New Member w/Oscar Data and Questions

[Treatedandtired]

I've been on APAP since June of 2019 after a diagnosis of mild obstructive sleep apnea. My AHI was 8, consisting primarily of hypopneas (28) and centrals (18). I had 109 spontaneous arousals which yielded a spontaneous arousal index of 18.9. I've had brain MRI and MRA, cervical MRA, cervical and thoracic x rays, blood work galore, EKG, ECG and just recently had a bunch of blood drawn to check for autoimmune disorders. This all seemed to begin a few days after hitting my head under a table and hyper flexing my neck a bit. No testing has revealed anything notable other than the sleep study and the cervical MRI which showed some age-appropriate disc and joint problems. Without carrying on too much further, my current symptoms are now and have more or less been since this all began (September 2018): fatigue/tiredness, easy to zone out at work or while driving, dry eyes which impacts my vision a bit and the tinnitus that I've had on and off has become more or less non stop.

I'm a masters swimmer and spin cyclist who exercises at least 4-5 times per week. 6' height and about 180 pounds.

Meidcations:
Levothyroxine to treat mildly high TSH 32.5mg
Valsartan for hypertension 80mg/day
Cymbalta for anxiety brought about by this change in my health 40mg/day

I'll attach some photos of last night's sleep. My AHI generally runs closer to 1 or less but last night wasn't great for some reason. Something I've noticed and have added a zoom shot of is some random spikes in my flow rate. Are these short awakenings/arousals that are disturbing my sleep? Thanks for looking!

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[Julie]

Hi - curious why your max setting is so relatively low...?

Have you looked into all those meds and how they may react with sleep and Cpap?

Btw. it is now believed that OSA is more likely the cause of weight problems than the other way around... and for some reason it's usually men who give their 'stats' here as if to prove they're not overweight. However OSA is more often a problem with e.g. a narrow jaws (resulting in a narrow airway) as often as not.

[Pugsy]

Research the side effects for your meds...especially the BP med and the Cymbalta
https://www.healthline.com/health/valsa ... de-effects
fatigue, bone and joint pain and some others

https://www.rxlist.com/cymbalta-side-ef ... center.htm
Fatigue, tiredness, drowsiness, trouble sleeping (plus it messes with the sleep stages), and some others

If you never ever hit your maximum pressure then what you have it set for is fine.

[Geer1]

I stumbled upon this video earlier today and it talks about arousal's and how to interpret flow data. Might be helpful.

https://www.youtube.com/watch?v=FMkBatUVu7s

Those do seem like they may be arousals, probably related to the high number of spontaneous arousals during your sleep study. Did the sleep doctor have any theories on what was causing them? Was it an in clinic test that could see if the spontaneous arousals were messing up sleep patterns?

Most of your symptoms seem related to tiredness. If I was to guess the CPAP has dealt with the mild obstructive apnea you are still having the spontaneous arousals and aren't getting proper sleep because of it. Maybe related to medication like others have commented on or could probably be a number of other causes. Perhaps asking your doctor about performing an in clinic sleep test with CPAP equipment on would be of value (or a split test with CPAP half the night), especially if your first test was a home test that is only good for diagnosing sleep apnea.

[Treatedandtired]

Hi - curious why your max setting is so relatively low...?

Have you looked into all those meds and how they may react with sleep and Cpap?

Btw. it is now believed that OSA is more likely the cause of weight problems than the other way around... and for some reason it's usually men who give their 'stats' here as if to prove they're not overweight. However OSA is more often a problem with e.g. a narrow jaws (resulting in a narrow airway) as often as not.

I set the pressure so low as it rarely runs above 8 but there were a few times when it would jump to 9 or more and that seemed to wake me up. Limiting the upper level seemed like a reasonable solution.

I've read about what you're saying regarding BMI and OSA. My intent wasn't so much to prove I'm not overweight as to show that I'm doing what I can to keep my energy up. Thanks for the feedback!

[Treatedandtired]

Research the side effects for your meds...especially the BP med and the Cymbalta
https://www.healthline.com/health/valsa ... de-effects
fatigue, bone and joint pain and some others

https://www.rxlist.com/cymbalta-side-ef ... center.htm
Fatigue, tiredness, drowsiness, trouble sleeping (plus it messes with the sleep stages), and some others

If you never ever hit your maximum pressure then what you have it set for is fine.

Thanks for linking those pages. I'll take a look later this AM. Both drugs were started after I began having sleep issues though it seems like they might be making things worse.

[Treatedandtired]

I stumbled upon this video earlier today and it talks about arousal's and how to interpret flow data. Might be helpful.

https://www.youtube.com/watch?v=FMkBatUVu7s

Those do seem like they may be arousals, probably related to the high number of spontaneous arousals during your sleep study. Did the sleep doctor have any theories on what was causing them? Was it an in clinic test that could see if the spontaneous arousals were messing up sleep patterns?

Most of your symptoms seem related to tiredness. If I was to guess the CPAP has dealt with the mild obstructive apnea you are still having the spontaneous arousals and aren't getting proper sleep because of it. Maybe related to medication like others have commented on or could probably be a number of other causes. Perhaps asking your doctor about performing an in clinic sleep test with CPAP equipment on would be of value (or a split test with CPAP half the night), especially if your first test was a home test that is only good for diagnosing sleep apnea.

Thanks for the youtube link. I'll take a peek and see what I can make of it. My sleep study was an in lab study. I've seen two sleep doctors, a pulmonologist and neurologist, and neither had much to say about my sleep other than CPAP was what they suggested and once I had been on it for 3-4 months they thought that my numbers were fantastic. They did offer up a laundry list of things that I should do to assure good sleep, things like avoiding caffeine, dark bedroom, no screen time before bed, etc. and I more or less follow all of those rules. It's frustrating for sure. The second sleep study is something I hadn't considered. I struggled to sleep in my first study and that was with a benadryl on board at the time, so volunteering to do it again would take some determination!

[Treatedandtired]

I wanted to add that I've noticed some variations in my respiratory rate which I think might just be due to REM sleep, though I wanted to see what you all might think of it. You'll see that on the 8th and the 12th of November I began the night with a much faster respiratory rate than the balance of the night.

Also, I do have one more med I didn't list, I take half of a 3mg melatonin each night before bed which seems to help me sail off to sleep in short order.

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[Pugsy]

REM stage sleep doesn't normally happen so soon after sleep onset and the first REM stage doesn't normally last that long.
Google "sleep stages" and look at the normal hypnograms to get an idea about when REM normally occurs and how long it lasts.

[Treatedandtired]

I zoomed in on the flow rate of an area where my respiratory rate was supposed to be close to 28 but the flow rate indicates only 11 breaths within a minute, which makes more sense. Apparently the machine or the Oscar software is getting confused.

screenshot-20191113-121448.png

[Geer1]

Thanks for the youtube link. I'll take a peek and see what I can make of it. My sleep study was an in lab study. I've seen two sleep doctors, a pulmonologist and neurologist, and neither had much to say about my sleep other than CPAP was what they suggested and once I had been on it for 3-4 months they thought that my numbers were fantastic. They did offer up a laundry list of things that I should do to assure good sleep, things like avoiding caffeine, dark bedroom, no screen time before bed, etc. and I more or less follow all of those rules. It's frustrating for sure. The second sleep study is something I hadn't considered. I struggled to sleep in my first study and that was with a benadryl on board at the time, so volunteering to do it again would take some determination!

I would look through your results and find some good examples of what you believe might be arousals not related to breathing issues. Print them out and have them ready next time you see doctor.

Then I would set up appointment with doctor, mention that your original sleep study showed numerous spontaneous arousals and that you believe you might still be having them and show them the charts. Ask what can be done to try and figure out what may be causing arousals and if a second test with cpap would be helpful.

In my experience doctors always focus on the easy stuff first. They probably saw the arousal number before and figured maybe it would be fixed by cpap. They started you on cpap and your results indicate apnea is under control and that cpap is working but what it doesn’t tell them is anything related to non breathing related sleep issues. When you refresh their memory on arousals they may have ideas on ways to diagnose them, one idea to me would be a second sleep study with cpap equipment so they can get data and confirm the issue still exists even though breathing is under control. It is easier to diagnose a problem if you can eliminate some of the variables.

I recorded myself sleep one night and noticed I jerk an arm, leg or head prior to most arousals. The question is are the jerks being caused by low oxygen due to obstructed breathing and therefor apnea being the cause for those arousals or are the jerks the cause of those arousals and the fact I have sleep apnea just means I have a multi faceted sleep problem? Like yourself first step is cpap to rule out sleep apnea, if I am still having issues and especially if I record myself still waking up with jerks while doing cpap I will be confronting the doctors about it and pursuing further diagnostics.

[Pugsy]

viewtopic.php?f=1&t=174268&p=1283319&hi ... o#p1283319

Ballistocardiographic artifacts

Essentially the machine double counting respiration rate because of a weird little dip in the flow rate.
Common and we just ignore it.

[Treatedandtired]

Thanks for the youtube link. I'll take a peek and see what I can make of it. My sleep study was an in lab study. I've seen two sleep doctors, a pulmonologist and neurologist, and neither had much to say about my sleep other than CPAP was what they suggested and once I had been on it for 3-4 months they thought that my numbers were fantastic. They did offer up a laundry list of things that I should do to assure good sleep, things like avoiding caffeine, dark bedroom, no screen time before bed, etc. and I more or less follow all of those rules. It's frustrating for sure. The second sleep study is something I hadn't considered. I struggled to sleep in my first study and that was with a benadryl on board at the time, so volunteering to do it again would take some determination!

I would look through your results and find some good examples of what you believe might be arousals not related to breathing issues. Print them out and have them ready next time you see doctor.

Then I would set up appointment with doctor, mention that your original sleep study showed numerous spontaneous arousals and that you believe you might still be having them and show them the charts. Ask what can be done to try and figure out what may be causing arousals and if a second test with cpap would be helpful.

In my experience doctors always focus on the easy stuff first. They probably saw the arousal number before and figured maybe it would be fixed by cpap. They started you on cpap and your results indicate apnea is under control and that cpap is working but what it doesn’t tell them is anything related to non breathing related sleep issues. When you refresh their memory on arousals they may have ideas on ways to diagnose them, one idea to me would be a second sleep study with cpap equipment so they can get data and confirm the issue still exists even though breathing is under control. It is easier to diagnose a problem if you can eliminate some of the variables.

I recorded myself sleep one night and noticed I jerk an arm, leg or head prior to most arousals. The question is are the jerks being caused by low oxygen due to obstructed breathing and therefor apnea being the cause for those arousals or are the jerks the cause of those arousals and the fact I have sleep apnea just means I have a multi faceted sleep problem? Like yourself first step is cpap to rule out sleep apnea, if I am still having issues and especially if I record myself still waking up with jerks while doing cpap I will be confronting the doctors about it and pursuing further diagnostics.

I'll do just that, wrt to the examples of arousals to show my sleep doc. I have a follow up with a rheumatologist in a few weeks to go over autoimmune and testosterone blood work. Provided that doesn't show anything, the sleep doc is my next stop (I already have an appointment scheduled in December anyway).

Regarding arousals, I found a study where they tested persons without sleep problems in an overnight PSG and reported the average spontaneous arousal index for different age groups. My index was 18.9. The arousal index for my age group was 16.5, +/- 5.6. I'm within that range. This isn't to say that it isn't part of my problem, but it does make me wonder just how significant a portion of my problem it might actually be. Perhaps I'll pick a night in which I thought I slept well as well as one in which my sleep was less than ideal and count the average number of flow rate spikes per hour.


http://jcsm.aasm.org/articles/030305.pdf

[Treatedandtired]

viewtopic.php?f=1&t=174268&p=1283319&hi ... o#p1283319

Ballistocardiographic artifacts

Essentially the machine double counting respiration rate because of a weird little dip in the flow rate.
Common and we just ignore it.

Interesting. Thanks for the clarification and taking one more thing to be worried about off of my list!

[Julie]

I'm not sure you understand which of the min. or max pressure settings does the 'work'. Most of us leave the max setting at 20 or at least above 15 unless there's a specific and diagnosed reason not to and it can 'cap' Cpap help unnecessarily when the pressure wants or needs to go higher. It's the min. setting that you need to work on to address events... and yours is quite low. I'd raise it by a couple of points for a few nights to see how you feel and raise the max to at least 15... it is not responsible for your feeling about it.