Persistent fatigue

[Barios]

Hello, I am a 29-year-old French individual (sorry if my writing is poor). I have been using a machine for almost 4 months due to severe sleep apnea with an AHI of 35 per hour.

On paper, everything seems fine. My AHI is now at 0 or 1, which is excellent. There are not many leaks or other apnea events recorded. I have an excellent average of 3 hours of deep sleep, and currently, I sleep for an average of 9 to 10 hours per night.

The problem is that I feel even more fatigued since I started using the PPC machine compared to before. There are phases where I literally can't bear my own weight, and I have no strength, in addition to feeling tired throughout the day. I have undergone a full-body scan and multiple blood tests, but no issues were found. I am not on any medication, and I have been sleeping at a fixed time for over a month.

My sleep doctor told me that it couldn't be due to the machine because, according to him, everything is fine. However, I still have doubts.

I am using a Loweinstein Prisma Smart Max machine with the Fisher & Paykel Eson 2 nasal mask. I hope you can help me. Thank you.

https://imgur.com/2mompxl
https://imgur.com/dZAEXHk
https://imgur.com/5ZgwRLC

[Sissy63]

I am in the same boat. For the most part everything looks good pn paper, but I don't feel that way. I just changed mask and now trying to increase my pressure.

Unfortunately, there seems to be more than AHI and leaks rates to consider, but most doctors don't look beyond that.

What is your pressure? I can't really tell by your graphs.

There are way more qualified people who can assist you, so hopefully they will offer suggestions soon.

The relentless fatigue is awful.

[Barios]

My pressure is at 6 - 12

[chunkyfrog]

4 months may not be enough for everyone.
Everybody is different.
Hang in there.

[ozij]

Try to find out what the "obstruction" chart means.
I don't know the Sigma, but I'm guessing what we see there is what ResMed machines call "Flow limtations".
Flow limitations are often indications of something obstructing the air flow.
Some machines (e.g. ResMed machines) respond to Flow Limtations by raising the pressure immediately. Others don't. Yours seems to be one of those that dont' though it is responding to snores and "Resporatory Effort Related Arousal" events, of both of which you still have.

You graphs show:
Quite a bit of what they call "osbstruction"
They show quite a bit of "respiratory instability" - both in the chart of that name, and in the "Flow chart".
Some snores and RERA's.

These phenomena - and how you feel make me think that your minimum pressure is too low, and those obstructive respiratory phenomena are keeping from sleeping well. (If you how the machine can know how deep you sleep, please tell us - the only info the machine has is your breathing, and that is far from being a reliable single indicator of depth of sleep).

If it were me, I would start raising the minimum pressure - gradually - to see how that affects the "obstructions" the "flow" and the "respiratory instability. Restful sleep happens when your breathing is stable.

[Barios]

However, it is indicated that I have a great amount of deep sleep, generally between 2.5 to 4 hours per night. Regarding my machine, I haven't set up any expiratory pressure relief. Should I do it?

It doesn't bother me at all at this level because the airflow rate is low, and I don't have any issues in that regard. I will try increasing my minimum pressure from 6 to 7 to see if there is any difference, but I have some doubts. At one point, I tried various different pressures, both fixed and others, but I didn't feel any benefit. However, I didn't look at the graphs. I will test it tonight.

Regarding the obstruction, here is some additional information that may be helpful.

https://imgur.com/3g1TOjD

[ozij]

However, it is indicated that I have a great amount of deep sleep, generally between 2.5 to 4 hours per night

Please explain:
Why you trust the machine's ability to inidcate "deep sleep" when all it has us your breathing.
What the additional information you posted means.

Does your machine ever show you when it thinks you're in deep sleep?

When you make changes, make only one at a time. and stick to the new setting for a week or so -- unless the results are catastrophic.

[Barios]

I have no idea how the machine calculates my deep sleep time, and I don't know how to get the answer. I also tried to find out what "obstruction" means, and I think it refers to the rate of obstruction in my airways.

[Barios]

But could the phenomenon of obstruction possibly disappear with a higher pressure setting?

I managed to obtain the statistics from a time when I set the pressure to a fixed 10 to test it. Here are the results, and it seems much worse, yet there were almost no AHI events.

https://imgur.com/iGbRr0G

[ozij]

I have no idea how the machine calculates my deep sleep time, and I don't know how to get the answer.

Which is why I suggest we ignore it. If you're healthy, and feeling so tired, you can't be getting deep sleep.

I also tried to find out what "obstruction" means, and I think it refers to the rate of obstruction in my airways.

Makes sense.

I managed to obtain the statistics from a time when I set the pressure to a fixed 10 to test it. Here are the results, and it seems much worse, yet there were almost no AHI events.

AHI is not the only indication sleep disordered breathing.
The side bar reports on the first three screen shots show you reach you spend 95% of your time or less of it at a pressure of 8.5. In other words,10 was much higher that the automatic algorithm on this machine thinks appropriate. No wonder it was a bad night.

How long have you stayed at each pressure when making experiments??

Can you get a titration study in a lab, that is, a study where they check your response to different pressures?

[Barios]

I have tested various fixed pressures ranging from 8 to 14, if I remember correctly. I would try them for a day or two, and then change when I realized I was still feeling fatigued. At one point, I tried a pressure of 8-12 for about a week, I'm not sure exactly, but I was still tired. However, I didn't check the reports on the application.

I don't think I can conduct this kind of experiment in a sleep laboratory in France. It doesn't appeal to me, and I'm not sure if it even exists here.

[Catnapper]

Persistent fatigue can come from a deficiency of vitamin B12 and/or anemia.

[Barios]

My blood tests are fine, and I recently checked my iron levels, which are also good. The strangest thing is that I am actually much more fatigued since I started using the machine. I tried three nights without the machine, and I had less fatigue, although I still experienced some because my AHI is still at 35 per hour without the machine.

[Miss Emerita]

In addition to tests for B-12 deficiency and anemia, you might check whether your blood-work has included tests for low thyroid, B-6 deficiency, Lyme disease, autoimmune disease (especially in the connective-tissue disease family), and low testosterone (if you are a man). I know you attribute your current level of fatigue to your use of the machine, but it's important to understand whether something in addition to apnea or other respiration problems of sleep might be contributing to your fatigue.

If the "obstructions" your seeing on your chart are indeed like flow limitations, EPR can be helpful. But as ozij, who is very experienced and knowledgeable, has explained, it's important to make one change at a time and stick with it for about a week before trying to assess its effects on your sleep. You might also find it helpful to make daily notes about your settings and how the night seemed to go subjectively, how you feel during the day, and your data concerning AHI, leaks, snores, "obstructions," or anything else that might bear on your rest. This can help you spot correlations and patterns that might yield insight.

[zonker]

in to follow up with what miss e. said. i kept a journal for a year to help my focus in on my sleep apnea journey including the very data she spoke about.

it was invaluable in helping me fine tune my therapy.