NEED HELP: Optimized therapy to perfect numbers-bad sleep

[sleepyzzzz]

I have been fine tuning my machine (aircurve10 vauto) and masks for the past 3 months after resetting myself to try one last time and make this work, i started with pillows mask, controlled to no leaks, and you can see the machine spiking pressure every REM cycle EPAP around 6-7 PS around 3 to 4
you can see the oscar screenshots for it here: 

[sleepyzzzz]

My problem with pillow mask is that after EPAP 7.2 I get chipmunks cheeks, so to higher pressure i need FFM, so I started using F30, F30i with decent leak control, same pressure spikes from machine, disconnected sleep while gradually increasing EPAP, and PS as here:

[sleepyzzzz]

so based on previous numbers I got the EVORA mask, and used the 99.5% EPAP for few nights, kept tweaking leaks untill last night i got almost no leaks and almost flat pressure lines, but STILL SAME AROUSALS after a REM cycle, you can notice that machine kept increasing the 99.5% each time so last night the highest EPAP was around EPAP 14, but still in the zoomed in airflow, you could see some limitations followed by arousal without machines detecting any need to increase pressure, these screenshot for last night are my best optimized numbers for the past 3 months yet, I STILL KEEP WAKING UP!

so right now I am yet at another impasse, I don't think the answer is to increase EPAP more, as you can see in the screenshots:

[sleepyzzzz]

I'm sorry for the plethora of screenshots, i'm trying to give a bigger picture to what i have been doing, if you could read all that, I'd be very interested if you have an advice
thank you

[palerider]

What's your question?

Also, stop trying for perfection, there's no such thing in sleep.

[Pugsy]

You need to try to figure out what is causing the poor sleep quality and I don't see anything in your OSCAR reports that screams "fix me and you will sleep better".
I don't think your crappy sleep is from airway issues and the machine only fixes airway issues.

As far as waking after a REM cycle....did you know that is a normal thing? Google "sleep stages" and look at the normal hypnograms and you will see what I mean.

Other awakenings or arousals....could be a lot of stuff. Google "sleep maintenance insomnia causes" and start reading.
The list is miles long.

Medication side effects is usually what I look at first. Are you on any meds? If so, what?
Any other health issues that might impact sleep? I have sleep maintenance insomnia from my arthritis pain.

[Miss Emerita]

Just curious: why are you using the machine for 11 - 14 hours a night?

It isn't easy to identify REM sleep from Oscar information, and often it is impossible. Do you think you wake up after REM because you can remember dreams you were just having? We dream in all sleep stages, not just REM.

Around how often or how frequently do you think you wake up each night -- at least as far as you can remember?

[zonker]

post deleted by author

[robysue1]

sleepyzzzz,

As Pugsy points out, there's nothing in the data that screams, "Fix Me!" and your sleep problems will be better. And as Pugsy points out, brief wakes after a REM cycle are both pretty common and considered normal. The thing is, however, that a person who is not worried about "bad sleep", will wake up at the end of a REM cycle, quickly establish that there's no need to wake up further because all is well, and then go immediately back to sleep. When these post REM wakes last less than 5 minutes, the person doesn't even remember them when they get up in the morning.

So one thing that I suspect that you are doing is prolonging the wakes when you do wake up so that they last long enough for you to remember them in the morning and so that they are long enough to contribute to the feeling that you are not sleeping particularly well. You may not be intentionally prolonging the wakes, but if you wake up and start worrying about why you are awake yet again, that's enough to do it.

So one thing I would recommend is to try to not worry quite so much about the wakes. When you find you've woken up after a REM cycle, tell yourself it's normal and allow yourself the privilege of going to sleep without fretting about the wakes.

The next thing is that as Pugsy says, sleep maintenance insomnia can be caused by a lot of things: Medication is one of them. Bad sleep hygiene habits is another. And other health problems that are not related to sleep apnea is yet a third.

I also want to pick up on an observation by Miss Emerita: She notes that you are using your machine anywhere between 11-14 hours a night. It could be that your problem with less-than-good sleep is being caused by too much time in bed. I know that's counter-intuitive, but the fact is that most people only need about 8 hours of sleep per night and trying to force yourself to sleep far more than that can lead to problems with excessive amounts of wake-after-sleep-onset, or WASO for short.

The problem with a lot of WASO is that tossing and turning and fighting for sleep just does not lead to good quality sleep. You may feel a lot more rested if you were getting 7.5 hours of sleep while lying in bed for a total of 8 hours on a regular basis.

So here's another idea for you to consider:

First, ask yourself how much actual sleep do you think you get on a typical night when you use the machine for 11-14 hours?

Second, ask yourself whether you think you might be able to function on a total of 8 hours of decent quality sleep, which is roughly the amount of sleep needed by a typical adult human being. If so, then what you need to do is consider restricting your time in bed to no more than about 9 hours. If you get 8 hours of sleep in a 9 hour time in bed window, your sleep efficiency is about 88%, which is pretty decent, but not quite ideal. But if you get 8 hours of sleep in a 10 hour time in bed window, your sleep efficiency is 80%, which is low enough to start feeling like there is something messing with your sleep.

The most effective way to increase your sleep efficiency that I know of is to restrict the time in bed so that your body learns to consolidate the sleep cycles and not wake up for every little thing that might be causing you to toss and turn. It can take a few weeks to a few months for the body to figure it out, and yes, in the meantime you can feel like you are functioning on not enough sleep. But if you are feeling like there's something wrong with your sleep when you are trying to get 11-14 hours of sleep at night, then that's a pretty good indication that the body doesn't want or need to spend that much time in bed.

[sleepyzzzz]

thanks all for the replies, I would like to clarify few things before posting a new screenshot:
1- i'm taking sedating medications: clonazepam, amytriptilin, quietiapine, prepronalol, why? because they put me back to sleep when i wake up, and prolong my sleep time.

2- why i'm staying 11hrs+ in bed? because when i was staying less, with all the arousals, it's almost sure that will wake up "zombie".

3- what is zombie? it is when i get up from bed, feel pressure on my brain, not able to focus or do anything untill i go back to sleep, and at least "release the pressure" on my brain by shutting my eyes and getting those slow brain waves, it is hard for me to nap as as soon as i "drift to sleep" i could feel my airway collapsing with snore sound and immediate arousal.

4- is it normal to wake up after dream? i used to not when this all started 5 years ago, i "remember" the dream as soon as i wake up, and even though i could sleep back right away, there is a correlation between the numbers of arousals and waking up zombie: the more the # of arousals, the higher the chance i'll become zombie for the whole day.

5- without the machine, i could keep waking up on loop each sleep onset, and if I bypass that and actually sleep, the number of arousals is much higher than with using the machine.

[sleepyzzzz]

For comparison sake, this is last night data, I used Resmed pillow mask, highest epap I can tolerate with this mask which is 7. Highest PS i ever used with pillow which is 5.
I had still arousals, i'm not zombie, but I noticed that toward the end of sleep, the time between arousals is much shorter than with the Evora mask and higher EPAP/PS which is around 75mns to 90 mns but with the pillow epap7/PS5, it was as little as 25mns sleep.

2nd observation is you can see some sort of flow limitation in airflow before arousals or sometimes that does not lead to arousal ( i shutoff/on the machine each conscious arousal to mark it on the flow graph).

[Miss Emerita]

You turned off the machine twice, it appears. Does that mean you had only two conscious arousals? That's completely normal.

I also want to emphasize something robysue said: short arousals really do not mess with your sleep much at all. She suggests that arousals under 5 minutes should not be of concern.

A while back, I used a Dreem head band, which has an EEG function, to track my sleep. From that I learned that for me, short wake-ups didn't interfere with the normal progression of sleep stages; only the longer ones did.

Are you taking all of these drugs regularly? Please review your drug regimen with your doctor. The medications you are using can cause daytime drowsiness, dizziness, tiredness, or difficulty in thinking. Don't stop using any of them suddenly, but you may do well to taper off some or all of these.

Please give serious thought to the advice robysue has given you about limiting your time in bed. You may feel as though without your 11-14 hours, you'll be sunk. That might be true in the short run, but in the longer run you could be doing yourself a big favor by restricting your time in bed.

I don't myself see value in looking more closely at your Oscar charts. You are having a lot of trouble feeling rested during the day, which is awful, but the answers to your problems will not come with changes to your settings or continued efforts to anaylze your data.

[robysue1]

thanks all for the replies, I would like to clarify few things before posting a new screenshot:
1- i'm taking sedating medications: clonazepam, amytriptilin, quietiapine, prepronalol, why? because they put me back to sleep when i wake up, and prolong my sleep time.

That's a potent set of medications. Did one doctor prescribe them all or are you getting different scripts from different doctors? Most doctors are not willing to prescribe multiple drugs to be taken at the same time as sleep aids.

While clonazepam is sometimes prescribed off label for sleep problems, its FDA approval is for treating seizures and panic disorder. While clonazepam can increase the amount of REM and decrease arousals in many people, in some unlucky people long term use of clonazepam can trigger insomnia and increase arousals. Clonazepam can also cause daytime sleepiness and fatigue.

Amytriptilin is an antidepressant which is often prescribed for insomnia even though there's very little scientific evidence that amytriptilin is actually effective against insomnia. Its side effects can include an increase in daytime fatigue and sleepiness.

Quietiapine is an antipsychotic drug that is used in treating bipolarism, but it is also prescribed (off label) for insomnia. Again, there is not much scientific evidence for its effectiveness in treating insomnia. Again, daytime drowsiness and fatigue are listed among the side effects.

Propranolol is a beta-blocker that is usually prescribed for certain kinds of heart problems. It's also used to treat anxiety and it can be used (off label) as a migraine preventative. Among its common side effects are difficulties with sleeping and nightmares. I didn't quickly find a source that said propranolol was commonly prescribed off label for insomnia.

In other words, most of these medications are sometimes prescribed off label for insomnia primarily because their side effects include increased drowsiness, and hence it's assumed that if they are taken at or close to bedtime, they may help a person get to sleep and/or stay asleep. But the evidence that they will reliably work that way is scant.

And since daytime drowsiness and/or sleeping problems are listed in the side effects for all of these medications, it seems to me that you may be over medicated. However, all of these are powerful drugs and you can't just discontinue them cold turkey. Please talk to the doctor(s) who prescribed these drugs about the fact that they are not improving your sleep and ask whether you need to be on them all. And if not, what's the best, safest way of weaning off the ones you don't need to be on.

And quite frankly, if you are sleeping for 11+ hours, you don't need to prolong your sleep: You are already getting more sleep than your body probably needs or wants. And it could be the excessive amount of sleep is itself causing your sleep to be bad.

2- why i'm staying 11hrs+ in bed? because when i was staying less, with all the arousals, it's almost sure that will wake up "zombie".

3- what is zombie? it is when i get up from bed, feel pressure on my brain, not able to focus or do anything untill i go back to sleep, and at least "release the pressure" on my brain by shutting my eyes and getting those slow brain waves, it is hard for me to nap as as soon as i "drift to sleep" i could feel my airway collapsing with snore sound and immediate arousal.

Some of this sounds much more like depression and/or anxiety manifesting itself with depressive like symptoms. Because it seems to me like what you've previously told us is that even with 11-14 hours of sleep, you're still waking up feeling like a zombie.

4- is it normal to wake up after dream? i used to not when this all started 5 years ago, i "remember" the dream as soon as i wake up, and even though i could sleep back right away, there is a correlation between the numbers of arousals and waking up zombie: the more the # of arousals, the higher the chance i'll become zombie for the whole day.

In a person with typical healthy sleep habits and no pathological sleep problems, the person sleeps for somewhere around 8-9 hours. During that time, the person goes through 5-6 complete sleep cycles, each of which lasts roughly 90 minutes and each of which typically ends with a REM cycle and (possibly) a brief awakening. If the wakes are less than 5 minutes in length, the person typically doesn't not remember waking up at all during the night. And the 5 or so post-REM wakes have little affect on how the person feels in the morning. It's also worth noting that the REM cycles typically increase in length as the night goes on, while the time in deep sleep (i.e. Stage 3 or delta sleep) typically decreases with each full sleep cycle. A person with genuinely good sleep typically does not remember their dreams, or perhaps remembers the dreams from the last REM cycle when they wake up in the morning.

For people with badly messed up sleep, the first thing is to determine why the sleep is so badly messed up in the first place. With untreated sleep apnea, the breathing problems lead to brief 10-30 second arousals/wakes and/or O2 desats multiple times an hour. In other words, with untreated sleep apnea, a person may be waking up or arousing dozens of times every single hour. And yes, all those respiratory related arousals lead to feeling like a zombie in the morning, even though the person may not remember a single one of the wakes. CPAP fixes the problems caused by respiratory related arousals and desata by preventing the airway from collapsing in the first place, and that usually improves the sleep.

For people with untreated periodic limb movement disorder (PLMD), the arousals are caused by the periodic limb movements. And again, this can happen multiple times per hour, all night long. Fixing the PLMD reduces the number of arousals and typically improves the sleep.

For people with sleep maintenance insomnia, there are typically a large number of spontaneous arousals that go beyond just the usual post-REM arousal/wakes. And the person may remember a large number of wakes. Or the person may remember spending a lot of time tossing and turning and fighting for sleep. The actual number of arousals and wakes may be far fewer than a person with untreated sleep apnea or untreated PLMD, but because those wakes and arousals are longer in duration, the person is more likely to remember them and because of the extended WASO, the person may very well feel like a zombie in the morning.

For sleep maintenance insomnia, the solution is not more sleep. It's figuring out a way to consolidate the sleep cycles so that you stand a chance of actually sleeping for a full sleep cycle rather than dozing in and out of a very light sleep for most of the sleep cycles. And one way of encouraging the body to consolidate the sleep cycles is to not stay in bed for 11+ hours hoping that additional light dozing is somehow going to equal quality sleep.

5- without the machine, i could keep waking up on loop each sleep onset, and if I bypass that and actually sleep, the number of arousals is much higher than with using the machine.

Nope. When you don't use your machine, you are arousing/waking briefly after every single hypopnea and apnea in order to unblock your airway and restart your breathing. You don't remember any of those wakes because they're only 10 seconds long. But they keep coming every few minutes and that prevents you from actually getting the sleep you want. You probably also had a large number of spontaneous arousals as well, but they too were short (because your body was determined to get back to sleep) and you didn't remember them.

The problem is that now your OSA is treated, you still seem to be having a lot of spontaneous arousals and now your brain is waking up after each of them saying, "Why the heck am I awake? Why can't I stay asleep since I'm not waking up with breathing problems all the time?"

My guess is that if you simply forced yourself to get up and function on 8 or 9 hours of sleep for a few weeks that your body would start to consolidate the sleep cycles.

[sleepyzzzz]

I appreciate all the advice, and many of the things you said my brain is convinced of .
the problem is my body does not understand, although it's "normal" to wake up through the night, when it happens to me, i wake up zombie.
i know the meds are too much, without them i'm more zombie
I would like to tell you that this is a 5 years struggle, so believe me when i tell you, i did not end up with this post suddenly, i have tried everything there is about sleep from sleep hygiene, to surgeries.
at the end, i'm handicapped, i am not able to have a fixed schedule and go to work, and the only thing i could feel makes a difference in my night apart from all the added meds ( i did not use meds for 3.5 years of this "situation" ), i think is the Bilevel machine, there are some magic nights where i sleep 6 hrs straight with the PAP and wake up rested, but using the same numbers in other nights does not work, my body keeps "shifting" adapting, mutating, i don't know how to explain it, but i tried cpap, S mode, Vauto and all kinds of paramters, i'm still struggling to keep the arousals mute each night.
from my notes/experience, PS > 3 helps
sometimes i feel a steady pressure is better like the Smode and sometimes i return to vauto, my body responds to low pressure high PS almost same as high epap high PS. MY first ever sleep study before surgeries had 14AHI and 42 REM AHI, i know each time i wake up i feel i just woke up from a dream, i have 6, 7 dreams at night that i remember most each night, i also "SEE" flow limitations on my airflow, sometimes it is at the expiratory cycle, sometimes is narrow or double peaks at inhale, and although i'm not able to fix these, they show that there is something wrong in my respiration mechanism when sleeping.

[Miss Emerita]

I don't think you should worry about flow limitations. The kinds of "dents" you're seeing don't indicate that there is something wrong with your respiration mechanism.

robysue gave you a lot of information about the side effects of each of your medications. As I think you're saying, your brain knows you won't get your sleep sorted out until you taper off all the drugs you're taking. So listen to that good brain of yours!

Could you make an appointment with your main doctor within a day of reading this? Just make the appointment; that's all you need to do right now. That's step one. Then when you go, can you explain to the doctor what drugs you're taking and at what doses and frequencies? And can you explain that you want to taper off and ask for advice about the best way to do that? That would be step two.

Step three would be following the roadmap the doctor gives you. Once you've tapered down and off, you'll be ready to try out the ideas robysue has suggested for consolidating your sleep.