Low AHI and still tired

EliteSword · Post by **EliteSword** » Mon Sep 14, 2020 10:36 pm

Background: I've had issues with sleep quality since around the time I entered high school. I woke up most days up feeling like a zombie. So I did an at home sleep study and was diagnosed with mild sleep apnea. These were the results:
AHI: 10.3
Minimum O2 saturation: 92%
RERAs/hr: 16.1

Physical stats:
Height: 6'2"
Weight: 170 lbs
Age: 24

I also exercise regularly (weightlifting and cardio) and eat healthy.

Current situation: I picked up a CPAP machine 3 months ago and have been using it every night. I immediately noticed a significant improvement with a minimum pressure of 4, but I was averaging 5 - 6 hours of sleep. It was clear I wasn't getting enough REM sleep. So I played around with the pressure setting, increasing it by 0.4 every 1 - 2 weeks depending on how I felt. At a setting of 8 I was getting enough REM sleep but I felt terrible upon waking up. I dialed the pressure back a bit and now my current settings are:
Pressure: 6
Humidity: 5

I've attached a screenshot of my CPAP data from OSCAR from last night. I have a low AHI but I still feel terrible. Most of the apnea events happen during the later half of my sleep. I'm guessing my apnea worsens during REM sleep. Historically I've observed that I feel better on nights where I only get 5 - 6 hours of sleep. So where do I go from here? I can think of two parameters to play around with: pressure and sleeping position. I prefer to sleep on my back because sleeping on my side makes me feel worse and kills my shoulders.

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 10:39 pm

Do you wake up during the night very often?

Do you take any medications of any kind? If so, what?

mper!? · Post by **mper!?** » Tue Sep 15, 2020 8:37 am

Hi, Elite

_ my first impresion: your FR and CA's suggest to me you would arousal/awake a lot. It would have to find out why (respiratory-driven or other causes).
good luck

mper!? · Post by **mper!?** » Tue Sep 15, 2020 8:41 am

--- it may happens you would still have problems with some flow limitatio (either flagged or not);
---- could you post some 10min-windows of FR, TV, and Inspiration time ;

good luck

Miss Emerita · Post by **Miss Emerita** » Tue Sep 15, 2020 10:09 am

Welcome, and congratulations on starting treatment for your apnea.

Are clear airway/central apnea events the main component of your AHI most nights? And do you know the breakdown of your AHI when you had your sleep study (obstructive, central, hypopnea)?

I see that in your sleep study you had 16 RERAs per hour -- that plus your AHI of 10 means a lot of disruption of sleep. Was there any notation about restless legs or periodic limb movements?

When you post your next chart, could you rearrange things a little, by stacking the following graphs in this order:

Events
Flow rate
Pressure (the pressure graph rather than the mask pressure graph)
Leaks
Snores
Flow limitations.

To get all of those into one screen shot, you can grab the gray bars that separate the graphs and move them upward to squeeze them a little.

I'm guessing you're short on REM, but I'm not seeing evidence that your CAs are occurring during REM sleep. We normally have sleep cycles of around 60 to 90 minutes that take us from Stage 1 (shallow transitional stage) to Stage 2 (cruising along) to Stage 3 (deep) to REM. I'm not seeing that kind of timing for your CAs. Then again, your sleep "architecture" is probably pretty messed up, so it'd be hard to say when you might be getting in a bit of REM or deep sleep.

Physician · Post by **Physician** » Tue Sep 15, 2020 12:30 pm

Try getting EIGHT hours of sleep every night. Bet your fatigue will disappear in a few days.

Pugsy · Post by **Pugsy** » Tue Sep 15, 2020 12:39 pm

Physician wrote: ↑
Tue Sep 15, 2020 12:30 pm
Try getting EIGHT hours of sleep every night. Bet your fatigue will disappear in a few days.

Well....if the 8 hours is highly fragmented for some reason or other....we feel like crap. Been there myself.
Also if there are medication side effects complicating things....that won't change with 8 hours of sleep either.

Sometimes we do just need more sleep but we also need good quality sleep and make sure medication side effects aren't a potential culprit in unwanted symptoms.

Finally...sometimes we just can't get 8 hours of sleep for various reasons. Just because we want it doesn't mean we get it. Been there, done that and have the TShirt.

EliteSword · Post by **EliteSword** » Tue Sep 15, 2020 8:13 pm

Pugsy wrote: ↑
Mon Sep 14, 2020 10:39 pm
Do you wake up during the night very often?

Do you take any medications of any kind? If so, what?

I don't wake up all that much, usually 1 - 2 times. And I don't currently take any medications.

EliteSword · Post by **EliteSword** » Tue Sep 15, 2020 8:23 pm

mper!? wrote: ↑
Tue Sep 15, 2020 8:41 am
--- it may happens you would still have problems with some flow limitatio (either flagged or not);
---- could you post some 10min-windows of FR, TV, and Inspiration time ;

good luck

I assume you mean around the apnea events? I've attached a few.

EliteSword · Post by **EliteSword** » Tue Sep 15, 2020 8:45 pm

Miss Emerita wrote: ↑
Tue Sep 15, 2020 10:09 am
Welcome, and congratulations on starting treatment for your apnea.

Are clear airway/central apnea events the main component of your AHI most nights? And do you know the breakdown of your AHI when you had your sleep study (obstructive, central, hypopnea)?

I see that in your sleep study you had 16 RERAs per hour -- that plus your AHI of 10 means a lot of disruption of sleep. Was there any notation about restless legs or periodic limb movements?

When you post your next chart, could you rearrange things a little, by stacking the following graphs in this order:

Events
Flow rate
Pressure (the pressure graph rather than the mask pressure graph)
Leaks
Snores
Flow limitations.

To get all of those into one screen shot, you can grab the gray bars that separate the graphs and move them upward to squeeze them a little.

I'm guessing you're short on REM, but I'm not seeing evidence that your CAs are occurring during REM sleep. We normally have sleep cycles of around 60 to 90 minutes that take us from Stage 1 (shallow transitional stage) to Stage 2 (cruising along) to Stage 3 (deep) to REM. I'm not seeing that kind of timing for your CAs. Then again, your sleep "architecture" is probably pretty messed up, so it'd be hard to say when you might be getting in a bit of REM or deep sleep.

Thanks! Yes, every night nearly all of the apnea events are clear airways. I wasn't given more granular data from the sleep study unfortunately, I only know the composite AHI.

There was no mention of limb movements.

I've attached charts from the past couple nights.

I've read that REM tends to be more concentrated in the latter half of sleep and I've noticed that I seem to get more CAs during that time, which is why I thought they might be occurring during REM sleep.

Pugsy · Post by **Pugsy** » Tue Sep 15, 2020 8:53 pm

The CAs/centrals you zoomed in on appear to be post arousal.
Go here and watch the videos so you can learn about arousal breathing. Check for evidence of arousals in your flow rate.
The AHI might be low but you may still be having a lot of arousals for some reason and we don't always remember the arousals.
http://freecpapadvice.com/sleepyhead-free-software

It is normal to wake up briefly after a REM cycle though. Normally we don't remember it but it is normal.
The arousals can mess with the sleep cycles though and cause us to not get the normal amount of each cycle....and that can mess with how we feel during the day.

EliteSword · Post by **EliteSword** » Tue Sep 15, 2020 8:55 pm

Physician wrote: ↑
Tue Sep 15, 2020 12:30 pm
Try getting EIGHT hours of sleep every night. Bet your fatigue will disappear in a few days.

Before starting CPAP therapy I tried to rule out as much as possible. And indeed, one of the things I tried was to get at least 8 hours of sleep each night. Sadly, it didn't make a difference.

mper!? · Post by **mper!?** » Wed Sep 16, 2020 10:13 am

" I don't wake up all that much, usually 1 - 2 times. And I don't currently take any medications"

......Well, Elite, Pugsy already have got the point. I was not talking on wake-ups (you have conscious of); but rather, on arousal (3 to 15 sec; unconscioues), awakening ( more than 15 secs; maybe conscious or not);

..... and, yes, indeed, you arousal/awakening a lot; all your centrals would be false events, either SWJ or back-to-sleep transitions.

Then, you would have to find out why you arousal/awakening that great deal; does not look associated with respiratory effort, maybe. You could choose among (1) RLS musle contraction and groaning (my audio-recorded cases), which keep going stronger when I wake up; (2) unusual PLMS; (3) pain ; (4) sounds whatever; (5) touch.....and so on.

good luck

mper!? · Post by **mper!?** » Wed Sep 16, 2020 10:22 am

--- wonder how round would be your FR inspirations; still flat-topped or not ?...curious to see some 2-min windows anteceding your arousal/awakenings.

good luck

joeljjk11 · Post by **joeljjk11** » Wed Sep 16, 2020 12:48 pm

I am certainly no expert and am only speaking from my own experience but the pressure can have a lot to do with how you feel. If it is too low or too high I will not feel great, typically when it is too high for me I do not have energy and am tired throughout the day. Also just from looking at your stats I noticed you have EPR of 3 but your pressures are very low. This could be making you feel like you are not getting enough air, I know I would feel like this. Just something to think about.

Low AHI and still tired

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