New user, low AHI but not rested

Hi, new member here. I've had a CPAP machine for about 15 years. I've always had low AHI - extremely rare to have a night over 5 and usually average around 1, but that said I have long periods of feeling horribly unrested and unable to think every day which last for months at a time. This time around I haven't slept well for at least 6 months and I've noticed that injuries are no longer healing - they get inflamed and just stay inflamed and I feel like my body isn't clearing the inflammation because of the lack of deep sleep.

The last time I was referred to a sleep clinic the nurse or doctor simply told me my AHI was around 1.2, so I was therefore already treated and go away. Since then I discovered this forum and got OSCAR and have been making my own adjustments. It seems to have helped a little in the past but this time around I'm looking at my charts and just feeling a little bewildered as to what adjustments to make.

Really the biggest problem for me during the past year is that I can't seem to wear the mask for more than a few hours during the night. I'm averaging 3.5 hours per night over the last month. Part of the problem is that I drink a lot of water during the day and wake up to pee at least 5 times a night and when I get back in bed I often fall asleep without the mask on. But other times I put it on and wake up with it off, which leads me to suspect that my settings need adjusting.

I'll attach some recent screen shots of the entire night. I also have a lot of 3min screenshots showing different breathing waveforms that I've noticed and wanted to ask about but I"ll save those for a follow up question.

Screen shots: The one with AHI 0.28 left me feeling rested
The one with AHI 0.19 did not leave me feeling rested
The one with AHI 2.6, again, not rested

Thanks in advance for any advice you can offer I really really appreciate your help!!

Welcome, pajaro! The forum has run out of room for attachments, unfortunately. Could you upload your screenshots to a hosting site for images like Imgur and then share the links?

Sorry, figured I would try in case there were more servers now, but uploading to imgur is probably better anyway

So it might be better if I start with some specific questions. I have included links to some full night graphs at the bottom in case you need the context, but I was more interested in learning how to read my charts at the 3 min. to 20 min time scale so that when I look at my charts I can pan through them from left to right and create a narrative in my head of what happened.

Question: My first question is what is up with these different breathing waveforms that I see when I zoom into the flow rate chart at the 3 minute time scale? Do they mean anything? Are some of them more good or bad? Are they associated with different sleeping positions? Here are 3 or 4 different patterns that show up a lot.

1) https://imgur.com/ify1NoR --- I would describe as having the plateau in the middle of the breath, This is most common
2) https://imgur.com/Qq00Ssl -- wavy stuff at end of exhale
3) https://imgur.com/uypFFxy -- No plateau and rounded peaks -- not as common as 1)
4) https://imgur.com/jBGk18Z -- plateau on bottom -- possibly a variation of 3?

...And of course if you see anything that looks weird as far as settings please let me know! It's been a while since I tinkered with the settings and not knowing what I was doing who knows what craziness I put in there!

If it helps, here are some full night graphs:

https://imgur.com/8w42P0i -- not well rested
https://imgur.com/rp3y0m6 -- did feel somewhat rested
https://imgur.com/7oTQebn -- a typical night, both in terms of hours of use and AHI
https://imgur.com/yJDdQm2 -- last night, fearful and anxious dreams all night, although not feeling too bad today

You probably need to study this
https://www.ncbi.nlm.nih.gov/pmc/articl ... figure/F2/

https://imgur.com/8w42P0i -- not well rested
Hard to see with tiny numbers but this appears to show approx 5 hours of sleep...why the big gap???
I know when I only get 5 hours sleep I feel like total crap the next day no matter now low the AHI might be.

Your other reports....lots of gaps in therapy...why?

Always get around 5 maybe 6 hours of use...how much of that were you actually asleep do you think?

Hi Pugsy thanks for the quick reply!

Waveforms:
Thank you for the link to the article! I'll take a closer look, but it seems from the caption that different wafeforms could be causing flow limitations? That would be in agreement with what I am seeing in the OSCAR plots.

I'll read the article, but offhand, do you know what causes the different types of wafeforms? (positional, mental, etc...?)

Also, I've noticed that the transition between different waveforms often happens through an event like an obstruction, hypopnea, or something similar that is too short to be flagged as an event. Do you know why?

Also, how common are some of these waveforms? Does everyone do it? Is it something that gets worse with age? (I'm 43 btw)

Gaps in therapy:
You mentioned the numbers were tiny, Is there a way to do my graphs better to make the numbers bigger?

I'm not sure why the big gaps occur. I'm sleeping 9-10 hours a night, and every night I go to bed with the plan to have the mask on all night.

I know it doesn't help that I'm incredibly thirsty during the day and having to get up 5-6 times a night to pee . When I try to ignore the thirst and not drink my heart starts pounding and I feel agitated and can't relax enough to sleep. I've seen doctors for this condition and they ran a bunch of tests but didn't discover the cause.

But when I get back in bed the plan is always to put it back on. That either doesn't happen or I rip my mask off in my sleep! I have no idea what is happening though, even trying to be conscious of it for years! I was hoping that there might be some clue in the OSCAR data. Do you know what kinds of clues I would be looking for?

EDIT: Oh yeah, I think I'm asleep 99% of the time my mask is on

Thanks again for your help!

pajaro wrote: ↑

Thu Apr 13, 2023 9:19 am

I'll read the article, but offhand, do you know what causes the different types of wafeforms? (positional, mental, etc...?)

No, sorry...while I know flow limitations can happen I don't have very many and I haven't dug deep into the causes.

I do know that if you are experiencing any nasal congestion the FLs could be related to the nasal congestion.
Any nasal congestion going on?

pajaro wrote: ↑

Thu Apr 13, 2023 9:19 am

Also, I've noticed that the transition between different waveforms often happens through an event like an obstruction, hypopnea, or something similar that is too short to be flagged as an event. Do you know why?

Probably more related to awake/arousal related breathing. Our awake breathing is much more irregular than asleep breathing. That is normal to see.

I have a good example here. The asleep breathing is circled in red. All that other stuff and the associated flagging are what we call SWJ or sleep/wake/junk.
We may or may not remember the awakenings.

pajaro wrote: ↑

Thu Apr 13, 2023 9:19 am

I know it doesn't help that I'm incredibly thirsty during the day and having to get up 5-6 times a night to pee . When I try to ignore the thirst and not drink my heart starts pounding and I feel agitated and can't relax enough to sleep. I've seen doctors for this condition and they ran a bunch of tests but didn't discover the cause.

Were you checked for diabetes? Those symptoms are well known to be associated with diabetes.

pajaro wrote: ↑

Thu Apr 13, 2023 9:19 am

I'm not sure why the big gaps occur. I'm sleeping 9-10 hours a night, and every night I go to bed with the plan to have the mask on all night.

During those gaps you aren't getting any therapy for your OSA...that alone could be a factor in not feeling rested.
If you are actually sleeping that entire time it's most definitely sub optimal therapy because it looks like around 5 or 6 hours of therapy...rest of the time you could well be having a truckload of apnea events and we know what that does to the body.

Turn SmartStart off and lets see what shows up or doesn't show up during those gaps.

Pugsy wrote: ↑

Thu Apr 13, 2023 9:43 am

Any nasal congestion going on?

Maybe nose always a little stuffy, I'm not sure how normal that is.

Pugsy wrote: ↑

Thu Apr 13, 2023 9:43 am

Were you checked for diabetes?

Yes, even diabetes insipidus, nothing showed up, :sigh:

Pugsy wrote: ↑

Thu Apr 13, 2023 9:43 am

Turn SmartStart off and lets see what shows up or doesn't show up during those gaps.

It appears that it already is off. That's the ramp, right?

Pugsy wrote: ↑

Thu Apr 13, 2023 9:43 am

Probably more related to awake/arousal related breathing.

From looking at your examples of awake/arousal breathing, it appears that I am having very brief arousals throughout the night punctuating the sleep. Can you look at the following graphs to see if I'm interpreting these windows correctly as sleep on either side of a brief arousal?

https://imgur.com/CE0tHsC --possible arousal, no apparent reason
https://imgur.com/AoU8xW3 -- possible arousal, very slight flow limit
https://imgur.com/YFlV3FI -- possible arousal terminating flow limit
https://imgur.com/Y4GZOW4 -- possible arousal terminating leak, not much flow limit
https://imgur.com/12mBLUc -- possible arousal, no apparent reason


And now, if I still have your attention, I know I'm taking a lot of your time here, I've noticed that about 90-95% of my flagged events are preceded by what looks like an arousal. It was always explained to me that events cause a restriction of oxygen which leads to an arousal. In my plots it almost always seems to happen in reverse, the arousal immediately precedes the event and then after the event instead of being aroused I usually fall right back asleep. Here are some graphs:

https://imgur.com/uMbRpK6 -- arousal before OA, no leak or flow limit
https://imgur.com/Y3cA86Z -- arousal before OA, no leak, terminating small flow limit
https://imgur.com/SgeRHUr -- arousal before CA, no leak, no flow limit
https://imgur.com/HX0YuGf -- arousal before (and slightly after) UA, terminating leak, very little flow limit
https://imgur.com/n4rsQCM -- arousal leading to RE, RE, RE, H sequence, no apparent cause

Are my interpretations of intermittent brief arousals correct?
Would brief arousals every 20 or 30 mins make me feel unrested?
Can you help my understand why the arousal seems to precede the event?

Thank you in advance for your help!

I'm pretty concerned by your excessive thirst. Pugsy has mentioned diabetes; there are also other conditions that can cause this symptom. More here, from a trusted web site:

https://my.clevelandclinic.org/health/s ... polydipsia

Don't let this drop. Sometimes we have to push fairly hard to get the medical care we need. Three things you could do to help your doctor understand your symptoms: keep track of the number of ounces of fluids you drink on average during a 24-hour period. If you use several glasses or mugs to drink fluids, use measuring cups to figure out how much they each hold. You could also track the number of times you pee during each 24-hour period. And finally, you could take your pulse when your heart-rate goes up when you resist drinking fluids. Get a piece of paper and write this stuff down every day for a couple of days.

Pugsy has mentioned nasal congestion as one cause of flow limitations. Another is the relaxation of the tissues lining the pharynx, which is further down in your airway. It then takes a little more effort to inhale. Try increasing your EPR to 3 to see whether that helps. (EPR drops your pressure when you exhale; by the same token it increases your pressure when you inhale, which may help keep the tissues in your pharynx stented a little better.)

pajaro wrote: ↑

Thu Apr 13, 2023 11:09 am

It appears that it already is off. That's the ramp, right?

SmartStart is NOT the same thing as ramp. Totally different setting.
Check your manual.
https://www.respshop.com/manuals/ResMed ... %20her.pdf

Turn SmartStart off if it is on/enabled. If your SmartStart is really already off you got some major problems with things or whatever is causing those gaps if you really are thinking you were asleep for 8 hour 9 hours and the machine is showing 5 hours of use.

Arousals don't have to have a reason. There's this thing called "spontaneous arousals" where we simply don't know why...very common and very normal.
Those arousals you shared...I think spontaneous arousals primarily.

Miss Emerita wrote: ↑

Thu Apr 13, 2023 11:17 am

I'm pretty concerned by your excessive thirst. Pugsy has mentioned diabetes; there are also other conditions that can cause this symptom. More here, from a trusted web site:

https://my.clevelandclinic.org/health/s ... polydipsia

Don't let this drop. Sometimes we have to push fairly hard to get the medical care we need.

Yes, it is amazing to me that the doctors are getting paid to help you and yet won't really invest any time into helping you, but on sites like this people are willing to spend more time than the doctors are willing to spend out of the generosity of their hearts, for free. Thank you for that!

About 5 years ago these symptoms were really bad and I did push a doctor to help me, and ended up thousands of dollars in debt because they weren't telling me that each time they did a lab I was going to be charged around 500 dollars and I had a large deductible to meet! They never did find the root cause of it.

Miss Emerita wrote: ↑

Thu Apr 13, 2023 11:17 am

Three things you could do to help your doctor understand your symptoms: keep track of the number of ounces of fluids you drink on average during a 24-hour period. If you use several glasses or mugs to drink fluids, use measuring cups to figure out how much they each hold. You could also track the number of times you pee during each 24-hour period. And finally, you could take your pulse when your heart-rate goes up when you resist drinking fluids. Get a piece of paper and write this stuff down every day for a couple of days.

Yes, I did this before when I was working with that doctor. I might start doing this again, although it's harder than it sounds.

I was drinking too many sugary drinks about a month ago and I've now adjusted my diet and started exercising a lot. Maybe it just takes a while to adjust, or maybe now I'm sweating too much and its throwing off my electrolytes. So complicated

Miss Emerita wrote: ↑

Thu Apr 13, 2023 11:17 am

Pugsy has mentioned nasal congestion as one cause of flow limitations. Another is the relaxation of the tissues lining the pharynx, which is further down in your airway. It then takes a little more effort to inhale. Try increasing your EPR to 3 to see whether that helps. (EPR drops your pressure when you exhale; by the same token it increases your pressure when you inhale, which may help keep the tissues in your pharynx stented a little better.)

Okay, yes, I'll do that. I can't even remember now why I backed that off to 2, it used to be at 3. My graphs from about a year ago show that I was sleeping pretty well and my EPR was 3 then, so I'll definitely move that back to 3.

Pugsy wrote: ↑

Thu Apr 13, 2023 11:37 am

SmartStart is NOT the same thing as ramp. Totally different setting.

Wow, how have I had this machine for 15+ years and not even realized I had that setting?? I'm going to try it now

Pugsy wrote: ↑

Thu Apr 13, 2023 11:37 am

If your SmartStart is really already off you got some major problems with things or whatever is causing those gaps if you really are thinking you were asleep for 8 hour 9 hours and the machine is showing 5 hours of use.

Definitely sleeping 8-10 hours, I'm just not getting the mask on before I fall asleep. There have been some times though when I apparently ripped off the mask while sleeping and turned off the machine. But mostly I think its just being too out of it when I get back in bed. My thinking is that maybe the settings aren't right for me anymore and so subconsciously my brain doesn't want to have the mask on

Pugsy wrote: ↑

Thu Apr 13, 2023 11:37 am

Arousals don't have to have a reason. There's this thing called "spontaneous arousals" where we simply don't know why...very common and very normal.
Those arousals you shared...I think spontaneous arousals primarily.

Oh okay, good to know. Any thoughts on why almost all of my flagged events would be preceded by an arousal?

pajaro wrote: ↑

Thu Apr 13, 2023 12:34 pm

Any thoughts on why almost all of my flagged events would be preceded by an arousal?

Because these machines can't tell if we are asleep or awake. They only measure air flow and sometimes arousal related breathing irregularities can cause the machine to flag something that isn't asleep breathing.
I tend to think of them as false positives.
Working on a thread where we dig deeper and show examples of those false positives.
viewtopic/t186231/Examplesmouth-breathi ... gging.html
My second image in the first post shows a truckload of OA flags but they were all arousal related. I wasn't asleep when those OAs were flagged. This is common for me....about 75 % (up to 90%) are arousal related SWJ. I don't sleep so soundly...back/pelvic pain issues. I know I wake often tossing and turning due to the discomfort.

That thread is a work in progress and I just haven't felt like doing the work to get more examples.
Been a bit unwell lately. I will do more later when I have more time and energy to compose stuff.

So when we see arousals that immediately precede a flagged event (can be OA, central or hyponea) there's a really good chance the arousal caused the irregular breathing which got flagged by mistake.
Now when we see an arousal after the flagged event then the apnea event likely caused the arousal.

Here's one where I think I was asleep and the OA happened and then after the OA flag is the arousal related breathing which is typical.



Arousal related flagging below



This appears to be 2 real asleep flagged OAs. The slight increase after the flag is call a recovery breath which is common to have after an apnea event. Flow rate settles down quickly though so went back to sleep quickly and don't have a memory of this happening.

Pugsy wrote: ↑

Thu Apr 13, 2023 1:39 pm

Because these machines can't tell if we are asleep or awake. They only measure air flow and sometimes arousal related breathing irregularities can cause the machine to flag something that isn't asleep breathing.

So then you would interpret those examples I provided in the previous post as me waking up for a few breaths and then holding my breath for 10-20 seconds before falling back to sleep? Seems possible. In this case most of my flagged events would in essence be psychogenic, like as in central apneas?

Sorry about the late reply, I got busy and it took me a couple of days to think of a coherent follow-up question anyway


New Question:
Looking at my sleep data this morning from last night reminded me of another question I meant to ask. Pretty much all of my sessions seem divided up into blocks of different types of breathing. Take this session, for example from last night:

https://imgur.com/fmmBOWK

What I am seeing is 37 minutes of very regular breathing at a lower amplitude (after the initial awake period settles down) followed by an hour of much more irregular, higher amplitude breathing. I was as asleep during all but the final minute of this session.

Are these different stages of sleep (REM vs non REM for example), different sleeping positions, or something else entirely?

Thank you!