what are the facts? physiology 101

Oh, and in my case, on night 1 of CPAP therapy no more night-time peeing and that miserable side-effect of apnea hasn't recurred...yippee

It did, however, take me 18 months to get my BP average down to 130/68-70 so I could completely stop the Cozzar (I'd been dropping the dosage as my BP dropped).

1000% Yeah, I've been 100% compliant since I got my equipment Aug 6, '07 -- I'm not sleeping without my equipment...ever.

A few links for nmevan


Physiology of OSA


http://pats.atsjournals.org/cgi/content ... type=HWCIT


OSA and hypertension

http://www.nejm.org/doi/full/10.1056/NE ... 5113421901

Physiology of CV disease in OSA

http://erj.ersjournals.com/content/29/1 ... f_ipsecsha

Muse,

You've done a really good job at explaining just how severe apnea with desats can and does cause damage and symptoms.

And I've no doubt that if my apnea were left untreated, it would only be a matter of time before I started having problems with things like you describe:

PSG: AHI=62, all hypops, 1.15 mins of Stage 3 sleep & no REM all Stages 1 & 2, no abnormal heart rhythms, no limb movements, desatted to 83% (not all that low ). But, at the time my BP had risen to 215/110 from my family's usual low BP something like 65-70/60. I pee'd typically 8-10 times/night. I'm sure I had brain lesions like all severe apneics who've had brain scans at diagnosis as I had the typical cognitive & memory deficits of many with untreated severe apnea.

But what you are describing here is not quite what I'm asking about: You were having desats that were NOT minor/negligable in size; you clearly were already suffering from physical damage caused by the sleep apnea; and you were clearly symptomatic. So your CPAP is clearly acting in a way to treat the damage that has already been caused by the apnea as well as treat the symptoms of those problems. Hence, it's easy to see that you would notice a big positive difference in how you feel since starting CPAP.

In my case, there were no desats lower than 91%. I got into REM in both studies---the % of time in REM was a bit less in the diagnostic study, but then again, I slept a whole hour less in that study than I did in the titration study. [It may well have been the apnea OR it may have been that the diagnostic study was done in a hot room in which I could hear the traffic outside, while the titration study was done in a cool room with no traffic noise. I'm personally inclined to think both things contributed to less sleep in the diagnostic study.]

Stage 3 sleep is another issue altogether: Stage 3 was present during my diagnostic sleep study, but was completely absent from the study done with a CPAP machine. And I've had many nights in the last 6 weeks where I've woke up wondering whether I'm still not getting into Stage 3. That might explain why I'm still feeling so sleepy during the daytime and so exhausted all the time.

BP: Well, my (daytime) BP a week after my diagnostic was still a nice 105/65. Nightime pressure? Well I suppose it could be higher, but I don't know. Certainly there was nothing in the sleep study that indicated any problems with night time BP.

Night time peeing (nocturnia): Not for me---I've never had any excess need to go to the bathroom at night. Before CPAP, I'd wake up needing to go the bathroom maybe once a month or so. I know that this is a common symptom. And you've given me good insight into why it's an important symptom and how the untreated apneic episodes lead to this. So in my case, I assume that if I am diligent and continue to use my CPAP every night (like I intend to), then I should never develop this symptom and the underlying BP problem that causes it since I currently do not have this symptom nor (to the best of my knowledge) the underlying BP problem that causes it. In that case, my CPAP is acting prophylactically---it is preventing a problem from developing rather than treating an existing problem. Clearly a good thing. But I really can't expect CPAP to reduce my "frequent need to pee at night" since I don't have any need to go pee at night.

Cognitive and memory problems: Before CPAP I had (by far) the best memory in my family. And in my extended family. And among my friends and coworkers. Really---people would comment on just how freaky good my memory was---both short term and long term. Now since starting CPAP I feel like I'm wandering around in a fog all the time. I can't remember my day-to-day schedule even with trying to remember writing everything down. My already not great spelling has become really horrible. [Google is great for helping me figure out how to spell words that the posting editor flags---if I notice the little red line under the word.] And the fog started during my first week of CPAP. It's starting to lift (I think), but my mind is not working normally now. I seem to be having frequent problems with losing words when I talk with my husband. That was not happening this summer just prior to my starting CPAP. And since the S9 is reporting good AHI almost all the time (most typically between 0.5 and 1.5), I don't think my new cognitive and memory problems are (directly) due to my apnea. But since they started right at the time I started using the S9, it's not unreasonable to assume that somehow CPAP itself is causing them, although what the mechanism would be is beyond me.

You also write:

Another effect of 5 yrs of untreated apnea...ta da, are ya ready for it...diabetes. And most type 2 diabetics have apnea. Apparently apnea activates diabetes genes...lovely huh?

Again, I've no doubt that if left untreated that apnea can lead to type 2 diabetes. But I am not diabetic now. (Yes, I know this to be true---I had a physical exam in July that included a routine fasting test for blood sugar; it was normal.) So here again, at best my CPAP will decrease the chances that I develop type II diabetes as I age and that's again a prophylactic treatment that isn't going to change how I feel today. [And age of onset of type II diabetes in my family ranges from early 80's to never.] So again, this is a great reason for me to keep using my CPAP machine, but that doesn't mean that my CPAP is actually helping my body undo damage that is not yet there.

So I come full circle:

Is the main reason that a person like me---with moderate apnea and NO desats to speak up and completely asymptomatic---is told to use CPAP for the rest of my life prophylactic? In other words, is the main benefit of using CPAP to a person like me preventative---i.e. as a treatment to minimize the chances that I will eventually develop a whole host of serious physical problems that untreated apnea may/will cause farther down the line in say a 5 or 10 year time frame?

Or is there a therapeutic aspect to CPAP for my body right now in the present even though I don't have any evidence of the kinds of physical damage you are talking about right now?

Now don't get me wrong: I know I'm lucky that I've been diagnosed apparently before the apnea has started to take a physical toll on my body. And if that means that CPAP is mainly prophylactic, that clearly doesn't mean it's worthless. After all, if CPAP can prevent me from developing so many of the symptoms and physical problems so many of the posters regularly talk about as having been caused by or aggravated by apnea, then that's a real good reason for sticking with CPAP.

But I do wish someone could explain to me why I'm feeling so much worse since starting CPAP.

Robysue as you described your hypopneas indicate reduced breathing by at least 50% with arousals. Your brain is waking you up before you have a significant desat. Of course it will likely worsen with age if untreated. What PAP is really doing for you right now is helping you stay asleep, since you don't have the hypopneas waking you up. There are many vital body processes that happen during sleep which were constantly being interrupted before therapy. Hormone production is different during sleep and wake. So you are restoring the chemical balances in your body at night and restoring proper nighttime body function. Many patients that have a lot of arousals feel very tired for the first several weeks, even months, on PAP therapy because they are catching up on sleep. It may be that you do have reduced stage 3 sleep. This is very common in sleep apnea where there are lots of arousals. The brain tends to keep you in REM for prolonged periods until your sleep debt is repaid. This is called REM rebound. This can make you very tired during the day. Give it some additional time and likely you will start to feel better and your sleep cycle will normalize.

Guest, that makes sense. It took me 3-4 wks to go from bone-weary exhaustion to plain old tired and that slowly improved over the next 8 months; took several months before I began remembering fragments of dreams, something that'd been missing for many yrs (now back to quite vivid again when I remember 'em and no more really bizarre ones anymore). Many here report similar increase in daytime sleepiness (EDS) and poorer sleep for awhile in the beginning. REM rebound...interesting, will do some investigating...thanks for posting this!

The Guest wrote:Robysue as you described your hypopneas indicate reduced breathing by at least 50% with arousals. Your brain is waking you up before you have a significant desat. Of course it will likely worsen with age if untreated. What PAP is really doing for you right now is helping you stay asleep, since you don't have the hypopneas waking you up. There are many vital body processes that happen during sleep which were constantly being interrupted before therapy. Hormone production is different during sleep and wake. So you are restoring the chemical balances in your body at night and restoring proper nighttime body function.

Ok, this makes sense to my mathematically oriented brain. So hormonal things should be getting back into a "normal" pattern for me now that I'm on CPAP. And maybe at some point in the future when they're back to "normal" I might actually feel better than I did before CPAP. But right now, I'd love to simply feel as good as I did back in July and August before I started CPAP.

Many patients that have a lot of arousals feel very tired for the first several weeks, even months, on PAP therapy because they are catching up on sleep. It may be that you do have reduced stage 3 sleep. This is very common in sleep apnea where there are lots of arousals.

This is where things no longer seem so logical to me: I was NOT tired or sleepy during the day before I started CPAP, even though my RDI indicates I was arousing approximately 23 times an hour---which works out to be an arousal about every three minutes or so. Now, I'm not denying that my body was indeed suffering from sleep deprivation of some sort due to the apneas---but the sleep deprivation had NOT (yet) lead me to crave sleep in any way. I wasn't feeling like I needed to fall asleep all the time. I didn't even feel particularly tired on most days. I had plenty of energy to do my job (college teaching) very well and still had enough energy at night to do things with the family. And every time I filled out a questionaire like the Epworth Sleepiness Scale (one version is posted at http://www.sleepeducation.com/SleepScale.aspx ), I'd score well in the "You're getting enough sleep" category.

But now that I'm no longer waking up every three minutes in order to breathe properly, I'm suddenly dealing with problems with daytime sleepiness and daytime exhaustion and daytime grogginess of proportions that I've never experienced before in my life. Three days after starting CPAP I developed severe and almost incapacitating daytime sleepiness. For the first time in my adult life I have been afraid to drive during the day because I now feel like I might just fall asleep at the wheel. About the same time I developed severe and almost incapacitating daytime exhaustion---exhaustion of sort that I have literally not felt since being the mother of a newborn who's not yet sleeping through the night. And most disturbing has been that my mind has been lost in a CPAP fog since about day 3 or 4 on the machine. I find it very difficult to concentrate long enough to grade my papers for example. And it's hard for me to remember my daily appointments even when I've got them written down on a calendar. And it's much harder to follow conversations now than it was pre-CPAP. And even now, when I fill in an Epworth Sleepiness Scale questionaire, my score clearly lands me in the most sleepy group that's told, "See a sleep specialist immediately."

Since a doctor-authorized reduction in pressure and a switch to APAP about 3 1/2 weeks ago, the daytime fog is slowly starting to lift. The daytime sleepiness is still problematic, but now largely confined to the hours immediately following lunch and supper. But the exhaustion still remains----I find that I have little or no energy to do anything physical. Walking up the two flights of stairs to my office wears me out; it did not do that in July and August before I started CPAP.

And my exhaustion and sleepiness (along with a nasty bout of aerophagia) has gotten the attention of the PA in my sleep doctor's office. I've already had several phone conversations and two in person follow-ups with her and another scheduled at the end of this month. She's ordered some standard blood tests (thyroid, iron levels, vitamin D levels, etc.) to see if there might be something else going on. Now understand, I had the same set of standard blood tests (except for thyroid) done back with my annual physical in July and everything was normal.

The brain tends to keep you in REM for prolonged periods until your sleep debt is repaid. This is called REM rebound. This can make you very tired during the day. Give it some additional time and likely you will start to feel better and your sleep cycle will normalize.

Again, this seems to be a favorite refrain here on cpaptalk.com. But I was getting plenty of REM sleep before CPAP: The REM in my diagnostic study was a bit lower than normal---but a signifcant part of this is that after first getting to sleep at around midnight, I woke up around 1 AM due to the room being very hot, the traffic noise being very disturbing, and the wires being very uncomfortable. The sleep stage graph shows me being AWAKE for most of the period between 1 AM and 2 AM, and I clearly remember being awake for an extended period of time that night after waking up uncomfortable due to the hot room. But the sleep stage graph also shows that I went into an extended 30 minute REM period at 3:30AM---90 minutes after falling asleep at 2 AM. I didn't have a chance to get into a second REM cycle that night only because the study was over at 5 AM. [And oddly enough, unlike most people, my AHI was LOWER during REM than non-REM.]

And getting into REM during my diagnostic sleep study dreaming was not particularly unusual for me: I've always dreamed a lot. And there has not been any decline in my dreaming in the last few years.

And now that I'm on CPAP, I don't feel like I'm dreaming anymore than pre-CPAP. Indeed, on my worst nights on CPAP, I have woken up feeling like I did NOT get into REM and do any dreaming. And that is a very disturbing feeling for me. Fortunately, it's been a good two or three weeks since I last had such a horrible night on CPAP that I woke up feeling like I'd not done any dreaming.

I honestly think it's stage 3 sleep that my body is craving. And it's not clear to me that I'm getting into stage 3. Certainly that was the case during the titration sleep study. I slept much better at the titration study---both in the sense of how I actually felt in the moring and in the sense of the objective evidence concerning total sleep time. But I never got into stage 3 during the titrtation study, even though I did have a brief period of stage 3 in the diagnostic study.

Here are some resources on dementia/brain damage and sleep apnea.

Dr. Steven Park

Researchers found that when people with Alzheimer’s and OSA are treated with CPAP, cognition and memory improves. This study was published in the November edition of the Journal of the American Geriatrics Society. They estimated that about 70-80% of Alzheimer’s patients have at least 5 apneas every hour.

….

Another study showed that people with sleep apnea had significantly reduced blood flow rates to certain critical areas of the brain. Other studies have shown that the acoustic trauma from snoring can worsen carotid artery plaque formation.

http://doctorstevenpark.com/sleep-apnea ... rs-disease
http://doctorstevenpark.com/can-sleep-a ... zheimers-2

Brain Structural Changes in Obstructive Sleep Apnea
from the book Deadly Sleep by Dr. Mack Jones


A number of neuroimaging studies have been performed on patients with OSA

including CT, MRI. PET and SPECT scans, revealing various defects, but none has

displayed anything quiet as astonishing or as dramatic as in a study published in

SLEEP July7, 2008, by Dr. Paul M. Macey. et.al. (10) The report reveals results of a

new MRI technique called DTI (Diffusion Tensor Imaging). Without going into details of

this new test, let me tell you that it is an extremely sensitive method of determining

damaged nerve fibers (axons). This new test, not available until recently, reveals

multiple areas of brain damage in OSA patients never known to exist.


DTI revealed various sized color-coded yellow-orange patches of brain damage

scattered throughout the brains of a group of forty-one men and women subjects with

OSA. Their ages ranged from thirty-eight to fifty two years old and they had not yet

been treated. The areas of nerve fiber injury are located in critical regions of brain

including prefrontal, temporal and parietal lobes. The cerebellum and brainstem were

equally involved. This is the first report of DTI imaging of a middle aged group with

OSA to my knowledge. The findings are momentous.

Other resources:

Study links sleep apnea to memory loss http://newsroom.ucla.edu/portal/ucla/uc ... 51534.aspx

Sleep apnea's effect on the brain may be more severe than previously thought http://www.physorg.com/news163245364.html

And an encouraging report:

CPAP Therapy Restores Brain Tissue in Adults with Sleep Apnea
Obstructive sleep apnea patients had reductions of gray-matter volume at baseline but showed significant gray-matter volume increase after 3 months of CPAP therapy, according to a research abstract at SLEEP 2010.

Results indicate that obstructive sleep apnea patients showed focal reductions of gray-matter volume at baseline in the left hippocampus, posterior parietal cortex, and right superior frontal gyrus. Significant gray-matter volume increases were observed after 3 months of CPAP therapy in hippocampal and frontal structures. No further improvement in gray-matter volume was observed after 1 year of CPAP therapy.

"OSA patients showed cognitive impairment associated with neurostructural damage affecting specific cerebral regions," said principal investigator Vincenza Castronovo, PhD, clinical psychologist and psychotherapist and sleep laboratory coordinator at the University Vita-Salute San Raffaele and San Raffaele Scientific Institute in Milan, Italy. "In addition, we show that most of the neuropsychological deficits are reversed after three months of treatment with CPAP and, for the first time, that such cognitive improvements parallel an increase of grey-matter volume in specific hippocampal and frontal brain regions. The increase of grey-matter volume in these regions is significantly correlated with the improvement at neuropsychological tests of executive functioning and short-term memory."
http://www.sleepmeeting.org/PosterViewing.aspx

‎1. Go to Google maps.

2. Go to "Get Directions."

3. Type Japan as the start location.

4. Type China as the end location.

5. Go to direction #43.

Robysue let me first say that I am glad you are now on APAP. Perhaps a portion of your trouble was an inadequate pressure.

Before PAP you definitely were sleep deprived and tired. That is a scientific certainty based on your sleep study. Previously your brain likely adjusted to the sleep deprivation in a way that allowed you to function and perhaps that included your lack of perception of fatigue. Beginning PAP therapy has forced your brain to readjust its perception of your sleep deprivation. Now your brain realizes it can function properly at night and has removed that survival mode you were previously in. The truth is you are less sleep deprived now than before PAP. You are feeling the adjustment now that you are able to perceive your tiredness.

Perhaps I should have more clearly explained REM rebound. Now that normal breathing/sleep function is restored your brain wants to repay your sleep debt. To do that, it tends to keep you in REM significantly longer than what is normal until the sleep debt is repaid. For example, you might be in REM sleep now for 4-6 hours per night instead of about 2 hours per night, the norm. That would cause severe fatigue, but will resolve over time. That is why I said that likely your stage 3 sleep is reduced, because of the time spent in REM. And just because you are not remembering your dreams does not mean you are not dreaming.

My suggestion is to stick with it. You are improving. Keep working with your doctor and keep coming back for encouragement. You will be better than ever in the very near future!

roster wrote:‎1. Go to Google maps.

2. Go to "Get Directions."

3. Type Japan as the start location.

4. Type China as the end location.

5. Go to direction #43.

Now that is funny!!!

roster wrote:‎1. Go to Google maps.

2. Go to "Get Directions."

3. Type Japan as the start location.

4. Type China as the end location.

5. Go to direction #43.

How do you keep finding this stuff?

Robysue, in addition to what The Guest noted, you might want to try some mile exercise late in the afternoon, very earlier in the evening. A longer walk is the type of thing that can help. I agree with what The Guest notes. It sure sounds as if you are struggling with REM rebound. A little bit of exercise will help you feel better. And trust me, I know just how hard it can be to do when you don't feel like it.

Here's hoping you start feeling better soon!

M.D.Hosehead wrote:

roster wrote:‎1. Go to Google maps.

2. Go to "Get Directions."

3. Type Japan as the start location.

4. Type China as the end location.

5. Go to direction #43.

How do you keep finding this stuff?

Lots of friends who know I am a glutton for silliness.

Many patients that have a lot of arousals feel very tired for the first several weeks, even months, on PAP therapy because they are catching up on sleep. It may be that you do have reduced stage 3 sleep. This is very common in sleep apnea where there are lots of arousals.

This is where things no longer seem so logical to me: I was NOT tired or sleepy during the day before I started CPAP, even though my RDI indicates I was arousing approximately 23 times an hour---which works out to be an arousal about every three minutes or so. Now, I'm not denying that my body was indeed suffering from sleep deprivation of some sort due to the apneas---but the sleep deprivation had NOT (yet) lead me to crave sleep in any way. I wasn't feeling like I needed to fall asleep all the time. I didn't even feel particularly tired on most days. I had plenty of energy to do my job (college teaching) very well and still had enough energy at night to do things with the family. And every time I filled out a questionaire like the Epworth Sleepiness Scale (one version is posted at http://www.sleepeducation.com/SleepScale.aspx ), I'd score well in the "You're getting enough sleep" category.

But now that I'm no longer waking up every three minutes in order to breathe properly, I'm suddenly dealing with problems with daytime sleepiness and daytime exhaustion and daytime grogginess of proportions that I've never experienced before in my life. Three days after starting CPAP I developed severe and almost incapacitating daytime sleepiness. For the first time in my adult life I have been afraid to drive during the day because I now feel like I might just fall asleep at the wheel. About the same time I developed severe and almost incapacitating daytime exhaustion---exhaustion of sort that I have literally not felt since being the mother of a newborn who's not yet sleeping through the night. And most disturbing has been that my mind has been lost in a CPAP fog since about day 3 or 4 on the machine. I find it very difficult to concentrate long enough to grade my papers for example. And it's hard for me to remember my daily appointments even when I've got them written down on a calendar. And it's much harder to follow conversations now than it was pre-CPAP. And even now, when I fill in an Epworth Sleepiness Scale questionaire, my score clearly lands me in the most sleepy group that's told, "See a sleep specialist immediately."

Wow, robysue, Often I read your posts in here and have to check to make sure they were written by you and not me! Our symptoms since starting
therapy seem very similar.

Interesting that in both our cases or oxygen desats were not too severe, and (do I remember this right) that we both had mainly hypnopeas and not apneas.

Good luck with your switch to APAP! Keep us posted!

In my case I switched DMEs and found a therapist who actually spend nearly an hour fitting masks. So as of Thursday night, I am now sleeping with a nasal mask instead of the swift FX pillows I was using. When she tried to fit my swift FX which I took along with me, she couldn't do it with out leaks, and concluded that my nostrils are just the wrong shape for the pillows. Ok, getting OT here so I'll start another thread about this.

larry63,

Good to hear from you and good to see that your still working hard on making this CPAP stuff work. I'm glad to hear you've been able to find a different DME. Some of your posts describe real nightmare scenarios.

You are right: During my diagnostic test, my desats were minimal at most (02 nadir was either 91% or 92%, with the obvious observation that 100% of the test time my O2 levels were above 90%. And the vast majority of my events were listed as hypopneas with arousal.

Best of luck,
robysue