Fractured sleep

I've now been on cpap for 6 weeks, and have a consistently low AHI (1.2 was my highest, but it's usually below 0.5). An objectively measurable difference is that I no longer produce large amounts of urine during the night, and no longer wake up (with back teeth floating) to go to the bathroom multiple times per night. BUT -- I still wake up multiple times each night, and sometimes have trouble getting back to sleep. I've been doing this thing (suggested by somebody here) that each time I wake up, if I am sufficiently awake to do it, I reach over and hit the "Stop" button on my A10. I have AutoStart turned on, so if I just hit the button, it will start back up after a couple of breaths. Here is my list of session times from last Thursday night:

11/20/14 21:28:57 21:51:59 00h 23m 02s
11/20/14 21:55:17 23:37:18 01h 42m 01s
11/20/14 23:37:54 23:53:55 00h 16m 01s
11/20/14 23:54:59 00:15:00 00h 20m 01s
11/21/14 00:15:20 00:35:21 00h 20m 01s
11/21/14 00:36:33 00:58:34 00h 22m 01s
11/21/14 00:59:36 01:06:37 00h 07m 01s
11/21/14 01:07:26 01:21:27 00h 14m 01s
11/21/14 01:22:24 02:25:26 01h 03m 02s
11/21/14 02:26:36 02:48:36 00h 22m 00s
11/21/14 02:50:04 03:41:05 00h 51m 01s
11/21/14 03:42:00 03:58:01 00h 16m 01s
11/21/14 04:00:40 04:55:41 00h 55m 01s
11/21/14 04:56:06 05:15:07 00h 19m 01s
11/21/14 05:15:28 05:45:28 00h 30m 00s

And here is the Sleepyhead graphs:


Reading in this article http://www.journalsleep.org/Articles/250302.pdf about sleep fragmentation, they talk about arousals every one minute or ten minutes, though -- and that's a couple of orders of magnitude worse than what I'm seeing.

So what's the story? Is this level of arousals a problem? I still feel pretty crappy, am still pretty sleepy throughout the day -- but what's the chance that twiddling with my apap settings is going to help this? I also have thyroid problems and psoriasis and probably psoriatic arthritis, and I'm pretty sure a cpap machine isn't going to fix any of those things!

I forget, what happens when you have tried straight pressure?

cathyf wrote:I've now been on cpap for 6 weeks, and have a consistently low AHI (1.2 was my highest, but it's usually below 0.5). An objectively measurable difference is that I no longer produce large amounts of urine during the night, and no longer wake up (with back teeth floating) to go to the bathroom multiple times per night. BUT -- I still wake up multiple times each night, and sometimes have trouble getting back to sleep. I've been doing this thing (suggested by somebody here) that each time I wake up, if I am sufficiently awake to do it, I reach over and hit the "Stop" button on my A10. I have AutoStart turned on, so if I just hit the button, it will start back up after a couple of breaths. Here is my list of session times from last Thursday night:

11/20/14 21:28:57 21:51:59 00h 23m 02s
11/20/14 21:55:17 23:37:18 01h 42m 01s
11/20/14 23:37:54 23:53:55 00h 16m 01s
11/20/14 23:54:59 00:15:00 00h 20m 01s
11/21/14 00:15:20 00:35:21 00h 20m 01s
11/21/14 00:36:33 00:58:34 00h 22m 01s
11/21/14 00:59:36 01:06:37 00h 07m 01s
11/21/14 01:07:26 01:21:27 00h 14m 01s
11/21/14 01:22:24 02:25:26 01h 03m 02s
11/21/14 02:26:36 02:48:36 00h 22m 00s
11/21/14 02:50:04 03:41:05 00h 51m 01s
11/21/14 03:42:00 03:58:01 00h 16m 01s
11/21/14 04:00:40 04:55:41 00h 55m 01s
11/21/14 04:56:06 05:15:07 00h 19m 01s
11/21/14 05:15:28 05:45:28 00h 30m 00s

And here is the Sleepyhead graphs:


Reading in this article http://www.journalsleep.org/Articles/250302.pdf about sleep fragmentation, they talk about arousals every one minute or ten minutes, though -- and that's a couple of orders of magnitude worse than what I'm seeing.

So what's the story? Is this level of arousals a problem? I still feel pretty crappy, am still pretty sleepy throughout the day -- but what's the chance that twiddling with my apap settings is going to help this? I also have thyroid problems and psoriasis and probably psoriatic arthritis, and I'm pretty sure a cpap machine isn't going to fix any of those things!

Perhaps worthy of consideration:
http://www.webmd.com/sleep-disorders/fe ... p-wreckers

Here's a question that came to my mind. If you awaken that many times would the AHI be accurate?
I rethought this and I guess it would be accurate for the amount of time but surely not a good indicator of quality sleep.

Great article, Jay! Yes, I know that I spend a lot of time awake listening to my husband snore and creating mental Sleepyhead graphs of his breathing.

49er -- I haven't tried straight pressure yet -- I need to get a mask that fits better I think. (I have a small, I think I need an x-small. Problem is that my DME is an x-small outfit and it takes them some lead time for the unusual stuff. )

I'm not really sure what to try for a straight pressure. Normally in the first sleep session I climb all the way to a pressure in the 15-18 range, but then wander back and forth between 12 and 14 for the rest of the night. I'm tempted to just try 16 or 17 -- the high pressures don't seem to bother me at all. One night I woke up and did the "is the machine really on?!?" moment. After holding my hand up in front of the mask and feeling the reassuring flow of air, I reached over and checked the readout on the machine. It was 15.4!

Do some reading about "sleep maintenance insomnia"

FWIW...if I were in your shoes and contemplating fixed pressures...I would start small and work upwards instead of wanting to use something near my max or even the 95% number to start with.
Instead I would start with something in the neighborhood of the median pressure..in your case maybe around 13 ish.

Pugsy wrote:FWIW...if I were in your shoes and contemplating fixed pressures...I would start small and work upwards instead of wanting to use something near my max or even the 95% number to start with.
Instead I would start with something in the neighborhood of the median pressure..in your case maybe around 13 ish.

I think that sounds reasonable, too. I've been worrying that if I lower the max pressure I'm going to stop the machine from preventing events during that first sleep period where the pressure often goes high. But with an AHI that usually runs between zero and 0.5, maybe I can afford to let a few more events through in exchange for better sleep?

cathyf, your FL and Snore charts look quite horrible, as if the machine does not do its job. Have you had a titration sleep study? And yes, low thyroid function is known to affect one's sleep. Do you control it with levothyroxine or anything like that?

UPDATE: I don't think that the low AHI is of any value in your case. Sadly, it is even bad for you: most likely, doctors and insurance look at it and shrugged off your complaints

Cathy:

it may have been me with the on-off suggestion as it is something I have done in the past to get a handle on this same problem.
Here is a recent night's heart rate data for me. The spikes are about 20 - 30 seconds in length and many of them wake me up.


Have you had any lab tests to see if the source of the awakenings can be identified? Endocrine issues can cause these.
I'm currently waiting of some lab tests that may help identify a possible source.

tan wrote:cathyf, your FL and Snore charts look quite horrible, as if the machine does not do its job. Have you had a titration sleep study? And yes, low thyroid function is known to affect one's sleep. Do you control it with levothyroxine or anything like that?

UPDATE: I don't think that the low AHI is of any value in your case. Sadly, it is even bad for you: most likely, doctors and insurance look at it and shrugged off your complaints

You know, tan, my husband (the one who thinks that the whole cpap thing is a crock) insists that I don't snore! I do take synthroid, and my thyroid numbers aren't bad, but I also have a pretty significant goiter and I think that my thyroid is pressing on my windpipe. Sometimes when I lie on my left side, which puts the right lobe of my thyroid -- my bigger one -- on top, I get a little squeaky wheeze at the very end of my exhale. It's only a second long at most, and I don't think the machine detects it. I sing in a church choir and 2 community choruses, and lately I've been feeling like I can't get my throat cleared even though I do good warmups. Last night I was getting occasional squeaks and having trouble keeping pitch into the second song we practiced.

Coming into this whole thing I was quite shocked to find that I was having apneas and hypopneas. I thought I had narcolepsy. My sleep study showed normal levels of rem sleep, so I don't have narcolepsy, but I still think I've got more going on in sleep than just breathing problems. I've never had a titration -- I had a sleep study which showed an AHI of 15 (45 during rem sleep), so they prescribed an APAP and let the machine sort it out.

cathyf wrote: I've been worrying that if I lower the max pressure I'm going to stop the machine from preventing events during that first sleep period where the pressure often goes high.

You will know real quick if those higher pressures are actually preventing full grown apneas or hyponeas that need more pressure or they grow up.
It's very possible that those higher pressures are simply a response to snores or flow limitations that might not even grow up to be full fledged flagged apneas or hyponeas. Might be something that isn't that big of a deal to just let happen if the end result is better quality and less fractured sleep.
Sometimes we have to make compromises.

I have no idea if the pressure changing is contributing to your fractured sleep or not. It certainly is something that needs to be ruled out though and it would be relatively simple to rule out.
Rule it out or prove it and then you can move on to looking at other potential culprits for the fractured sleep that aren't so easy to rule out or prove.

At this point after 6 weeks...quit dragging your feet and either choose a fixed pressure or really tighten that range up to a tiny range and at least prove or disprove the question "is pressure changing affecting my sleep quality". It's a relatively easy question to answer with maybe just a week at fixed or really tight range apap pressure.
In terms of your ugly flow limitation chart...if you were sleeping soundly and feeling decently I wouldn't worry about how ugly the FL chart happens to be.
If the experiment doesn't bear fruit and help the sleep or how you feel..then I have a couple of other "out on a skinny limb" pressure tweaking ideas you might try if you are up to it.
But ruling out the pressure changes being a contributing factor needs to be done first before we go out on that skinny limb. It's too easy to pass up trying and it is far from an impossible scenario that you might be sensitive to those changing pressures.

Finally..there's always the possibility that your wake ups aren't related to sleep disordered breathing at all and no amount of tweaking will help but we might as well keep turning over rocks to look for answers until there are no more rocks to turn over.

cathyf wrote:I've never had a titration -- I had a sleep study which showed an AHI of 15 (45 during rem sleep), so they prescribed an APAP and let the machine sort it out.

Well, this explains a lot. You need another study with your APAP to determine your proper pressure settings or whether you have other sleep disturbing factors, which may or may not be fixable with machines. What I find weird is that your FLs gets worse as pressure rises turbulence?

cathyf wrote:You know, tan, my husband (the one who thinks that the whole cpap thing is a crock) insists that I don't snore!

what's he basing that on? not hearing you over HIS snoring? *lol*

palerider wrote:

cathyf wrote:You know, tan, my husband (the one who thinks that the whole cpap thing is a crock) insists that I don't snore!

what's he basing that on? not hearing you over HIS snoring? *lol*

BING!!!! WE HAVE A WEINER!!!

Sleep apnea is easy... Husbands who refuse to go to the doctor are a lot harder! I have considered whacking him over the head with a frying pan, and then taking him to the ER to treat the concussion, but I'm worried I'll just be back here wondering about using my APAP in jail!

cathyf wrote: ... I do take synthroid, and my thyroid numbers aren't bad, but I also have a pretty significant goiter and I think that my thyroid is pressing on my windpipe. Sometimes when I lie on my left side, which puts the right lobe of my thyroid -- my bigger one -- on top, I get a little squeaky wheeze at the very end of my exhale. It's only a second long at most, and I don't think the machine detects it. ...

I had an enlarged thyroid and my son was always remarking about my wheeziing and sounding as if I was out if breath. The first thing I noticed after it was removed was "I can breathe!!"
My thyroid was compressing my trachea and restructing my breathing. You might ask your doctor if that was possible in your case. Since you are on Synthroid, your thyroid is likely not function very well anyway.