Should the goal be a low AHI, or to feel good?

[frh]

I just saw the sleep doc to get the results of my new sleep study. I was supposed to see him on Monday, but his office changed the appointment. (I am scheduled for orthroscopic nissen fundoplication surgery tomorrow, so I won't really be able deal with this until I start to recover.)

I readily admit I am not in any way qualified to interpet any of this. But on the second page of the report under Polysomnographic Data, the second paragraph jumped out at me.

Paragraph 1. "The patient was started on CPAP at a setting of 4 cm of water which was increased to 5 cm of water with minimum oxygen saturation of 88% and mean oxygen saturation of 94%. 56 minutes of REM sleep was seen and the patient also slept in supine position at this setting." I'm not sure why he talked about supine position. I spent 51 minutes in a supine position, 3 hours and 3 seconds on my left side and 1 hour 44 minutes and 27 seconds on my right side. I had 2 centrals and 3 hypopneas on my right side, 3 centrals and 1 hypopnea on my left side and none in the supine position. (It appears that I did not have any obstructive events.)

Paragraph 2. "Sleep architecture showed a sleep efficiency of 85.3% with total sleep time of 5 hours and 36 minutes. 16.8% of the total sleep time was spent in REM sleep, but no slow wave sleep was seen and most of the time was spent in light stages of sleep." I did not expect to see the words "light stages of sleep." I took a 10 mg Ambien just before the RT wired me up.

Paragraph 3. "The patient did not have any significant number of limb movements as the limb movement index was 3 during the night."

OK, they started me at 4 cm for 1 hour and 49 minutes. My AHI was 3.1. Then they raised the pressure to 5 cm for 4 hours and 45 minutes and my AHI was 1.2. Then they woke me up and sent me home. It is no surprise to me that my pressure went from 6 to 5 three weeks after turbinate reduction surgery. (And I can breathe through my nose for the first time in my life.)

My oxygen levels were what also what I expected. For the last month (after turbinate reduction surgery) my average AHI has been around 2.5. And 1.0 is not unusual. What is not right is that I still feel like crap without supplemental O2.

I almost fell asleep at the wheel several times while driving home from the sleep study. As soon as I got home I hooked-up the CPAP machine and turned on the O2. I slept for 2-1/2 hours and had an AHI around 12.5.

I tried to get the doc to talk about the disconnect between AHI and how I feel, and he just wouldn't go there. He told me something else is wrong and to talk to my GP about it. My GP is supportive, but he really doesn't know much about sleep apnea. I really thought this sleep doc was going to help me get it all figured-out, but I guess I am on my own.

Edit: My sense is that not having a decent airway through my nose had a lot to do with having obstructive apneas before the trubinate reduction surgery. Now that I can easily breathe through my nose, my problem seems more related to hypopneas and centrals. My gut feeling is the problem with my sleep has become now more neurological than physical. Especially since I seem to e a light sleeper, even when I take ambien. The sleep doc is a neurologist, so I am totally confused about where to go from here.


Suggestions? Comments?

[LoQ]

I had 2 centrals and 3 hypopneas on my right side, 3 centrals and 1 hypopnea on my left side and none in the supine position. (It appears that I did not have any obstructive events.)

I wonder if you could clarify what you mean by this. You say you did not have any obstructive events. I assume, then, that "2 centrals" means 2 central apneas, "3 hypopneas" means 3 central hypopneas, "3 centrals" means 3 central apneas, and "1 hypopnea" means 1 central hypopnea.


If not, what did that all mean?

[frh]

LoQ, I don't have enough time tonight to scan and clean-up the charts, then send them to my album so I can post them. So my attempt to clarify what I was trying to say will have to do.

On page 3 (but is really page 5 of 10) there are two charts. The first is chart is labeled Apneas and shows 5 under the Central column. That column also indicates the Mean Duration was 13.9 seconds and the Longest Event was 15.8 seconds. The other chart is labeled Hypopneas and shows 4 in the Obstructive column. That chart indicates the Mean Duration was 14.9 seconds and the Longest Event was 16.6 seconds.

There is a lot of other stuff in the report that I wish I had enough time to post.

With an AHI of 1.2, I should have felt great. Instead, I had one of the worst days I have had since starting CPAP. I need help figuring out why I need supplemental O2 at night to feel decent in the day when nothing in the sleep study or my ResScan reports seem to support it. I don't even know where to start looking for the clues. I thought a neurologist was the right kind of doctor, but this guy is just not going to help me figure it out.

[LoQ]

OK. So there were obstructive events, they just happened to be hypopneas.

[Desperate_in_DM]

I haven't gotten my sleep study report yet. But when they called me the day after my study I was told my AHI was 27. First night on the CPAP my AHI was 14.8. Within a week my AHI was 0.3. It's been 0.5 or under for 3 weeks now. I do not feel better and in fact I feel worse than before I ever used the CPAP. I went in for a download and consultation with a RT a week ago. She told me that I should be feeling "normal" based on my download. She implied that my sleep apnea may not be why I've felt horrible for almost 3 years and perhaps something else is to blame. She said the doctor would discuss my sleep study with me on 9/15 and could also discuss whether CPAP therapy is what I need or not.

So for me low AHI has meant absolutely nothing. I felt better (not much, but at least functional) when my AHI was 27 without the CPAP than I do now after a month of treatment.

[LoQ]

frh, what was the outcome with the oxygen? Did you discuss it with the doctor? Would your GP be willing to prescribe O2 for you?

Is there a reason why you need a doctor to continue to do O2? I think if you feel good with your way of doing it, I personally would not worry about the AHI being at an "acceptable" level.

I went in for a download and consultation with a RT a week ago. She told me that I should be feeling "normal" based on my download. She implied that my sleep apnea may not be why I've felt horrible for almost 3 years and perhaps something else is to blame. She said the doctor would discuss my sleep study with me on 9/15 and could also discuss whether CPAP therapy is what I need or not.

This is the RT at the DME? I don't think the RT at the DME is going to know whether or not you should be feeling better at this point. For some people, it takes years of therapy and tweaking to get to a point where you actually feel better.


Sleep is a complicated field of study that is in its infancy. You'll have to bear with the medical community as it slouches towards adolescence.

[Goofproof]

YES, Both! Jim

[Desperate_in_DM]

This is the RT at the DME? I don't think the RT at the DME is going to know whether or not you should be feeling better at this point.

No, this was a respiratory technician at my sleep clinic who told me that.

She seemed like an idiot though. I had only been using the machine for 3 weeks and was explaining to her how to read the "reports" off the machine, which in my understanding is a very common machine. She then used the SD card and did a download and from that information said I should be feeling "normal".

[frh]

frh, what was the outcome with the oxygen? Did you discuss it with the doctor? Would your GP be willing to prescribe O2 for you?

I tried to get him to discuss why I feel so much better with O2. He just didn't want to go there.

When I got home I called the GP and made an appointment for September 7th. I don't know if he will write a prescription for me, or send me to another specialist for more testing.

Is there a reason why you need a doctor to continue to do O2? I think if you feel good with your way of doing it, I personally would not worry about the AHI being at an "acceptable" level.

Today is a good example of why I want a doctor involved. I had to square things away with the admissions people at the hospital. They wanted to know about my medications. I totally lucked out that my turbinate reduction surgery was done at a sister hospital in their system and my need for O2 at the last surgery was documented. So I will have it for this hospital stay.

There are other reasons why I want a good doc involved. Something has to be wrong if it takes O2 to make me feel good in spite of a low AHI. I have good days and bad days. They don't always match my AHI level. And I don't consistently have days when I can stay alert and focused into the evening. The economy has pretty much knocked my business down the tubes and Social Security won't start until next year. Right now I am feeling too brain dead to make it through an employment interview.

I suspect that ambien might be depressing my breathing at night. It doesn't get me to sleep or keep me asleep like it did when I first started taking it. And I think it might be interfering with my ability to stay alert and focused during the day. I really want to stop taking it, but every time I stop for a couple of days I don't really sleep, my AHI jumps into the 12 to 14 range, and I feel crappy and dysfunctional during the day. I tried to get the sleep doctor to talk to me about that, and he just said to keep taking ambien.

I asked him if my sleep study data indicates shallow breathing, and did not get an answer. I tried to ask him if there were other sleep medications that would not affect my breathing. All he would tell me is I need to see my GP if I want to change my medications and a pulmonologist if I am having lung problems. I feel like after all these months I am back at square one.

By the way, in the last 6 months I had a lung function test, two nuclear stress tests, and I wore a heart monitor for 3 weeks. My lungs and heart are great, but my heart rate gets a bit slow at night. (But not slow enough to concern to the cardiologist.) My blood pressure is under control and I was tested for diabetes. My wife thinks I have chronic fatigue syndrome or some weird autoimmune disease. Perhaps it's just my obsessive compulsive nature, but I just need to get it all figured-out.

[ozij]

My oxygen levels were what also what I expected. For the last month (after turbinate reduction surgery) my average AHI has been around 2.5. And 1.0 is not unusual. What is not right is that I still feel like crap without supplemental O2.

That is what your neurologist wants explained by anothe specialist.

[ldj325]

Once again I must post stressing that i am not any expert in sleep medicine--just a thinking user trying to figure all this out. But it seems that the key issue is not AHI levels, per se, but oxygenation levels that are important. The only importance of AHI is that it tends to be some indication of oxygenation levels.

As a real life example, I have found that, in examining my detailed flow charts that I have a lot of 6-8 second apnea "episodes" that go un-flagged on my ResScan 3.11 software because they don't meet the reporting criteria of 10 seconds or longer to qualify as full apnea. Maybe this is Ok and maybe it is not. The real issue is how much oxygen my body is receiving, not some artificial (from an organic point of view) measure such as AHI. And as far as "organic criteria" goes how we feel (over time) is a better bottom line measure than some statistically generated number.

[frh]

ozij, I went to the other doctors first and had the standard heart and lung tests done. If I have to go back to those doctors, I need a more focused approach. I feel like I am just going to get blown-off by them if I don't know what specific questions to ask.

"The patient was started on CPAP at a setting of 4 cm of water which was increased to 5 cm of water with minimum oxygen saturation of 88% and mean oxygen saturation of 94%. 56 minutes of REM sleep was seen and the patient also slept in supine position at this setting."

ld, it appears my oxygen saturation is OK according to the numbers, but that does not match how I feel. It was almost accidental that I found out O2 makes me feel better. That disconnect is telling me something is wrong that I need to figure out.

[ozij]

ozij, I went to the other doctors first and had the standard heart and lung tests done. If I have to go back to those doctors, I need a more focused approach. I feel like I am just going to get blown-off by them if I don't know what specific questions to ask.

I see what you mean.

You said you're going for Nissen fondoplication. I take that to mean you may have GERD.

Acid bathing your upper airway may cause congestion, flow limited breathing, disordered sleep and lower oxygenation.

Does that make sense to you?

O.

[LoQ]

There are other reasons why I want a good doc involved.

I totally agree it's much better to have a doctor on board. My comment was more of a "last ditch" solution. Having a supportive doctor is probably worth doctor shopping.

Perhaps it's just my obsessive compulsive nature

I could not disagree with this more. You don't seem at all like a hypochondriac. I think you have a genuine problem. The solution appears to be supplemental oxygen. If there were another solution that didn't involve oxygen I suspect you'd take it.


On the ambien, I don't know anything about it, but in reading your posts I conclude that there is a good chance your perceptions about it are on target. I cannot remember, have you tried melatonin instead of ambien? With melatonin, sometimes less is more, so start with a very small dose, maybe 0.5 mg.

[LoQ]

But it seems that the key issue is not AHI levels, per se, but oxygenation levels that are important. The only importance of AHI is that it tends to be some indication of oxygenation levels.

The real issue is how much oxygen my body is receiving

Au contraire, mon ami. There can be lots of sleep disruptions that prevent you from having restorative REM sleep but which do not affect your oxygen levels. That can leave you feeling exhausted every day. I suspect that possibly some people's bodies sense a reduction in oxygen before the SpO2 is lowered, and that causes a responsive stir to eliminate the reduction. THAT kind of arousal keeps oxygen levels good but causes sleep disruption, preventing restorative sleep.

This may be frh's problem. His system may be very sensitive to small changes in oxygen level that are small enough to not register as a "dangerous" reduction in oxygen (according to medical texts) but that cause an arousal preventing good sleep. Adding oxygen to the system may be working for him because it reduces his "sensitivity" by raising the bar for arousal. I hope that makes sense.

And what about PLM? People who have that can be VERY fatigued because their sleep was not restorative, yet it has nothing to do with their oxygen levels.