2 PSG Studies w/ RERAS, Unsure OSA/UARS Diagnosis and APAP Pressure

[SleepyTeacher]

Background: 
-30m, 5'10, 205
-Constantly been tired since my 20's regardless of 6-12 hours. Maybe 1 day everyone few months I feel like I slept and am refreshed. 
-Daytime fatigue affects my personal life and career. Brain fog, memory problems, sometimes executive functions.
-Increased anxiety and mood, I always feel like I'm sleep-deprived. 
-Wake up multiple times per night. Occasionally I wake up and try and go back to sleep but can't because it still feels like I am half-dreaming. Very disorienting. The only thing to do is physically get out of bed for 10 minutes or so, wake up a bit, then go back to bed. It's like my brain is stuck in REM sleep/N3



Health: 
-Had tons of medical and blood work over 2 years, even a brain MRI (updated MRI shows no change and white matter was a mistake) 
-Had a positive ANA for Schlerdoma (CREST) but no symptoms for 2+ years. 2nd ANA was negative. They were not concerned.
-Have MTHFR mutation (can't process folic acid) so now avoid enriched foods.
-slightly low on Vitamin D this winter.
- 9 ug/dL lead level (I shoot USPSA) has been lowered, only went up a year ago. 



Meds:
-Wellbutrin 5 months ago to help with mood, Xanax ONCE in a blue mood for anxiety (.5mg 1 every 2 weeks)
-Taking all my vitamins, fish oil, and Methylofolate (helps with MTHFR)




Sleep Studies: Both are attached:
Study 1: Study on 1/7/22. It was a horrible experience, they were very late and in a rush. I felt like I was awake for pretty much the whole time. I legit was in my head going "man, this really sucks, when will I fall asleep..." for what to me felt like the majority of the night. Woke up multiple times.



AHI of 4, RDI of 9. 
REM AHI 17
Spontaneous arousals 3.9
PLM 10.7, only 0.7 arousals index
Slept mostly on the side. 



Study 2: They wanted to repeat the study, went much better this time. They made me sleep on the back majority. Was hard but felt like I slept better than in the first study. 



AHI 5, RDI 22
REM AHI 25
(114 RERAs)
Spontaneous arousals 5.1
PLM 11, only 1.0 arousal index



Dr. things mild OSA and possibly UARS goes with Resmed Airsense APAP 6-16 pressure with EPR set to 2 with p10 nose pillows


OSCAR:
Day 1-3 no SD card. I used just P10 pillow, fell asleep for 7 hours the first day. Actually felt like it did something. Wasn't refreshed, but better than my usual sleep. I thought it was great until day 3 when I woke up to my lips starting to flutter and chip munk cheeks.



Day 4:  OSCAR data. 2.69 AHI Realize I am having bad mouth leaks. Sleep felt decent besides.



Day 5: OSCAR GREAT sleep first 4 hours, terrible sleep last 4 hours. 0.70 AHI 



Day 6: OSCAR. Put EPR on 3 forgot to plug in the SD card. Woke up in the middle of the night and put it in. Horrible night's sleep.



Day 7-9: OSCAR. Started using mouth tape because of leaks and I did not believe the low AHI numbers. Started to see a lot more APNEA show up (Central, OA, and H)




My flow limit is all over the place and my graphs look awful. Some of the CA are deep inhaling and movements. 



I have been looking at my flow limits and each breath sequence, very rarely are mine in good curves, with lots of dips at the top. This picture is from the "best" flow limit of the night.



I feel much worse than when I started. I wake up more, and I feel pretty bad. Some nights I only need 6-7 pressure...other nights 15! I do think 2 EPR is best. It could just be that I am waking up because of the p10 pillows. Even though I nose breath 99% of the day, and my tongue is always on my pallet, when I fall asleep my mouth stays closed but my tongue droops juuuuuust enough where I got bubbles of air in my cheek and wake me up regardless of chin strap, mouth tape, or mouth guard. Going for a full face mask fitting on Wednesday. 


Any advice or suggestions would be wonderful. I know I need to stick to one thing but not sure if my diagnosis is wrong and I don't even need CPAP, or its the p10 air bubbles causing me to wake up. 



Thank you,



-Sleepy Teacher

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Sleep study 1

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Sleep study 2

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OSCAR charts

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OSCAR Cont

[SleepyTeacher]

OSCAR & FLOW

[SleepyTeacher]

I apologize for long message and disorganization. I tried to just insert an IMGUR link to the studies and then graphs but it did not allow me.

It is strange that the primarily sleep on my stomach and side that the first sleep study shows only 1 event, and 1 RDI for side......

But then on the second sleep study....which was primarily on back, it showed 4 AHI and 11 RDI for time on my side.  So bizarre and inconsistent, makes me feel like I don't know what is the actual diagnosis.

[SleepyTeacher]

First part of 1st study

[SleepyTeacher]

I went and got my F20 facemask on Monday. Used it Monday night. Slept ok, still tired.

I used it last night and woke up extremely tired. I woke up multiple times during the night and felt like I barely slept.

I know that the seal and leaks were good, and the pressure looked good. Feeling very defeated. 


Meeting with sleep Dr. today.


Any help would be appreciated, attached are last two days with F20.

[Sleeprider]

Overall, your therapy is effective, but with relatively high residual flow limitation and ineffective minimum pressure. You will need to take minimum pressure to 9.0, maximum 14.0 and EPR at 3. This should reduce flow limitations and arousals as well as minimize the variation in pressure you experience through the night. If you don't find a minimum of 9.0 to be tolerable to start, you can use an auto ramp from what you do tolerate, however these are not particularly high pressures considering EPR results in 9/6 to 14/11 range. Your closeup from April 12 shows a pattern of recurring arousal that may be respiratory or limb movement. Once we get an idea of your results from EPR 3, we can take another look to see if we can better decipher the pattern. You seem to do much better for leaks with the F20, however your leak rate with the P10 is barely above the large leak rate for small portions of the night. What are your thoughts on comfort vs leaks? I think you should pursue comfort rather than perfection in leaks.