What to do when most/all events are "Clear Airway"?

After a few months of tinkering with settings and masks, here's where I'm at (as a healthy young male, healthy weight, untreated 10.0 AHI, not a mouth breather):

• Airsense autoset 11
• Set to CPAP mode, constant pressure of 11.0
• EPR full-time at level 2
• P30i large pillows
• Heated hose set to 86 deg and humidity level 4 (if I go to 5, I run out of water by morning and it hurts my throat)

Now, most nights, I am around 0.5 to 1.0 AHI, almost entirely "Clear Airway" events as notated in OSCAR.
Occasionally I'll get a really bad night with other events, which are usually hypopneas or OAs.
I rarely/never get UAs, CSRs, or REs.

Here are a bunch of recent nights' data:

1. Jan 30
2. Jan 29
3. Jan 28
4. Jan 27
5. Jan 26
6. Jan 25

I know this AHI is low, but I really want to improve it because I am still not sleeping restfully. I often experience fatigue, eye twitching, and dry eye during my day and evening.
I often wake up fully a couple times per night and have rarely been experiencing dreams recently.
Some questions...

1. Should I schedule a second sleep study? My first was without a CPAP and now they want me to come back for a titration study, but I'm not sure how much this would help.
2. Is there a different kind of professional I should consult with (like a LankyLefty type of technician who can help me interpret the OSCAR data)?
3. Should I raise/lower my EPR? I tried last night with EPR of 1 and pressure lowered by 1 and it went horribly. I'm worried about lowering it much as it may increase my flow limitations.
4. Should I raise/lower my pressure? It seems there may be some overventilation happening (from some quick research) but I am still trying to understand all of this stuff.
5. What else can I try? My sleep hygiene/habits are strong and science based.

mcrick wrote: ↑

Thu Feb 01, 2024 8:30 am

most nights, I am around 0.5 to 1.0 AHI . . . still not sleeping restfully

You may get more payoff by focusing on and improving other aspects of good sleep beyond sleep-breathing. A few open-airway events being reported by a home machine is normal, since occasional pauses are fine when transitioning to sleep or switching between stages. Such pauses would be ignored in a lab/center study.

mcrick wrote: ↑

Thu Feb 01, 2024 8:30 am

rarely been experiencing dreams recently

Perhaps rarely remembering dreams, which may be a good sign of better sleep, not worse sleep.

mcrick wrote: ↑

Thu Feb 01, 2024 8:30 am

My sleep hygiene/habits are strong and science based.

Perfecting them may still do more for you than focusing overly much on sleep-breathing home-machine data. Increasing early day heavy exercise and possibly a trial of completely eliminating all caffeine and alcohol for a while may, for example, be the sorts of things your doc might sign off on as an approach more likely to improve your quality of sleep.

And recently, diet has been in the spotlight in particular of late, it seems.

“ 'We’re finding more evidence that improving your diet can lead to better sleep,' says Marie-Pierre St. Onge, PhD, director of the Center of Excellence for Sleep and Circadian Research at Columbia University Irving Medical Center in New York City. 'All of the research is pointing toward similar findings: The foods and dietary patterns that are associated with better sleep tend to be lower in glycemic index [meaning they have less effect on blood sugar levels], low in saturated fat, low in added sugars, and high in fiber.' Turns out, the reverse is equally true. Foods with the opposite attributes can get in the way of a good night’s sleep."--Foods to Eat for Better Sleep
(One of the simplest and most effective ways to improve the quality of your sleep is to improve the quality of your diet) By Sally Wadyka; Updated January 4, 2024.

I wish you the best in finding the best sleep possible.

Thanks for the reply!

Where I am struggling is that I have already become diligent with these sleep habits... I exercise, I drink decaf coffee in the morning, I go for walks to get sunlight in the morning and at sunset, I don't eat within a couple hours of bed, I reduce screentime before bed, I meditate, I stretch... yet improvement has been marginal at best.

That's why I'm hoping to fine tune settings on the CPAP to see if I can squeeze out some better sleep from that, before turning to yet another sleep study or other large investments.
I don't know what else I could do to naturally improve my sleep. I also try not to become too crazy about the habits because that could start working against me (i.e. extra sleep anxiety).

I added some info on diet from an article in Consumer Reports in my reply above.

Everything in life affects sleep, just as sleep affects everything in life.

Follow your gut feelings on it all as you explore possibilities. But no one has perfect sleep, just as no one has a perfect life.

Find joy in the small improvements, and take full advantage of every bit of progress.

Let's all keep at it.

Others may have better suggestions for you than I. But if your average AHI over time is that low, don't let CPAP become the hammer in your hand that makes every health and sleep issue start to look like a nail.

There really isn't much information in your graphs that one could use to improve your therapy.

You're also in straight CPAP mode. One of the advantages of APAP mode is, watching how much and the circumstances of pressure changes can be valuable in finetuning therapy.

Looking at some of your events, they didn't appear real at all, they looked like arousals. You did indicate that you often awaken. I doubt that the minimal events your experiencing can be cleaned up significantly, nor do I think they are responsible for some of the symptoms you're experiencing.

The EPR change you made last night may not be responsible for the horrible night you experienced. Fine-tuning doesn't mean tinkering, and you can't (necessarily) draw the conclusion that the EPR decrease was responsible for that one "horrible" night.

Going on another Sleep Study will be a waste of time, even getting a titration will be of little value. Simply put, practitioners don't fine-tune. And there is little posted data that can be used to finetune.

Sometimes, it just takes time to get back to sleeping well after starting therapy.

I agree with what Lazarus and DS have written. I'm curious whether you have a copy of your sleep study; if you do, does it say anything about leg movements or RERAs?

Your CAs aren't themselves a problem; they're a symptom of a possible problem, which is frequent arousals. Arousals can be full wake-ups or just times when you're kicked out of deeper sleep into more shallow sleep. Arousal breathing tends to be deeper and irregular; you can zoom in to scroll through and see it. The deeper breathing can lead to pauses in your breath (through either the CO2 regulation system or a neurochemical system involving sensors in your chest muscles). If the pauses are 10 seconds or longer, a CA is flagged. But the CAs aren't messing with your sleep; the arousals are, both the ones with and the ones without CAs.

Thanks all for your insight. I gather that the arousals seem to be seldom driven by apneas and rather something else.

Here's the info from my sleep study: https://imgur.com/a/UD0jeV3
There's no major concern for RERAs and leg movements from it, from what I understand.
Note that I'm a side sleeper but was instructed to fall asleep on my back. For the portion of the study while I was asleep on my side, I still had apneas (though fewer).

I guess my question is where to go next with this information. Is it a neurological issue? How do I address the arousals if not caused by apneas / something pulmonary? I'm not sure where to go next and my sleep specialist has not been helpful. "Your CPAP data looks good so I can't really help further."

Many thanks for posting the sleep study. A few things jump out at me:

* most of your events were hypopneas,

* you had an arousal index of 22.8,

* as you note, you had the great majority of your events during supine sleep, which is not your normal sleep position.

Of course, data collected during one night may be of limited value, but my initial take-away is that if you had slept on your sides during the test, you would not have been diagnosed with sleep apnea. You would, however, have been told you have many arousals during the night -- arousals that are not related to breathing issues.

So what does one do about frequent arousals whose cause is unknown? First, be very rigorous about the guidelines for sleep (see below); second, consider trying CBTi (cognitive behavioral therapy for insomnia). And I feel completely under-qualified to say this, but I am not convinced using PAP therapy is right for you. I hope others will weigh in on all this.

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.

Miss Emerita wrote: ↑

Fri Feb 02, 2024 12:46 pm

I feel completely under-qualified to say this, but I am not convinced using PAP therapy is right for you.

It needed to be said, IMO.

My view is that some people need the opportunity to try PAP to see if stabilizing the airway helps at all and if the added comforts of EPR and bilevel are soothing enough to the sleep brain and nervous system to make a significant difference.

If sleep position is a factor, then PAP can be a helpful protection for some. But for those with sensitivity issues that take precedent over airway-patency issues, PAP can be more cumbersome than helpful. It's a very individual thing. And for some people, arousals during a sleep test are just going to happen.

I believe the patient plays the key role in making the ultimate judgment call. I personally would never put pressure on anyone to continue PAP without clear indication it is needed or helpful for that specific person. But I always respect the reflex of sleep docs who give borderline patients the opportunity to give PAP the full shot just to see if it makes a big difference in quality of sleep and thus quality of life and safety.

My 2 cents, only. And I certainly ain't no doc.