Diagnostic opinions PLEASE! OSA under control, but...

I’m a long-time CPAP user, and the OSA is under control, yet I’m still wiped out. I’m not taking any medications that would cause me to feel tired. I have very fractured light sleep, and I wake up in the early morning hours with anxiety & sometimes with the physiological symptoms of a “fight or flight” reaction. Per lab results, PLMS is minor & without arousals, so it seems that RERA’s (UARS?) are the only things left for me to consider. Supporting logic is as follows:

I have both a PB Goodnight 420E and a Resmed S8 Auto. I run them both at very narrow settings – tightly centered around my lab titrated pressure (which is 11.0). The following results are based on many months of use, so the data is valid (no short-term “data noise”):

On the Resmed S8 I’ve tried 10.6-13.0 with no EPR, and also 11.6-13.0 with an EPR of 1.0. With EITHER setting, I get a "95th percentile effective pressure” of 11.6, with a maximum pressure ever seen of 12.0, and only briefly. My AHI is averages in the 3.0-4.5 range.

The 420E reports a HUGE number of “runs” (flow limitations). They number 10-25 (or more) per hour, and the pie chart shows that 12%-28% of the time I’m in a “Flow Limited” cycle state. Also, the pressure will oftentimes “run away” and max out at the upper limit (12.5) for long periods of time. Per recommendations on older threads here, I’ve tried turning off the IFL1 response setting, but I get the same result. (Note: I limit the upper setting on the 420E at 12.5 instead of 13 to reduce aerophagia problems.) I’ve also tried running the 420E in straight CPAP mode, but I get the same report of numerous flow limited cycles all night long. However, my overall AHI is even lower on the 420E than the S8. (Apparently a “flow limited” state or “run” is not scored as a hypopnea.)

ANY ideas, speculation, or hypothesis to either support or disprove my thoughts are welcomed and sincerely appreciated!

Thanks in advance!

Well, with all the flow limitations (runs?) on the PB Goodnight 420E, thinking the continuing daytime sleepiness and tiredness problems along with the fractured sleep could be caused by UARS is a reasonable hypothesis. Maybe not the only one though, but certainly reasonable.

I'd report the continuing OSA-like problems to the sleep doctor's office and also let them know what that data from the PB Goodnight 420E is showing.

But I'd also think about getting some blood work done at my PCP to rule out numerous other standard causes of fatigue (thyroid, low vitamin D, low iron come to mind immediately).

And while you say you're not on any meds that could cause daytime sleepiness and general fatigue, are you on any that are known to potentially cause insomnia? Because the fractured sleep could be a case of insomnia caused by something OTHER than OSA. So a reasonable question to ask is: How's your sleep hygiene in general?

Robysue,

Thank you for your helpful suggestions. You are absolutely correct about the blood tests to rule out if anything else could be a physiological cause. I actually have already been tested for vitamin D, ferritin (iron), and thyroid (along with all other standard tests). I am on thyroid medication (the only med I'm on) but all aspects of that are under control (TSH, T3, T4, fT3, fT4). So I'm back to looking at nothing other than SDB as a primary causal factor.

I am actually seeing my sleep doc today but unfortunately, as well regarded as he is in the sleep medicine community, he is more of a 'Resmed guy' and the last time I brought him data from the Puritan Bennett 420E, he not only wasn't very familiar with it, but seemed almost dismissive of it. It will be interesting to see how he responds today to getting data from both the S8 and the PB machine. I'm also going to ask him directly if he feels that a BiPap could be an effective treatment to eliminate the "spontaneous arousals" that have been a long-standing feature on my PSG's. (not to mention it could help reduce aerophagia issues at the higher pressures that may be needed to eliminate all SDB events.)

Thanks Again!