new to all this and have a question

[kit15]

I wanted to start by saying a huge thank you to those of you on this board. Your wisdom and experience has been a real glimmer of hope for me since I started on this journey. I have already learned alot.

So, my story. I initially saw my primary care doc because my husband said that I started snoring (not all the time, but periodically and very loudly), and I had been having lots of frequent irregular heartbeats. Nothing else (weight, stress level, etc) had changed around that time. My doc ran lots of blood work, expecting to find an electrolyte imbalance. She suspected that the snoring was allergy related. But all the blood work came back normal, so she sent me for a sleep study and also had me do a 48 hour Holter monitor EKG. The monitor showed lots of PVCs, mostly at night, but within the daily "normal" range. The sleep study results were an AHI of 5.1 overall - with an AHI of 150 during REM sleep, and AHI of 3.4 in NREM sleep (all hypopneas) . My 02 average was 94% with drops to 83%. The catch was that I only had 4 minutes of REM sleep the night of the study (the last 4 minutes of the study), and overall slept very little that night. Although it was scheduled as a split-night study, given the timing of the REM sleep, they didn't have me wear a mask in the lab.

So the sleep lab doc who read the study diagnosed mild OSA (based on the 5.1 overall AHI) and explained the 4 minutes of REM as an anomaly. However, at my consultation appointment, I saw a different sleep doc who said that she believed that I had severe apnea that we just didn't see expressed in the study because I didn't sleep as I normally do. She was also concerned about the oxygen levels. She suggested either a second split-night lab study or a 3-week APAP trial with settings at 4-20 and then an oximetry trial after I was adjusted to sleeping with the PAP. She recommended the second option, and that's what I chose.

I've been using a machine for about 2 weeks. I had a rough first week getting used to everything, but I have been getting AHIs of between .4 and 2.1 in spite of that. I was sleeping much worse than usual, and when I looked Sleepyhead, it seemed (to my novice eyes) that the reason might be that I was being disturbed by the constant changes in pressure (pressures everywhere from 5 to 18). So I set the pressure to a constant 8, and the past two nights I feel like I have slept much better. I have started also started using lanolin and changed nasal pillow sizes, and things feel fairly good now.

A slight complication to the plan is that due to scheduling issues, my 3 week test will be more like 8 weeks. So I still have almost 6 weeks to go until my appointment. I plan to continue on therapy, but I wonder if I should keep messing with the settings. Daytime sleepiness was never a problem for me, and I feel about the same in the mornings now as I did before treatment.

So I'm wondering what you would do in this situation. I appreciate all the knowledge that you all have, and I'd like to hear what you think is going on. Do you think that I have severe REM-related apnea that is being more-or-less adequately treated with PAP, or do you think that I don't have clinically significant apnea (ie the NREM AHI of 3.4 is the accurate number) and that the REM patterns in the 4 minutes of sleep study were just bad data?

Thanks in advance for your help!

Here's a typical night with variable pressure, and one with the pressure set at 8:

[Pugsy]

We have no way to know for sure what your REM stage sleep might show in terms of OSA events but it is very common for OSA to be worse in REM stage sleep. Mine is. During my initial sleep study my non REM sleep was only 12 AHI but my REM sleep was 53 AHI....so nearly 5 times worse in REM sleep. Sleeping on my back (another instance where it's common for OSA to be worse or higher pressures needed) was never really that big of a difference but REM stage sleep was a significant factor.

If someone can't get to REM and stay in REM long enough to accurately evaluate the AHI during REM then it makes it tough. It wouldn't be an impossible scenario though and your report when using apap mode seems to lean a little towards some clustering of events that point to the airway collapsing a little happening in REM stage sleep.
REM stage sleep cycles and normally the first REM stage occurs around 90 minutes after sleep onset and as the night goes on REM cycles more frequently and lasts longer.
You can see the hypnogram here....just scroll down a bit and on the right side.
viewtopic/t103468/Need-help-with-screen-shots.html

Your fixed pressure report looks real good. I am not sure just how significant those snores are but if you are feeling good and sleeping well I don't know that I would worry about them....probably a small increase would prevent the bulk of them...like 0.5 cm.

If you want to continue with fixed pressure I do suggest that you go back to apap mode but just set the minimum to equal the maximum and the pressure won't auto adjust.
The reason is that with cpap mode your machine won't/can't flag flow limitations so we don't know if there were any flow limitations or not. Flow limitation flagging is only available in auto adjusting pressure mode but you can set the minimum to equal the maximum and the machine will function like cpap mode but FL flags will be available.

[kit15]

Thank you! This very helpful. I will try setting the min and max equal like you suggested and maybe also increase pressure by .5 to see if that helps with snores. If feel like I have so much to learn about all this!
Thanks!!

[bwexler]

Your original settings of 4-20, or wide open is probably one of the reasons many people fail CPAP.
If I were in your situation, I would set a range maybe 7-10 so the machine could actually do its job and auto titrate you.
In a few nights you would recognize the pressure trend and could tighten it up a bit. You could manually adjust your pressure a little at a time in CPAP mode, but that takes more time and effort than letting the machine do its job.
I would probably turn off the ramp feature as well.
Keep an eye on Sleepyhead so you can make any small adjustments you think might help.

[kit15]

Thanks for your help!
I have had it set on APAP 8-13 for the last two nights, and that seems to be going well, although I still seem to have what looks like a lot of snoring activity. It's hard to know if it's better or not, since I don't feel any different during the day, and overall I feel like I don't sleep as well on therapy as I did before I started it. But I guess if it's true that I have high REM numbers, then it's doing its job.

[library lady]

If it helps any, my snoring has not improved much in the 14 months I have been on cpap. I did increase the pressure a bit, but snoring improved very little. When I last saw the sleep doc, he wasn't concerned about the snoring because my AHI is consistently <5, usually <3, and my graphs look good otherwise. Over the last two months my average AHI is 2.

I think the important thing is whether the therapy is giving you better sleep, and keeping your AHI >5. That is the purpose of cpap, and it was not designed as an anti-snoring device. Snoring is not synonymous with apnea. Many snorers do not have OSA, and many people with OSA do not/have never snored. Some people may find that snoring decreases with cpap use, some may not.