Last Night Was First Night

[Iancdub88]

Would you guys help me read last night's results? It all seems to look good from what I can tell. It's just hard for me to know when I was actually sleeping. I guess there's no real way to know that. right?

https://sleephq.com/public/7e0724c5-111 ... 291b272260

[robysue1]

Would you guys help me read last night's results? It all seems to look good from what I can tell. It's just hard for me to know when I was actually sleeping. I guess there's no real way to know that. right?

The quality of your sleep is not just dependent on the APAP's data. It also depends on your subjective feelings about the night's sleep. And the purpose of xPAP therapy is two-fold: (1) The machine prevents the apneas from occurring so that (2) you are able to get sleep that feels subjectively very good in two ways: (a) you feel like you slept pretty soundly (very few wakes that you remember with no trouble getting back to sleep) and (b) you woke up feeling reasonably refreshed, rested, and ready to start the day.

So to answer your question about what last night's data says about your overall sleep, you need to make some seat-of-the-pants estimates (or wild guesses if necessary) about the following things without staring at your data in an effort to answer them:

1) How rested did you feel when you first woke up and got out of bed? Think about this on a simple scale: 0 = horrible, not rested at all and 5 = fantastic and eager to get up and face the day. [Note: It is not reasonable to expect that you will wake up feeling like a 5 every single day even after your xPAP therapy is optimized. The goal is to have lots more mornings with 3, 4, and 5s than you have 0, 1, and 2s.]

2) How long would you say it took you to get to sleep at the beginning of the night? A few minutes? maybe 20-30 minutes? 30-60-minutes? over an hour? [People with high quality sleep usually take about 10-20 minutes to get soundly asleep at the beginning of the night.]

3) Roughly how many times do you remember waking up? A range is fine. Or in English. But keep in mind that "a few" should mean no more than 2 or 3. "Some" means about 5 or so. "A lot" would mean anything more than 7 or 8. [People with high quality sleep may remember a few wakes since waking briefly after every REM cycle is not uncommon. But most of us don't remember any wake that is less than about 5 minutes long when we wake up in the morning---and that's ok.]

4) Do you remember any wakes where you had a lot of trouble getting back to sleep? [People with high quality sleep have no trouble getting back to sleep if they do wake up in the middle of the night.]

5) Put your answers to Questions 2, 3, and 4 together to get a very gross estimate of how much time you were asleep. And just as important, you'll be able to get a very gross estimate of your subjective sleep efficiency, which is just (time asleep)/(time in bed). To feel at our best, most of us need a subjective sleep efficiency that at least 85% or 90%: The more time we spend in bed not sleeping, the less rested we feel when we get up in the morning.

Once you have subjective answers to Questions 2-5, then it's time to look at the data and see whether it shows you sleeping more or less than you subjectively feel like you slept.

If you post your answers to 1-5, I'll try to look at your SleepHQ data with some care and give you my best opinion of whether your subjective ideas about your sleep tend to agree with the objective data from the APAP.

Having said all that, here's my take on the sleep apnea part of the puzzle: The machine is doing a good job of preventing apneas and hypopneas whenever you actually are asleep. The flow limitations may be a concern. Sometimes they are related to OSA problems and indicate the airway is not stable and at some danger of collapsing, which is why the machine is increasing the pressure when it detects a bunch of them around 2:00AM. But those flow limitations don't actually smooth out when your machine hits its max pressure of about 12 cm H2O. That could indicate several different things, and until I know whether you felt like you were tossing and turning most of the night, I don't care to speculate on why the Flow Limitations didn't smooth out with the additional pressure.

After 5:00 AM, there is some leaking going on. Is this an issue? That's hard to say. The leaks stay below Resmed's RedLine of 24 L/min and I'm sure Mr. Green Smiley Face showed up on the machine's on-board sleep data. In other words, these leaks are what I call "pesky leaks"---long lived, but relatively small leaks. So they're not affecting the efficacy of your PAP therapy. But they're long enough to ask the question: Do you remember being bothered by any leaks during the night? If you don't remember fighting any leaks, these leaks can be ignored. But if you remember waking up fighting leaks for an extended time during the night, then they might need to be troubleshot.

[Iancdub88]

1) How rested did you feel when you first woke up and got out of bed? Think about this on a simple scale: 0 = horrible, not rested at all and 5 = fantastic and eager to get up and face the day. [Note: It is not reasonable to expect that you will wake up feeling like a 5 every single day even after your xPAP therapy is optimized. The goal is to have lots more mornings with 3, 4, and 5s than you have 0, 1, and 2s.

I would probably say it's been a 2 most days including today and then by 7:30pm I can barely keep my eyes open. I push to stay up till 9:30pm but it has been a struggle.

2) How long would you say it took you to get to sleep at the beginning of the night? A few minutes? maybe 20-30 minutes? 30-60-minutes? over an hour? [People with high quality sleep usually take about 10-20 minutes to get soundly asleep at the beginning of the night.

I think probably between 15-30 minutes to fall asleep.

3) Roughly how many times do you remember waking up? A range is fine. Or in English. But keep in mind that "a few" should mean no more than 2 or 3. "Some" means about 5 or so. "A lot" would mean anything more than 7 or 8. [People with high quality sleep may remember a few wakes since waking briefly after every REM cycle is not uncommon. But most of us don't remember any wake that is less than about 5 minutes long when we wake up in the morning---and that's ok.

Probably between a few and some. I think I can think of 6 times.

4) Do you remember any wakes where you had a lot of trouble getting back to sleep? [People with high quality sleep have no trouble getting back to sleep if they do wake up in the middle of the night.

I woke up around 5:30 and couldn't get back to sleep and ended up just getting out of bed when my alarm went off at 6:30.

After 5:00 AM, there is some leaking going on. Is this an issue? That's hard to say. The leaks stay below Resmed's RedLine of 24 L/min and I'm sure Mr. Green Smiley Face showed up on the machine's on-board sleep data. In other words, these leaks are what I call "pesky leaks"---long lived, but relatively small leaks. So they're not affecting the efficacy of your PAP therapy. But they're long enough to ask the question: Do you remember being bothered by any leaks during the night? If you don't remember fighting any leaks, these leaks can be ignored. But if you remember waking up fighting leaks for an extended time during the night, then they might need to be troubleshot.

There were a couple of times that I was annoyed by leaks. It's whenever I try to sleep on my stomach. I would like to train myself to just stay on my sides.

[Iancdub88]

Now that I think about. There was quite a bit of tossing and turning.

[Iancdub88]

I'm starting to feel desperate for help. I've been so tired during the day that work has been a real struggle. It's leading to depression and I just want to get this stuff on track. I don't know what to do.

[robysue1]

I'm starting to feel desperate for help. I've been so tired during the day that work has been a real struggle.

I am starting to analyze the data that you posted on SleepHQ. It's going to be a while before I get done. It's also going to be a long post once I write it.

As for the fact that you feel desperate for help: Lots of newbies feel that way. Keep in mind that you are not alone.

How long (pre-CPAP) have you been feeling so tired during the day that work has been a real struggle? Or did this start after you started PAPing?

It's leading to depression

Any medical history of clinical depression, either in you or in close family members?

and I just want to get this stuff on track. I don't know what to do.

Unfortunately optimizing xPAP can seem like it involves a lot of trial and error. It also can seem like it involves some "two steps forward, one step backward" trials and tribulations. In other words, it's a process.

Think of it this way: Your body has been figuring out a way to sleep with all the interruptions from the obstructive events for a very long time. It intuitively knows how to arouse you often enough to keep you alive, but not so often that you didn't get any sleep at all each night before you started CPAP.

Now? The body is no longer being bothered by actual apneas and hypopneas where it feels like its being suffocated while attempting to sleep. But your brain and body don't (yet) know what to do with the new normal. On the one hand, when your body does fall asleep, those mini-suffocations are not happening, but your vigilant brain may still be worried that they will start happening if it allows itself to drift off into a genuinely deep slumber. So your subconscious brain may still be causing a lot of spontaneous arousals that allow it to verify that your breathing has not stopped. It can take the subconscious part of your brain a while to let go of its formal role in keeping you alive by waking you up when the obstructive events occurred. And, unfortunately, some of us have more stubborn subconsciousnesses that have a harder time letting go and relaxing and learning to let the CPAP do its job of keeping the airway awake while the body and brain get the restorative sleep they both need and are entitled to.

And add to that: There's all this new stuff on your face when you're trying to get to sleep. And it's blowing air directly at you. So there's a whole lot of new sensory stuff for both the body and brain to get used to---just in order to fall asleep each night. And that darn subconscious? It can misinterpret all these new sensations as yet another mortal danger----there's this MONSTER lying right on top of the nose for crying out loud! And it can take a while for the subconscious part of the brain to let go of those irrational fears about that MONSTER lying right on top of the nose and let the rest of the brain (and body) drift off into a high quality sleep. And, unfortunately, some of us have more stubborn subconsciousnesses that have a harder time letting go of the idea that the mask is some kind of MONSTER lying right on top of the nose!

And if you were tired and exhausted all the time before you started PAPing, your body also needs time to recover. Some people find that once they are sleeping well with the CPAP, they crave sleep even during the daytime. It's just their body trying to make up for lost time during all those years when it kept having to wake up dozens (or hundreds) of times each night just to restart the breathing.

You started PAPing on June 28. And you've had some rough patches in the early going. So you're not going to be one of those people (like my husband) who feels much better almost immediately. But there's still good reason to hope that you're not going to be an outlier like myself who took 6 months to notice any improvement in anything and a total of 9 months before being able to sleep more-or-less normally with the machine every night and waking up feeling pretty decent almost every morning.

[Iancdub88]

How long (pre-CPAP) have you been feeling so tired during the day that work has been a real struggle? Or did this start after you started PAPing?

I was tired most of the time but I could deal with it and focus on work on before PAPing. It's gotten a lot worse since I've started.

Any medical history of clinical depression, either in you or in close family members?

Yes, ive struggled with depression most of my life and so have many family members. This just seems to be making it worse.

Thank you so much for the info on what my body is doing. You're very informative and kind. I'm sorry if I've been annoying in any way.

[robysue1]

Iancdub88,

Here's the first of a set of posts I promised concerning the data you posted at https://sleephq.com/public/7e0724c5-111 ... 291b272260 along with the answers you posted here.

In this post, let's look at the subjective amount of sleep you got during the night.

Looking at the CPAP data, the time in bed is 10:35 pm (when you turned the machine ON) to 7:30 AM when you turned the machine OFF). Call it a total of 9 hours.

You took about 15-30 minutes to get to sleep and you remember at least 6 wakes. Since people don't typically remember wakes that are shorter than 5 minutes, we can assume that you had at least 30 minutes of WASO (wake after sleep onset), not counting the end of the night, which you describe as follows:

4) Do you remember any wakes where you had a lot of trouble getting back to sleep? [People with high quality sleep have no trouble getting back to sleep if they do wake up in the middle of the night.

I woke up around 5:30 and couldn't get back to sleep and ended up just getting out of bed when my alarm went off at 6:30.

while the CPAP data says it was turned off at 7:30. Let's say you were awake with the CPAP on your nose for about an hour before you turned it off.

Let's average the time to sleep, and say it took you (15 + 30)/2 = 22 minutes to get to sleep (rounding down). So that means you probably were awake at least 22+30+60 = 112 minutes during the 9 hours that you were in bed. 9 hours = 540 minutes. So your (subjective) estimated idea of how much sleep you actually got was around 540-112 = 428 minutes, or a bit less than 7 hours and 10 minutes. And your estimated sleep efficiency is 428/540 = 79.25%. And that's poor enough sleep efficiency to feel (subjectively) like you got a rotten night of sleep. And that sleep efficiency is low enough all by itself to explain feeling pretty tired all day long, regardless of the fact that the CPAP is preventing events from happening when you actually are asleep.

So if this night is typical of how well you are sleeping in terms of time it takes you to get to sleep, number of times you remember waking up, and how long you lie in bed fighting to get back to sleep when you wake up an hour or two before your alarm goes off, then I think your current problem might be categorized as continuing to have too many wakes during the night and too much difficulty getting back to sleep when you wake up about an hour before your alarm goes off.

Any history of insomnia? If so, how bad is/was it? And what (if anything) have you done to manage the insomnia in the past? And subjectively did any of the things you tried make any difference in terms of the insomnia?

And what can you do about these non-sleep apnea related problems?

First, you need to analyze your sleep hygiene: Are there behavior patterns that inadvertently lead to bad sleep? If so, you need to focus on trying to change those behavior patterns.

On this particular night, you might have been better off getting up when you woke up at 5:30 and starting your day rather than staying in bed trying to get back to sleep for an hour (or two?). Yeah, you probably would have hit the wall at some point. But if it was before 7:30 AM, you might just have been able to go back to bed and fall asleep quickly to get some decent quality sleep instead of an hour of SWJ. Or you might have struggled through the day, but it probably wouldn't have been much harder than the day actually was---particularly if you put the time between when you woke up (5:30? or 6:30) and when you actually got out of bed (7:30?) to good use doing something you enjoyed.

Next, examine your caffeine consumption. Also consider whether you ate too close to bedtime. Also did you get enough physical activity during the day, but also not too close to bedtime. And do you have a sleep inducing bedtime routine? Or do you go to bed feeling anxious about your sleep?

Also, examine your screen time habits: Do you watch TV, use your cell phone, or your laptop while sitting in bed before going to sleep on most nights? If so, you may need to build in a screen-free time before you go to bed. You may also need to limit activities that you actually do in bed to sleep and sex.

[Iancdub88]

Any history of insomnia? If so, how bad is/was it? And what (if anything) have you done to manage the insomnia in the past? And subjectively did any of the things you tried make any difference in terms of the insomnia?

No history of insomnia. I mean we all have sleepless nights but it's never been a chronic problem. I've usually been able to fall asleep pretty easily.

First, you need to analyze your sleep hygiene: Are there behavior patterns that inadvertently lead to bad sleep? If so, you need to focus on trying to change those behavior patterns.

I read a chapter of a book in bed. A physical book, not a Kindle or a tablet or anything. This has always helped me fall asleep.

Next, examine your caffeine consumption. Also consider whether you ate too close to bedtime. Also did you get enough physical activity during the day, but also not too close to bedtime. And do you have a sleep inducing bedtime routine? Or do you go to bed feeling anxious about your sleep?

I have one cup of coffee first thing in the morning and I never eat anything after dinner which is usually before 6pm. I get a goof amount of physical activity at work. Like I said, I tend to read a chapter of a book to induce sleep

Also, examine your screen time habits: Do you watch TV, use your cell phone, or your laptop while sitting in bed before going to sleep on most nights? If so, you may need to build in a screen-free time before you go to bed. You may also need to limit activities that you actually do in bed to sleep and sex.

For the most part, those are the activities the bed is limited to.

[robysue1]

Iancdub88,

Here's the first of a set of posts I promised concerning the data you posted at https://sleephq.com/public/7e0724c5-111 ... 291b272260 along with the answers you posted here.

In this post, I start looking at your data pretty closely. And I include screen shots so you can see exactly what I am talking about.

Beginning of the night
Here's a screen shot of what happens right after you turn the machine on around 10:35:


Are you using the smart ramp feature? I ask because I'm kind of surprised that the machine didn't increase the pressure after that first (fake) snore occurred minutes after you turned the machine on. It may be that the "smart ramp" programming is now used even if the smart ramp is off and it may be that the machine only increases pressure after it thinks you have in fact fallen asleep. This is something that I am not fully knowledgeable about since I started PAPing long before "smart ramps" were programmed into CPAPs and long before a "smart response" including a delay in increasing pressure right at the beginning of the night was incorporated into the machine's programming.

At any rate, it certainly looks like you did fall asleep by 10:44 or so. But you didn't stay fully asleep for long:

The two blips with large breaths are most likely arousals. The flow limitations between them are interesting and lead to a pressure increase. But whether the flow limitations are actually significant is a whole different question.

I suspect that you fell into a light transitional sleep by around 10:45, but you didn't transition all the way to real sleep for quite a while. In other words, if you are asleep during this snippet, it is very light sleep.

Zooming out a bit:

There are likely wakes/mini-wakes/arousals at the following (rough) times: 10:50, 11:00, 11:15, 11:30, 11:40, 11:57, 12:14(?), 12:25, 12:35(?), and 12:50. Some (most?) of these are probably just "arouse enough to turn over in bed" and are not worth worrying about. But at least 3 of them might be 5 minutes in length and might indicate a real wake rather than just an arousal to very light sleep. At any rate, it does not look like you've been able to transition to and stay in a real sleep for more than 30 minutes at a time.

Flow limitations are what is driving the pressure increases during this time frame. And it looks like the additional pressure is smoothing out your flow limitations. That might indicate that your flow limitations are in fact part of a sleep disordered breathing pattern. The machine is delivering enough pressure to prevent your obstructive events, but at your minimum pressure setting, it is not quite enough pressure to prevent all the flow limitations. If you are not having any problems with aerophagia, a small increase in the minimum pressure setting might help prevent the flow limitations in the first place. And that might reduce the number of micro-arousals and mini-wakes that seem to be causing the poor quality of your sleep.


12:50 AM to 3:10 AM
Here's a reasonable zoom level to show this roughly 2 hour 20 minute period:

My overall impression is that you were probably pretty soundly asleep during this time frame all the way from after the arousal/wake at 12:50 to when you woke up and turned the machine off at 3:07. Yes, there are a few spikes in the flow rate now and then---they're probably just when you moved around in bed and none of them look long enough to be a problem.

What might be problematic are the flow limitations that start around 2:04 and end by around 2:30. The machine increases the pressure in response to these flow limitations right after they start from 9.7 cm to 12 cm over a 6 or 7 minute period. The flow limitations do start to smooth out after the pressure reaches it and the machine starts decreasing the pressure. There's no strong evidence that you woke up during these flow limitations or the pressure increase, even when we zoom in more closely on that 25 minute period:

The fact that the flow limitations respond appropriately to the increase in pressure is evidence that they are probably sleep disordered breathing related, but don't come close to satisfying the machine's definition for flagging a RERA, H, or and OA. Again, if you are not experiencing any problems with aerophagia, this data indicates that a modest increase in minimum pressure might be useful.

As far as what caused this set of flow limitations? It could be related to a REM cycle. Or it could be related to your sleeping position. Did your sleep study say anything about whether your OSA is significantly worse in REM or when you're sleeping on your back?

More in the next post

[Iancdub88]

As far as what caused this set of flow limitations? It could be related to a REM cycle. Or it could be related to your sleeping position. Did your sleep study say anything about whether your OSA is significantly worse in REM or when you're sleeping on your back?

I did an at home sleep study so I'm not sure how I would find that. I do try to stay off of my back though.

[Iancdub88]

Are you using the smart ramp feature?

No, I don't think so.

[robysue1]

Iancdub88,

Here's the next post with the careful analysis of your data.

3:10 AM to 5:20 AM
This roughly 2 hour chunk of the night looks like this:

At this level of zooming, it looks like it took you 7-10 minutes to get back to sleep after you turned the machine back on around 3:10. Was that break a bathroom break? At any rate, at this level of zooming there's no evidence that you got caught in a nasty SWJ cycle unable to transition to full sleep.

There are possible arousals/mini-wakes at the following times: 3:56, 4:07-4:10, 4:24, 4:44, 4:59, 5:08-5:14. My best guess is that the arousals at 3:56, 4:24, 4:44, and 4:59 are just you turning over in bed: These are all very short in length. The stuff between 4:07 and 4:10 is probably a short wake. And the stuff between 5:08 and 5:14 is probably a real wake. And it may be long enough to be a problem since you report waking up early and not being able to get back to sleep. More on this in a bit.

Again, there are some flow limitations that lead to pressure increases. And the flow limitations seem to smooth out in response to the increase in pressure. Again, it may be that these flow limitations are REM related or supine related, particularly if your OSA was worse in REM or on your back during the diagnostic sleep test. And a bit higher minimum pressure might just prevent them from happening, and that might make you sleep a bit better. (As long as the increased pressure doesn't cause a problem like aerophagia.)


5:10 AM to 7:30 AM
Here's what this 2 hour and 20 minute chunk of the night looks like:

The first blip is the end of the restless period between 5:08 and 5:14. Then you've got what looks like arousals, wakes, and/or general restlessness (SWJ) at the following times: 5:28-5:31; possible restlessness between 5:31 and 5:48 (need to zoom in on this closer); a wake at 6:05--6:10, with possible restlessness starting as early as 6:00 (need to zoom in on this closer) and possible restlessness lasting until as late as 6:15 or 6:20; restlessness or a wake between 6:40 and 6:47; a clear wake at around 7:05, with evidence that you never fell back asleep before turning the machine off at 7:30.

Even at this scale, it's easy to put this together with your self-report of waking up about an hour before your alarm went off and could not get back to sleep. You may have dozed here and there for 10-20 minutes between 5:30 and 7:30, but it doesn't really look like you got as much as a 40-60 minute stretch of real sleep after 5:30.


Here's the period between 5:30 and 6:10:

At this level of zooming, it looks like you might have gotten some actual sleep between 5:45 and 6:05. But 20 minutes is not long enough for a full sleep cycle. So your brain may not have recognized this 20 minute stretch of sleep as "real" sleep while you were lying in bed thinking you could not get back to sleep.


Here's the period between 6:10 and 6:50:

At this level of zooming, it looks like you might have fallen into a very light sleep around 6:15 or 6:25, but again, you didn't sleep long---it looks like there's a clear wake just after 6:40. So again, I can see how your brain might very well have felt like you didn't fall asleep at all during this period.


Here's the period between 6:50 and 7:30:

At this scale it looks to me like you never really got back to sleep after 7:05, or if you did it was only for a few minutes here and there---nothing continuous enough to feel like real sleep. And it's questionable how much continuous sleep there is between 6:50 and 7:05.

Now sometimes when you wake up and allow yourself to pleasantly daydream and doze for a while before getting up, you'll see these same kind of SWJ patterns. The difference, however, is in the subjective feeling about the overall quality of the whole night's sleep. When you wake up too early and you try unsuccessfully to get back into a sound sleep to get one more full sleep cycle, your brain has good reason to interpret what's going on as "tossing and turning and not sleeping well". But when you consciously allow yourself to lie in bed knowing that you're half-asleep and half-awake because you're pleasantly enjoying that time in bed before you make the decision to get up, your brain is apt to interpret that period of SWJ very differently---it's likely to think of it as a relaxing bit of dozing before fully waking up and when you do get up, you're likely to say that overall you slept pretty decently.

Since you're not feeling well and since you report that you were trying to get back to sleep after you woke up an hour too early, it's reasonable to assume that all this potential SWJ in the last couple of hours of the night is problematic at this point in time. The problem, however, is not that the CPAP isn't working: When you are asleep, it is doing an excellent job of preventing your apneas and hypopneas from happening and it's dealing with the residual flow limitations in what looks like an appropriate way. The problem is that your brain doesn't want to be awake, but your brain also won't allow itself to get fully back to sleep.

Sometimes that can happen because the body feels sufficiently rested. As a new PAPer, it is possible that your body has gotten as much sleep in 7 hours of half-way decent sleep that has not been interrupted at all by the apneas as it used to get in 9 hours of apnea-interrupted sleep. So the body is saying to the brain: I've gotten enough sleep! even though the brain is saying No I haven't. In time the body figures out that getting 8 hours of better quality sleep (without the apneas) is far better than 9 hours of apnea interrupted sleep, and it naturally starts sleeping longer with the CPAP. And of course that pleases the brain. But until the body sorts out that it needs/wants more than 7 hours of half-way decent sleep that is not interrupted by apneas, the poor newbie PAPer is left with problem of "I'm waking up and can't get back to sleep". In this case, it can be best to humor the body and just get out of bed when you can't get back to sleep and it's within 60-90 minutes of when your alarm goes off anyway. Use that time to do some kind of quiet activity and if you start actually feeling like you are going to fall asleep, then go back to bed and fall asleep with the mask on your nose.

[robysue1]

How long (pre-CPAP) have you been feeling so tired during the day that work has been a real struggle? Or did this start after you started PAPing?

I was tired most of the time but I could deal with it and focus on work on before PAPing. It's gotten a lot worse since I've started.

Been there, done that, and have the scars to prove it.

Seriously, I'm sorry that you're struggling this way. In my case I was not particularly tired or sleepy during the daytime before my diagnosis. I had the sleep test done because my husband had witnessed my having apnea episodes and he was worried about my breathing at night. But I had a major crash & burn in terms of daytime functioning right after I started PAPing. At its worst, I was afraid to drive myself to work for fear I would fall asleep at the wheel---a feeling that I had never experienced before starting CPAP. And I looked physically exhausted to the point where coworkers were concerned about me and kept asking me if I was ill.

So my advice for dealing with your significant difficulty of adjusting to CPAP therapy is based on my looking back at both what I did and what I regret not doing much earlier in my own (eventually successful) struggle to become a happy PAPer.

Here's what I would recommend you do:

1) Report your problem of feeling even more exhausted than before starting CPAP to the sleep doc's office. They most likely will just tell you to keep trying, but it is important to document the problem you are having by reporting it to them. If they offer you an "emergency" appointment, accept it. If your PCP is the one who signed the script for the machine and you don't have a formal sleep doctor, ask the PCP for a referral to a sleep doctor and have the sleep test results sent to the sleep doctor.

2) Keep a simple sleep log to help document the extent of the problem. The log has to be simple enough where it does not add to your stress and anxiety about how you are feeling and how bad your sleep currently feels. You can either keep in on a computer (an Excel spreadsheet works) or on paper---whichever will create less stress for you. In the log you should note the following things each morning:

• Time you went to bed
• Time you got out of bed
• Estimate of how long it took you to get to sleep. No watching the clock in an effort to be more accurate! Clock watching will make things worse not better.
• Estimate of how many times you remember waking up during the night. Do NOT try to document the wakes in the middle of the night. Your goal is to teach your body how to get back to sleep quickly after waking up. Wakes that you don't remember are usually not disruptive to the overall quality of your sleep when they are not respiratory-related. And the CPAP has eliminated the arousals that were respiratory-related.
• Rate how rested you feel when you get up for the morning. Keep the scale simple: 0 = Awful like you got no sleep, 5 = Wonderful as in bright-eyed and bushy-tailed and full of energy. Long term, you want to see most of your morning ratings in the 3-5 range; don't ever expect to see mostly 5s. Short term, your goal is to eliminate 0s and 1s.
• Each evening rate how you felt during the day. Because you're dealing with depression as well as tiredness, you may need to break the daytime rating into two scores---one for the depression and one for the tiredness/sleepiness. Again, the idea is to keep it simple: 0 = Awful, 5= Wonderful. Long term, you want to seem most of your day ratings in the 3-5 range, but don't ever expect to see mostly 5s. Short term, your goal is to eliminate 0s and 1s.
• If something is clearly out of the ordinary, make a written note. Do this for both good things as well as bad ones. The first sign that CPAP was doing something positive for me was when the phrase, "Woke up with no hand/foot pain" started appearing in my sleep log multiple times each week.

3) If the doctor recommends a short term script for sleeping medication, seriously consider taking it. (Refusing to take sleeping medication for the first several months when I was dealing with a case of insomnia from hell combined with aerophagia while doing my best to sleep with the CPAP is my biggest regret. I think if I'd been willing to take sleeping medication much earlier I could have saved myself several months worth of agony.)

4) I also think that since your flow limitations seem to respond positively to the machine increasing the pressure, it's worth considering bumping up your minimum pressure setting just a bit. Because of my long battle with aerophagia, I never make that recommendation lightly. If you have not had any trouble with aerophagia, then I think a 1cm increase in min pressure is something to try. If you have been battling aerophagia, only increase the pressure by 0.2 or 0.4 cm at a time. In any case, if you do decide to increase the minimum pressure setting, use the new setting for at least 3-5 days before making any additional changes to the settings.

Any medical history of clinical depression, either in you or in close family members?

Yes, ive struggled with depression most of my life and so have many family members. This just seems to be making it worse.

Are you getting any kind of treatment for the depression? If so, is it through your PCP or do you see a psychiatrist or psychologist?

If you are getting treated for the depression, I would let the doctor treating the depression know that you are struggling with sleep problems and CPAP adjustment and that this is adversely affecting your mood. And really listen to the doctor who is treating you for the depression if they make recommendations about tweaking the treatment for your depression.

If you are not getting treated for depression, I would encourage you to mention this to your PCP. If you don't want to take medication, ask for a referral to a psychologist who works with patients with depression in non-drug ways, including cognitive behavior therapy.

Thank you so much for the info on what my body is doing. You're very informative and kind. I'm sorry if I've been annoying in any way.

You are welcome. This is my way of "paying it forward" to all the good folks here who helped me through my own very difficult transition. I got a lot of help from a huge number of people whenever I posted about my own peculiar combination of problems related to the start of my therapy. I also got a lot of just plain old emotional support when I needed to let off steam and just vent to someone who had actuall knowledge of what using a CPAP feels like.

And you're not annoying in any way. So there's no need to apologize.

[robysue1]

As far as what caused this set of flow limitations? It could be related to a REM cycle. Or it could be related to your sleeping position. Did your sleep study say anything about whether your OSA is significantly worse in REM or when you're sleeping on your back?

I did an at home sleep study so I'm not sure how I would find that. I do try to stay off of my back though.

Ask your doctor for a copy of the report, complete with the summary graphs. Even home sleep studies have a lot of data with some kind of summary graphs. The summary graphs should include a sleep stage graph and an event graph that are both correlated to the time. The summary numbers on the sleep study should have your diagnostic AHI broken down into both a REM AHI and a non-REM AHI as well as a supine AHI and non-supine AHI.

There's a lot of information packed into the sleep study report, even when it's just a couple of pages long. (Some of them are longer than others; it all depends on how the report is set up.)

Once you have a copy of the sleep report in your hands, take the time to read it. If there is stuff that you don't understand, it's worth scanning the report, blackening out all personal identifying information, and posting a copy to the forum with your questions about the sleep study report. Folks here will be able to help you understand what it says about your diagnosis.

Also if you don't have one, it's worth getting a copy of the actual script that was sent to the DME that set you up with your CPAP equipment.