Low AHI and still tired -- Oscar data inside!

[earnerd]

Hi all!

The subject says it all. I've been using CPAP full time (7-8 hours a night) for 2.5 years, and I still do not feel well-rested. I know that the CPAP is doing something because I do wake MUCH less often than I used to -- and because the one or two days in the last 2.5 years that I did not use it (traveling), I felt absolutely broken the next day. My AHI this time of year averages <2.0 and is nearly always less than 3.0 the rest of the year.

Due to the lack of restful sleep, I completed an in-lab overnight titration study a week or so ago. My previous mild apnea diagnosis came from an at-home study. My pressure, for the most part has been set to 9 min /16max since I have started therapy in 2018. I played around with changing the minimum pressure with no real groundbreaking changes to AHI, which we might not expect since it's already pretty low. After this most recent sleep study, my doc wanted to lower my pressure to 6 min / 11 max, which is interesting because my AHI was 10.0 at a pressure setting of 8 during this most recent overnight study. They also wanted me to use EPR 3, which suggested to me to look at flow limitations as an area that might need to be addressed? Specifically exhaling.

I am going to attach some Oscar data (and the sleep study data) and wanted to see if anyone might have some recommendations for next steps. One screenshot is from Oscar with last nights sleep with the new pressure settings and another with a zoomed in on a group of OA traces from last night. I also have been considering flow limitations effects on sleep quality so I am attaching a screenshot of what appears to be shallow exhales (?) from a previous night with my original pressure of 9-16.

This seems to be a much better resource than my actual sleep doc. Thanks in advance for any advice!

[earnerd]

I realized I cutoff the machine settings for the old and new pressure -- attached.

[Pugsy]

Do you take any medications of any kind? If so, what? Even OTC??

Can you do a screenshot of the May 27 report with minimum of 9...but not zoomed in on anything?
Hide the calendar so we can see more of the settings on the left side.

IMHO....lowering the minimum was the wrong way to go.

Your machine doesn't have EPR exhale relief which is something a ResMed machine has.
Instead Respironics machines have Flex exhale relief and while it is exhale relief it isn't like EPR in how it functions and you can't ever get a 3 cm drop with it even at the max setting of 3. The amount of reduction is based on how forcefully you breathe.

[earnerd]

No prescribed meds -- I do have asthma, but I take my regular med in the morning. I have recently (this week) been taking some magnesium before bed. But that is it. Full night of 27th is below. Thanks for the quick reply!

[Pugsy]

What position do you normally sleep?
May 27...on your back maybe?
Do you find that you spend much time at the beginning of the night awake and trying to fall asleep???

The machine went to 15 cm...during the first segment of the night and you had a lot of events flagged as well.
Rest of the night was pretty unremarkable.
Reducing the minimum and limiting the max was the wrong way to go IMHO
and this

interesting because my AHI was 10.0 at a pressure setting of 8 during this most recent overnight study

pretty much confirms it.

I think the minimum should have been increased instead of decreased. FWIW.

[earnerd]

I sleep 100% of the time on my back because I was habitually tweaking my neck/shoulders after starting CPAP -- maybe involuntary fighting to keep the pillow from pushing the mask off of my face?

Here are some sleep study results AHI results at varying pressures....

[Pugsy]

The arousals.....did they separate the arousals into respiratory related or spontaneous?
Your arousal index is fairly high and I would wonder if they were respiratory related or spontaneous (which means we don't know what to blame it on).

The titration study points to 10 AHI with the pressure of 8...not 10.
At 10 cm (which you spent the bulk of the time) the AHI was a nice respectable 2.3.

[earnerd]

I wondered about the arousals -- I wasn't surprised because I didn't feel like I slept a wink during the overnight study. They did not separate them out -- just saying "No significant ECG abnormalities were noted."

[Pugsy]

"No significant ECG abnormalities were noted."

That comment relates to the cardiac leads data....not arousal related data.

EEG....brain related data and sleep data since we need brain data to know if someone is asleep or awake

ECG...heart related data...no abnormal heart rhythm

[earnerd]

"No significant ECG abnormalities were noted."

That comment relates to the cardiac leads data....not arousal related data.

EEG....brain related data and sleep data since we need brain data to know if someone is asleep or awake

ECG...heart related data...no abnormal heart rhythm

Woops! Eyes are going too! "No EEG abnormalities were noted on the limited montage." Also, "No interictal or ictal epileptiform discharges were noted on the limited montage."

[clownbell]

@earnerd - May I chime in for a minute? I am a total non-expert, just another PAP user like you.

I use two pillows -- one soft and one stiff. If I put the soft pillow on top, my head depresses into the pillow and the pillow pushes my mask (N30) abound and causes leaks. HOWEVER, if I put the stiff pillow on top, my head sits on top of the pillow and the pillow dows NOT push the mask around. My leak results are MUCH better with the stiff pillow on top.

Pugsy probably thinks I have rocks in my head, and she is not alone in that regard, but that is my anecdotal two cents input. By the way, I have alternated the pillows to test my theory, and it DOES seem to be true.

[Pugsy]

Pugsy probably thinks I have rocks in my head,

Actually no....I am of the opinion that whatever makes/lets someone have successful cpap therapy under their belt is fair game.
Might seem a little weird to me sometimes but I have no doubt that I probably also do something that someone might think is a bit weird but it works for me and I am the only person I really have to please.
I have yet to find much about cpap therapy that doesn't come with a huge YMMV sticker and that includes beds and/or bed pillows or whatever it takes to get good sleep. Anything and everything is fair game and what might be a home run for one person could easily be a strike out for the next person.

Each person has to go through their own trial and error process figuring out what works or doesn't work for them.

Your 2 pillow deal would be a strike out for me because of my neck issues. My own bed pillow is next to flat and most people would hate it but I have a metal plate in my neck and I am short and pillows that are tall just kill my neck.
Though I do need good solid support for the neck from the rather flat pillow I use...

I have always thought that getting the sleep (and hopefully good sleep) is my primary goal here.....without sleep none of this stuff matters much does it?

But your 2 pillow deal...works great for you and I am actually very happy you are happy and I never even rolled my eyes at your way of doing things. ...
Sometimes I do admit to rolling my eyeballs at some stuff... but I didn't with yours because I know that bed pillow preferences and needs are one of those things that come with a HUGE YMMV sticker. It would be that way even if cpap wasn't being used.