Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
That's very helpful
My mind is racing, I am tired but wired and I am trying to figure out many things at once.
Basically I cannot for the life of me understand why I feel so exhausted every day
That's why I convinced myself that I have UARS based on the list of symptoms one finds all over the net
Sometimes Dr. Google is our friend. And sometimes Dr. Google is not all that reliable in terms of what's wrong with us.
Given what little you have told us about what the report from your NPSG says about the data gathered during that test, if I had to guess, I'd say that you've got at least two different sleep problems: (1) REM-based OSA and (2) Some kind of significant insomnia. The UARS you think you have and the REM-based OSA can be folded into a more general sleep disordered breathing problem if you want. But I think the insomnia includes some aspects that are not directly tied to sleep disordered breathing.
Keep in mind, I'm a math professor, not a doctor. So take everything I say about your diagnosis with a large grain of salt. Still from what I've read in your posts and seen in your data, I think you are underestimating the affect the insomnia is causing on your life and you are hoping that fixing the UARS will fix everything. But if your daytime symptoms are caused by UARS/OSA
plus the effects of insomnia
plus a potential depression and/or anxiety problem, then CPAP isn't going to fix everything all by itself.
And since you've stated things deteriorated rapidly last September, that points to other causes for your symptoms that should be investigated, in addition to getting some professional help for the sleep problems. Sleep disordered breathing usually does not suddenly deteriorate into a life-crushing daytime fatigue; it creeps up on people over several years or decades---and over time you finally start to realize that its been years since you felt rested or refreshed on waking and you realize that you can't dismiss that feeling as you are just getting older any more.
As ozij states:
ozij wrote: ↑Mon Feb 13, 2023 11:54 pm
You wait from September to December to address your fatigue until you literally can no longer work, and now in February you still haven't done anything in the way of a medical checkup. Nor have you done much about improving your CPAP therapy.
And you don't even sound worried about that sudden fatigue that seems to have come out of nowhere.
Something happened is September. Physical, or emotional,
and you need professional help in figuring out what happened to cause this sudden fatigue and detrioration.
And I concur: You need to get professional help in figuring out what's going on to create this sudden fatigue and its rapid deterioration.
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
Sleep doctors says that they checked for RERAs and I don't have any and therefore no UARS
It would help us help you if you would post images of the actual written report from your sleep test. Correctly measuring RERAs is still a bit controversial in the world of sleep medicine and not all labs even attempt to measure them.
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
What I have though is 104 micro awakenings TST and 27 obstructive hypopnea during REM, that's more or less 24 awakenings par hour
Sleep stages is a roller coaster and sleep efficiency is scored at 49.9% and AHI 5.6
We need the actual data from the report. In other words, the numbers you quote are somewhat meaningless without knowing such things as:
Total time in bed (TIB)
Total sleep time (TST)
Total time in REM
Total wake after sleep onset (WASO)
Latency to sleep onset
Latency to first REM period
Total number of each kind of respiratory event
Total number of each kind of respiratory event in REM
Total number of PLMs
Total number of PLM arousals
Total number of respiratory arousals
Total number of spontaneous arousals
I can say that a sleep efficiency of 49.9% indicates that insomnia is a pretty significant problem. But even there, we don't know if the insomnia problem is mainly a "get to sleep problem" with an extremely long latency to sleep onset or if it's mainly a "can't stay asleep problem" with a significant WASO or a problem that involves both a long latency to sleep onset and significant WASO.
And are the 104 micro awakenings broken down into types? How many are respiratory related? How many are related to PLMs? How many are listed as "spontaneous"?
If all 27 obstructive hypopneas occurred during REM, the REM AHI would be particularly important, and it would probably be significantly higher than the overall AHI for the night.
And if the overall AHI for the night was 5.6 and the only respiratory events were the 27 obstructive hypopneas recorded during REM, that would mean that you must have gotten about 4.8 hours of sleep during the sleep test.
It would also be useful to see the hypnogram in order for us to really understand what you mean when you say "Sleep stages is a roller coaster"
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
All this might be nothing to write home about for doctors but my list of symptoms says otherwise.
All this could point to
insomnia being a significant contributor to your list of symptoms, even without adding in the possibility of some significant contribution of REM-based OSA. And then the question becomes: What's causing the insomnia? And how do you and your doctors address the problem?
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
I don't know how much more I can push and try to advocate for myself considering that doctors don't believe it's UARS and that there are no facilities in Belgium to do a test with Pes (as far as I know)
First of all, you might not get as much meaningful data from a sleep test with Pes as you think: Pes monitoring is even less comfortable than all the usual stuff you deal with during an in-lab NPSG study. And clearly you had problems sleeping in the lab.
I think you need to raise the issue of REM-based OSA with your sleep doctor(s): How much REM did you get during the sleep study? And did all of the hypopneas occur during the REM periods? If so, the REM-based AHI may be the figure that needs to be looked at rather than your overall AHI.
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
- Basically I am trying to figure out from the Oscar graph if I can see evidence of flow limitation
Would you be kind enough to look at this graph and tell me if you can see clear evidence of recurring flow limitation
I mean if I have 104 micro awakenings and if they are all RERAs I should see them in the Oscar graph, right?
https://sleephq.com/public/8bd32265-46a ... 405f33bb6c
1) Yes, there are plenty of periods in this data that include flow limitations in your breathing. But it may not be as significant as you think it is. And some of the periods flagged as flow limited breathing may be sleep-wake-junk breathing where the real problems is insomnia rather than sleep disordered breathing.
2) You can't tell immediately from the CPAP data whether any of this flow limited breathing may have resulted in RERAs. If you scroll through all the data very carefully looking for recovery breaths at the end of each series of flow limited breaths you might be able to get a rough estimate of how many RERAs may have occurred during this night. I don't have the time, nor energy to do that. But at the end of this post I provide some examples from this data that illustrate what you need to be looking for as you scroll through the whole 7 hours of data while looking at the breaths in 5 minute long sections.
3) Given what you have said about your sleep study report, there's no real reason to believe that all of the 104 micro awakenings on your sleep study were RERAs. Some, possibly most of them, could have been plain old spontaneous arousals, which could indicate more of a problem with sleep maintenance insomnia than sleep disordered breathing. Some of them could be related to periodic limb movements, an in that case, we need to know how many PLMs you had and how many of those PLMs were associated with an arousal. Because untreated PLMD can also play havoc with the quality of sleep. And there is evidence of non-respiratory arousals in your CPAP data.
4) Given what you've said in your sleep study report about both the total number of micro arousals and the overall sleep efficiency of 49.9%, there ought to be significant periods of so-called sleep-wake-junk (SWJ) breathing mixed into your CPAP flow data: SWJ breathing is breathing that just doesn't look like sustained sleep breathing: It's breathing that has characteristics of wake breathing (larger breaths than sleep breathing that are more ragged over all) combined with very short stretches of breaths that might be sleep breathing, but they don't last long enough to make it clear that you actually got all the way to a real, light (stage 2) sleep. In other words, the overall breathing appears to either be wake breathing or breathing that's bouncing back and forth between wake breathing and possibly stage 1 sleep (transition to real sleep) breathing.
Seb-Sanfilippo wrote: ↑Mon Feb 13, 2023 11:17 am
- I am also bewildered that the APAP hasn't flagged any obstructive hypopnea since they are clearly present in my PSG would that mean that a pressure of 4 as ironed out those obstructive Hypopneas?
Yes, the most likely explanation is that 4cm is enough pressure to turn your OAs and hypopneas into flow limitations. The fact that worst of your flow limitations occur in three clusters that are about 90-120 minutes apart does raise the question: Are the worst of your flow limitations related to REM periods? There are also places in your CPAP data that look like "near misses"---i.e. things that are close to hypopneas but were not scored as hypopneas either because they didn't last a full 10 seconds or the decrease in flow rate was not quite steep or sudden enough to meet the machine's criteria for scoring a hypopnea.
Final comments:
In starting the tedious process of going through your flow rate data at a sufficient zoomed in level to see evidence of probable arousals based on the breathing pattern, it's possible to find examples of non-respiratory related arousals as well as examples of respiratory related arousals.
Here's a very good example of something that I believe is an arousal (and probably an actual wake) that does not appear to be respiratory related since the breathing preceding the arousal is decent sleep breathing with no noticeable flow limitations:
The arousal occurs at 12:22:50, and it looks like you get back to sleep by 12:23:30.
Here's a
possible RERA, but this is actually pretty ambiguous in terms of whether there are recovery breaths indicating a RERA has likely occurred:
Here the flow limited breathing is pretty obvious even if you don't bother to look at the flow limitation graph. The breaths between 1:17:20 and 1:17:40 are "bigger" than the running baseline for the breathing before this snippet, they immediately follow the flow limited breathing, and they are a bit larger than the more normal looking sleep breathing that follows them. Hence they might be recovery breaths and a RERA may have occurred.
Finally, I want to show two images that together show a stretch of what is most likely SWJ with some flow limited stuff thrown in. This stretch occurs just before you wake up enough to turn the machine off and back on.
Whether the wake was triggered by real flow limited breathing or whether the flow limited breathing is just part of the "junk" breathing caused by drifting in and out of stage 1 sleep before you finally wake up enough to turn the machine off is above my pay grade. But clearly you were quite restless for several minutes before you turned the machine off, and it is reasonable to assume that you were not truly asleep this whole time.
Because your NPSG identified a real problem with sleep efficiency, it might be worth getting a FitBit or similar device that attempts to measure your sleep cycles based on pulse rate and related data. While these things are nowhere near 100% accurate, they do a decent enough job of measuring the time it takes for you to fall asleep and WASO---the times you are awake during the middle of the night. If you have a long latency to sleep on most nights and/or a lot of WASO, particularly when using a CPAP, then you know you've got an insomnia problem.