

[Pugsy]

To be able to zoom in on the flow rate immediately prior to the wake up we need to know when the wake up happened.

The best way to for sure know when you woke up is to use the machine itself as a marker because waking up and looking at a clock and writing the time down or trying to remember the time is just not really possible.

Instead if you wake up reach over an push the button to turn the machine off and then push it again to turn it right back on. This will give you a break in the therapy line so you can see for sure when you woke up and then zoom in on the flow rate and see if anything stands out as a potential reason for the wake up.

Do you take any medications of any kind? If so, what?
Any other health issues going on...pain, etc?
Hows the bed comfort thing? Any mask fit issues?

Did you know it is normal to wake up after the completion of a REM stage sleep cycle? Most of the time the wake is so brief we don't form a memory of it but sometimes people will stay awake long enough to form a memory. It's normal to have multiple REM cycles during the night.
Google "sleep stages" and look at the hypnograms of normal sleep stages and see the progression through the night.

How are you feeling otherwise besides being annoyed that you woke up more than you would like?

[CarpeNoctum]

Hi Personxyz and of course Pugsy too,
Ive been on cpap for 6 years or so and feel so much better then before I started. But I also wake up a few times each night. It's not a harsh arousal...just an awareness of my breathing. My trick is to not be disturbed by it and do focused breath counting meditation to keep my mind from being carried away with thought. Back asleep in no time.
CN

[Personxyz]

Pugsy: Good thinking regarding how to record exactly what time I woke up through the night. I may do that, I could also pull the mask away for a few seconds to register a large leak. I don't take any medication or have any pain/health problems. My mattress is quite new and comfortable so I don't think that's causing any issues. I find the p10 mask to be really comfortable, I forget I'm wearing it after a few minutes of putting it on.

It seems whenever I wake up it's in the middle of a dream which fits with the sleep stages hypnograms I just looked up because the REM stage of sleep is at the end of each cycle. Also, it's usually 1 and a half hours roughly between the awakenings. The problem is I remember almost every single awakening, I also remember about 3-4 of the dreams I have each night (although as the day goes on I forget most of them). Most of the time I can get back to sleep within 15 minutes but it's not that rare for it to take over half an hour.

I do feel a little more rested since starting my PAP treatment but the improvement is sadly minimal. This fractured sleep really seems to be holding me back in life, it's incredibly frustrating.

CarpeNoctum: Ideally I want to find a solution that stops the awakenings from happening in the first place as they fracture my sleep so much.

[Pugsy]

There are arousals related to breathing issues and there are what is called spontaneous arousals which is pretty much a blanket name for we don't know what is causing the arousals.

The cpap can fix breathing related arousals but it can't do much for spontaneous arousals.

How come such a tight pressure range? I assume there is a reason why you are limiting the max when the machine wants to go higher???

Your flow limitation graph is a bit not so pretty but I have seen worse. I do not know if the flow limitations are playing a part in your unwanted arousals. It's possible...it is also possible that the arousals are just spontaneous and we don't know why.
Unfortunately the data from the machine doesn't always offer us much in definitive answers. At best we get some maybes.
It's also possible that you just have what is called sleep maintenance insomnia and there's a very long list of potential culprits there.
Breathing issues just one on a really big list.

[Personxyz]

Regarding the pressure range, I read that breathing can change as we enter different stages of sleep which causes the machine to increase the pressure, this then leads to arousal's. Looking at my previous nights sleepyhead data my pressure seemed to mostly be between 7-8 so I thought I'd keep the pressure range there so that the machine couldn't suddenly jump the pressure up when I entered a different stage of sleep. I've only done it one night and it wasn't a success but I figured I'd try it for a few nights as my AHI remains low.

Regarding my flow limitations, could it be UARS? I thought the RERA score would catch UARS and my score is really low. Would increasing the pressure be the only way to reduce flow limitation issues?

Concerning sleep maintenance insomnia, I'm currently putting together a sleep hygiene plan so hopefully that helps.

[Julie]

Just in case it happens to apply - if you sleep in such a way that your head drops down, cutting off your airway, that can affect flow rate of course and many people wear soft cervical collars that keep your head up better, your airway more open and jaws closed (if that applies too).

[zonker]

Concerning sleep maintenance insomnia, I'm currently putting together a sleep hygiene plan so hopefully that helps.

i would be very interested to know if this works for you. i, too have many arousals during the night. and like you i consistently stay under 2 for ahi. i'm 64 so i get that my sleep cycle is changing due to age. but still, would love to be able to just go to sleep and stay asleep.

good luck!

[Pugsy]

Unless you are having nasal congestion issues then the flow limitations are probably in the airway itself and the only way to open it up more is more pressure....either by increasing the minimum or my increasing the maximum and let the machine go where it wants to go.

I don't know where you got the idea that these machines suddenly make dramatic increases in the pressure as a response to something but they don't do anything in the blink of an eye. Any pressure changes made are over minutes and not seconds and most people sleep through gradual changes.

The RERAs you see on these reports are based on flow rate only and not sleep status. The know for sure if someone has a respiratory related arousal there has to be a way to measure sleep status for the arousal confirmation but we can't with these machines.
What they flag as RERA is your breathing "looks like breathing that is associated with someone who has had a respiratory related arousal which was confirmed by PSG sleep test that measured sleep status". It's close but not 100% perfect and remember....what you see flagged of anything is the stuff that doesn't get prevented. We have zero way to know the numbers of anything that might get prevented.

Is this UARS? Beats me. It might be but even if it was the usual therapy for UARS is cpap. If it was UARS that wasn't being well treated then I would assume at least a high RERA count and maybe a much uglier flow limitation graph.
UARS is really difficult to diagnose without having a sleep study using that Pes device because there's no certain thing to look for in breathing where we can say "aha...UARS" They can't even do it in a sleep lab without the Pes and they have a lot for data available in the sleep lab than we do from the machine's data.

If there was a strong UARS component there might be a hint of it with an in lab diagnostic sleep study where there was a mention of a high number of breathing related arousals even if they didn't meet criteria for one of the usual apnea flags.

Think about it for a minute...OA, central or hyponea have a certain set of criteria that needs to be met before a flag is earned. They all have to last at least 10 seconds and there is a varying level of air flow reduction that determines which flag.
Suppose you had 100 % blockage that only lasts 9 seconds. Do you think that if you had a few of these back to back that maybe your sleep quality might be affected?? Of course it could but at 9 seconds...no flag.

Now if you really want to dig deep and see if you have very many flow reductions that don't meet the criteria for a flag you can change some parameters in SleepyHead so that SH looks for those flow reductions that don't make criteria for a flag.
Might be useful to do in conjunction with the turning the machine off and on to know when you were awake so that you can look for anything that might have happened immediate before the break in therapy.

It's called custom user event flags....Preferences/CPAP tab...lower left where you can turn it on and set whatever parameters you want.
You will also likely need to rebuild the data to get the changes to take effect.

You probably also need to learn to distinguish between awake and asleep breathing flow rate.
See the videos here
http://freecpapadvice.com/sleepyhead-free-software

[Personxyz]

Thanks pugsy for your continued help here, I really do appreciate it.

I don't have any nasal congestion issues so the limitations are probably from my airway. I may get a neck brace as some people have had success with them on the forum. If not then I'll have to try a higher pressure range.

Thanks for the info about RERA/UARS. I've learnt a few new things which is important in the battle.

On a scale of 1-10 with 10 being good what score would you give my flow limitation for the nights SH data I posted at the top of this thread? I'm just curious because I don't really have the experience to determine what's good, average or bad.

After reading what you said I feel it definitely makes sense to get SH to show these flow reductions that don't meet the criteria for a flag. Do you have any recommendations for parameters with the custom user events flag section in sleepyhead as I'm pretty clueless. There's an option called resync machine detected events (experimental) in that section. Do you know what that means and whether I should tick it?

After I've set up the custom user event flags part, do I rebuild by just clicking data, rebuild cpap data and then just selecting my machine?

I'll check out the videos you linked too, thanks again for your help.

Julie: Thanks for the cervical collar recommendation, I've read good things about them. I sleep in the fetal position so my head probably does drop down a fair bit. I may look at some tomorrow on amazon.

Zonker: If I remember I may post my sleep hygiene plan on the forum either in this thread or by starting a new one. It might not be for a few weeks though as I'm reluctant to start it whilst I'm tweaking my machine settings as it leads to too many variables. If I improve I would not know what's helped and what hasn't. I wish you well and hope your situation improves.

[Pugsy]

I have no idea what the resync thing does. I didn't do it when I played with the custom user flags.

And i didn't get very many but then remember my FL graph is really boring.
Here's an old one. Compare yours to mine.


But yours isn't horribly horrible. I have seen much, much worse.
I don't have an example of a really bad FL graph handy but if a really bad one was a 10 yours might be maybe a 4 when on the low side and during the pressure increases where the FL increase maybe a 6.

Attached is a little screen shot of the parameters I set for the custom flagging. I had no idea what to choose.
I don't have very many custom flags but the ones I do are primarily UF2. Like 2 per hour average.
At this level under the microscope it isn't easy to see subtle changes in the flow. Sometimes I sit here and scratch my head because I can't see it but that doesn't mean the machine didn't sense it.

I have sleep maintenance insomnia but my problem is pain...good old arthritis. My personal thoughts about wake ups..and be sure you understand this is my own personal opinion and I have nothing to back it up.
We know that it is normal to wake after REM but most of the time we go right back to sleep. If we remember a dream then that means we got woke up during the dream (and we can dream in any sleep stage not just REM). We have to wake up to form a memory of the dream.
So we may or may not remember waking at the end of a REM cycle but if we do remember a half a dozen awakenings then I am of the opinion that we probably woke up more than that assuming some post REM awakenings that we don't remember.
It is an unrealistic expectation to think that we go to sleep and never ever wake up during the night. I know we would like to experience that but it's really a rarity.

So what do we do about sleep maintenance insomnia...we limit it as best we can by whatever means necessary based on the cause if we can figure out a cause. For me...half a dozen remembered awakenings is actually a good night. 90% are wake up in some sort of discomfort and turn over to change position and go back to sleep. The few nights that I can't go back to sleep in a timely manner...I bank on feeling like crap the next day. Since I know my main issues are
1...pain
2...crappy sleep hygiene from being on the computer too late and going to bed too late
I work on them the best I can. I am not perfect. Went to bed at 11:20 last night which was good for me but woke at 5:30 and couldn't go back to sleep. I feel my best when I can get close to 8 hours of sleep but its rare that the pain will let me stay in bed and sleep that long.

I don't wake up feeling like going and running a marathon...I have never ever been a morning person but with cpap therapy I don't wake up feeling like I just ran a marathon and got run over by a bus. I simply accept the fact that I have some sleep issues that the machine can't fix no matter how much I might want it to.

If your report was my report and I was having the wake ups and no other known potential cause. I would at least try killing some of those FLs on the off chance it might help. Unless more pressure causes problems (aerophagia mainly) it hurts nothing to at least try to kill them and see if it helps with the sleep quality or not. Now will it help...dunno but it's worth trying.

[palerider]

Regarding the pressure range, I read that breathing can change as we enter different stages of sleep which causes the machine to increase the pressure, this then leads to arousal's. Looking at my previous nights sleepyhead data my pressure seemed to mostly be between 7-8 so I thought I'd keep the pressure range there so that the machine couldn't suddenly jump the pressure up when I entered a different stage of sleep.

The whole "increase of pressure leads to arousals" thing is a tempting hypothesis, but if you hang around, you'll see that the vast majority of people sleep right through pressure changes... since even though they look abrupt on the chart, that's because the charts are so squished at standard view... those pressure changes happen over a period of minutes, they're gradual. It's much more likely, for most people, that they have breathing events, which DO disturb their sleep, and that's what wakes them up, at the same time that the machine is reacting to those events. A simple case of cause and effect getting misconstrued. The machine isn't "suddenly jump the pressure", so why would you think that it would?

That said, more minimum pressure, and allowing the machine to do what it wants, instead of limiting it's response ability, may further reduce your AHI (mine's usually under 0.5), as it is, you're having a sleep disturbing event one or two times an hour, on average. if that happens at a time when your sleep is light (rem), then it very well may disturb you enough that you become aware of what's going on, remember your dream, and get frustrated that you're "awake again".

Now that you know about sleep stages and the fact that it's completely *normal* to be just barely asleep, if not awake, between them, the best thing to do is to quite worrying about it, if you wake up, just turn over and go back to sleep.. People that feel they sleep soundly throughout the night are simply not remembering the brief awakenings between sleep cycles.

Ideally I want to find a solution that stops the awakenings from happening in the first place as they fracture my sleep so much.

Since it's *normal* to wake up between sleep cycles, these awakenings aren't fracturing your sleep. The only reason that these brief awakenings are bothering you is because you're focusing on them. Try to maximize the comfort of the mask, and minimize other tiny disturbances you have, and you may start not remembering the awakenings too. I've found that magnesium glycinate taken before bed seems to help ride through the normal brief awakenings.

[palerider]

I have no idea what the resync thing does. I didn't do it when I played with the custom user flags.

Best I remember, it makes an effort to diddle with the exact placement of respironics flags, so they look better on the chart... respironics data is ..... sloppy about the exact placement of flags. That was something that was added when I was providing data validate the current version (1.0 beta).

I might be mis-remembering it, but that's what my memories of years past is dredging up.

[Pugsy]

I found someone with a really horribly horrible FL graph.
I don't remember any of the particulars and the AHI is really low but FL is really horrible.

[Personxyz]

palerider: Your view on pressure changes does make more sense than what I previously read, the breathing events are probably occuring before the pressure increases.
My pressure before yesterday was set at 6-10 which keeps me below an AHI of 2 for most nights, I'll probably put it back at that soon. The thing I didn't make clear earlier is that some of these awakenings are likely not at the end of a sleep cycle. Usually in the second half of the night they occur more every hour or so. I read that your sleep gets lighter the longer the night goes on which could be why I wake more often in the second half of the night as I'm more vulnerable to arousal's awakening me then.

pugsy: Your FL graph looks a lot blanker than mine but on the left your flow limit 95% score is 0.13 which I usually beat. Mine seems to rarely go past 0.08. Your max flow limit score is quite a bit better than mine which is usually between 0.30-0.40.

I've just set up my custom flagging. My UF1 seems to usually be between 0.50-1.00. Occasionally it goes into the mid 1s. My UF2 seems to usually be between 2.50 and 4.50.

I didn't know you can dream in any sleep stage. I don't think all my awakenings occur at the end of sleep cycles as often in the second half of the night I wake every hour and sleep cycles last 90 minutes. I do seem to be dreaming every time I wake up though.

I'm sorry to here about your pain issues, both my parents have arthritis problems too, I'm only 24 so fortunately that's one thing I don't have to worry about.

My sleep hygiene can definitely improve and I'll be sure to work on it.

I am slightly reluctant to increase the pressure as I suffer from an uncomfortable amount of leaks if my pressure gets too high. I've also had aerophagia a few times as well. I may try a cervical collar first, if it doesn't help I'll get some lanolin to improve my mask seal and increase the pressure.

Here are the last 3 days data with the user flags added. I'm off to bed soon (I live in the UK and go to sleep around 9pm). I'll report back tomorrow with some updates when I've had a think about everything. It's a lot to take in.