New to Forum: 6 Months in and Sleep is Still Very Fragmented

[M'ohms]

from Pugsy
Next time you wake up in the middle of the night turn the machine off and on again real quickly if you find that you aren't going back to to sleep readily. That way we will see a blip in the flow and pressure line that we can look at to see if any clusters seen are around the time where the marker blip happens to be.

Pugsy,

Here is the report from last night--again I didn't sleep. I don't know if you can see my breaks throughout the night (I counted 9). In this shot, I could see them best in the leak line. It seems that my pattern behaves like this: the less I sleep, the lower my AHI; the better I sleep, the higher my AHI. I have been percolating on this idea for quite a while.

[M'ohms]

You can tell the breaks better in this shot from EncoreBasic:

[Pugsy]

Hmmm.
No clustering at all around the breaks in therapy which are fairly easy to see.
Maybe those ugly clusters aren't all awake breathing. Too soon to know based on one night though...did you spend much time awake during any of those breaks last night? Or was last night one of the nights where you went back to sleep each time fairly quickly (or for you fairly quickly)?

When you get your sleep studies try to find out of there is any positional component to your OSA being worse...like supine vs side sleeping and/or is your OSA worse in REM sleep.
I am thinking that with so many wake ups that you aren't getting much REM sleep...but maybe when things are a bit ugly on the nights when you sleep somewhat better you are actually getting some REM and your OSA is maybe worse in REM stage sleep. You know it is fairly common to have either supine sleeping or REM stage sleep affect the OSA.

[M'ohms]

Sir NoddinOff wrote:
Fragmented sleep can be a slugfest. It's not easy to beat because it combines the hardest challenges of CPAP therapy, with the worse parts of one's sleep hygiene, with the worse parts of sleep anxiety. That's not to mention ones meds (legal or otherwise), daytime stress, an unproductive or chaotic sleep environment, plus a crappy lifestyle (not that I'm suggesting you have succumbed to any of these things - just throwing it out for general consumption )

GIMME THAT HAMMER!

[M'ohms]

Pugsy wrote:
Hmmm.
No clustering at all around the breaks in therapy which are fairly easy to see.
Maybe those ugly clusters aren't all awake breathing. Too soon to know based on one night though...did you spend much time awake during any of those breaks last night? Or was last night one of the nights where you went back to sleep each time fairly quickly (or for you fairly quickly)?

When you get your sleep studies try to find out of there is any positional component to your OSA being worse...like supine vs side sleeping and/or is your OSA worse in REM sleep.
I am thinking that with so many wake ups that you aren't getting much REM sleep...but maybe when things are a bit ugly on the nights when you sleep somewhat better you are actually getting some REM and your OSA is maybe worse in REM stage sleep. You know it is fairly common to have either supine sleeping or REM stage sleep affect the OSA.

I was awake most of the night, not really dozing off until after 4:00 and then I was in and out quickly. I sleep in a recliner and try to avoid my back since it shoots air down my stomach. I am anxious to get a copy of my sleep study.

[Pugsy]

Keep doing the little breaks in therapy as markers when you are alert enough to do it. Don't obsess over it though as that will make the problematic sleep worse.
It doesn't look like your machine is picking up any awake/semi awake breathing irregularities (at least not last night) and maybe those ugly clusters are indeed real and maybe they are related to deep or REM sleep.
If that's the case I wonder if auto adjusting mode might be of benefit a little...tiny range to maybe help prevent the OAs without blowing you up too much. If those clusters are the real deal then it would appear that the pressure is sub optimal for those periods of sleep.

If you are sleeping in a recliner most of the time I assume pretty much always supine...
So that would leave REM stage sleep as the most likely suspect for the increase in events assuming they are the real deal.
I am documented much worse in REM stage sleep myself so I have a lot of experience with the wild fluctuations sometimes needed in REM sleep. During my diagnostic sleep study my AHI in non REM sleep was barely exciting at 12 per hour but in REM sleep I was kicking butt and taking names with 53 per hour. Big problem was that every time I was hitting REM and having the rapid succession of events then I would get kicked out of REM sleep with an arousal...so I rarely got deep sleep or REM sleep before I started on the machine.
Sometimes I need a lot more pressure in REM sleep and sometimes the pressure never varies much at all. A while back I eliminated supine sleeping as the cause for more pressure when I did and experiment for a month where I built a wall so that I simply couldn't roll over on to my back and I still saw some times where pressures went fairly high and sometimes where they didn't move much.
So for me since supine position doesn't seem to be a factor and I can't control REM that is why I use auto adjusting pressures and just let the machine do its job. I am lucky in that I don't have any aerophagia issues though.

So I am just thinking out loud here...wondering if maybe you have some REM stage sleep issues like I have. Of course you have to stay asleep to get to REM and you aren't staying asleep for some reason. REM stage sleep normally manifests itself about 90 minutes after sleep onset and then as the night goes on it cycles back more quickly and lasts longer and in the wee hours of the AM is when we typically have more REM.

Here's an example of what I mean with sometimes I need more pressure. I see something like this though maybe not quite so dramatic about once or twice a week.


Most of the time this is what I see

[M'ohms]

Here's last night's report:





I have wondered about moving to Auto mode...

Last night, I slept better. Still just as fragmented, but I was able to go to sleep quickly all night. I was awake mostly from 4:00 on this morning. I don't know why, but on each of the last 2 reports, I show a large gap in use. I never got up either night--just another off/on event.

[Pugsy]

Don't know why the obvious blank spot in the therapy line since you say you are sure you didn't leave the machine off for any period of time. Sometimes we get blank spots and don't know why. I have had them myself from time to time. I don't know if it is something related to the files on the SD card being perhaps corrupted so that the software just can't calculate things or what.
Sometimes I have been able to use a different software and there is no therapy break...sometimes it's consistent in all software.
Right now I have a weird thing with my Encore Basic software...it shows total blank usage for Aug 14 and 15...big zeros but Encore Pro and SleepyHead show the usage for those nights.

Your fractured sleep is obviously a problem and the cause is elusive. Have you ever tried auto adjusting mode? I don't know if it will make any difference....don't know if maybe the changes in pressure (assuming there are some) might even disturb your sleep more because some people who are real sensitive will find that the little changes in auto adjusting mode wake them up.
But at this point you are already waking up for some reason anyway. If you haven't tried it then I would think that it wouldn't hurt to try a small range to see what happens.

Since your body is used to the pressure support being fixed at 4 cm in your current mode I wouldn't go changing it.
If you want to use auto adjusting mode I would set your Pressure support at 4 minimum and 4 maximum and that will keep it like you are used to.
Maybe try EPAP minimum at 11 cm...and IPAP max at 17 cm....so a very small range similar to your current settings with just a little room to roam if needed. Just to see if the pressure line even moves in response to whatever it might sense.

In all honesty I am not at all sure that we can solve your fractured sleep with machine adjustments...mainly I am just thinking out loud at some "maybe" because we just don't know why your sleep is so fragile.
Since you have had fractured sleep for a long time...what have you tried in the past to try to reduce the fractured sleep?
Any meds? OTC or otherwise?
Have you done much research on sleep maintenance insomnia to see if anything stands out in your situation?

[M'ohms]

Don't know why the obvious blank spot in the therapy line since you say you are sure you didn't leave the machine off for any period of time. Sometimes we get blank spots and don't know why. I have had them myself from time to time. I don't know if it is something related to the files on the SD card being perhaps corrupted so that the software just can't calculate things or what.
Sometimes I have been able to use a different software and there is no therapy break...sometimes it's consistent in all software.
Right now I have a weird thing with my Encore Basic software...it shows total blank usage for Aug 14 and 15...big zeros but Encore Pro and SleepyHead show the usage for those nights. I have those kind of gaps as well.

Your fractured sleep is obviously a problem and the cause is elusive. Have you ever tried auto adjusting mode? Not yet.
I don't know if it will make any difference....don't know if maybe the changes in pressure (assuming there are some) might even disturb your sleep more because some people who are real sensitive will find that the little changes in auto adjusting mode wake them up. I am not sensitive to pressure changes (I know from apap).
But at this point you are already waking up for some reason anyway. If you haven't tried it then I would think that it wouldn't hurt to try a small range to see what happens.

Since your body is used to the pressure support being fixed at 4 cm in your current mode I wouldn't go changing it.
If you want to use auto adjusting mode I would set your Pressure support at 4 minimum and 4 maximum and that will keep it like you are used to.
Maybe try EPAP minimum at 11 cm...and IPAP max at 17 cm....so a very small range similar to your current settings with just a little room to roam if needed. Just to see if the pressure line even moves in response to whatever it might sense.
I will try that tonight.

In all honesty I am not at all sure that we can solve your fractured sleep with machine adjustments...mainly I am just thinking out loud at some "maybe" because we just don't know why your sleep is so fragile.
Since you have had fractured sleep for a long time...what have you tried in the past to try to reduce the fractured sleep?
Any meds? OTC or otherwise? I have tried 4 different Rx sleeping pills (no results), melatonin (no results), and benedryl (sometimes it helps).
Have you done much research on sleep maintenance insomnia to see if anything stands out in your situation? I have read a great deal on sleep hygiene, and I am pretty good at that. I will look up "sleep maintenance insomnia", if it is different. I'll keep you posted. Thank you for you continued help!

[M'ohms]

In researching sleep maintenance insomnia this evening, I expanded my search to include my thyroid replacement drug. This is what I found:

"Synthroid (levothyroxine sodium) is a synthetic compound identical to T4 (levothyroxine) produced by the human thyroid gland. Levothyroxine is the generic name for the drug. The drug is used to treat hypothyroidism due to many etiologies (for example, thyroid removal, thyroid atrophy, functional T4 deficiency, radiation treatment of the thyroid, and other causes). It is also used for pituitary TSH suppression. Common side effects include: fever, hot flashes, sensitivity to heat, headache, nervousness, nausea, insomnia, and transient hair loss. Some women experience menstrual changes. Serious side effects -- such as rapid heartbeats, chest pain (or both) -- are cause for patients to notify their doctors immediately.""

This could very well explain my situation since I have to maintain an artificially low TSH level (hyperthyroidism). Pugsy may have been on the right track by saying that my sleep problem may not have been caused by OSA. I will keep this info in mind as I continue to pursue Bipap improvements.

[Pugsy]

I take a pain pill during the day that comes with a "may cause drowsiness sticker on it" so one would think I should be able to take it at bedtime and sleep well....wrong...some people have a side effect listed like your thyroid...insomnia and it hits me so bad if I take one of those pills after 6 PM I am wired up till around 2 AM...either that or I get maybe 2 hours of sleep and then I am totally wide awake cleaning the house at 2 AM.

Sometimes we have to take meds that have unwanted side effects because those side effects are the lesser of the known evils when compared to what the med is supposed to address. IF the thryoid med is a contributing factor (it may not be the entire culprit) obviously you can't quit taking it but sometimes it helps to know that there is a possible reason for our problem and then we can discuss with our doctors what we might do to help reduce some or part of those unwanted side effects. In my case it was time of dosage and a change in pain meds for night time only. If I didn't take anything at all for pain at bedtime I wouldn't get good sleep because of the pain...but if I took that particular pain med at night I wouldn't get good sleep because of the unwanted side effect of insomnia...so we limit time of dosage and I take something else at bedtime. It took a lot of trial and error to find something that worked decently without making the OSA horribly worse.

Something to definitely talk to your doctor about though.
It's tough when we are in this situation where we are sort of caught between a rock and a hard place.

[M'ohms]

I feel like I've made progress, thanks to you Pugsy. I switched my pressures as per your recommendation. Here's last night's report:



In the back of my mind, I thought for the first time last night, that there might not actually be something else wrong with me (that represents a real effort on behalf of a number of people to figure out), and that it may just be my medication! I slept better--waking only 3-4 times during the night.

[49er]

I feel like I've made progress, thanks to you Pugsy. I switched my pressures as per your recommendation. Here's last night's report:



In the back of my mind, I thought for the first time last night, that there might not actually be something else wrong with me (that represents a real effort on behalf of a number of people to figure out), and that it may just be my medication! I slept better--waking only 3-4 times during the night.

I am so happy for you M'ohms. Much continued success.

49er

[M'ohms]

I went to my sleep doc today and got my sleep report. It looks like I have no positional apneas, but rather REM stage apneas. I have been sneaking my pressures up a little at a time to my present auto pressures of 13/20, PS 3-5. This has made a big improvement in how I feel; last Saturday morning, I felt so good I was giddy all morning! I honestly couldn't remember a time where I felt that good. My overall reports haven't changed much, and I'm still waking up (although not as much), but I do feel so much better.

BTW, my sleep doc was delighted that I have been proactive with changing my own pressures. Thanks to Pugsy for helping me on this part of my journey. If it weren't for the kind and supportive people on this forum, I probably would have given up! You will never know how important your efforts are to us newbies!