[CPAP] Intense Fatigue - Seeking Advice: CPAP Data Analysis

[PerplexedTom]

Hello lovely folks! I hope this message finds you all in good spirits.  I'm reaching out for some assistance regarding my CPAP data graphs.  Please forgive me if I have used the wrong thread subject prefix (I'll change it if there is something more appropriate).  

Approximately 6 months ago, I developed symptoms of very strong and crushing fatigue that so far have remained unresolved.  It's worth noting that I was diagnosed with severe obstructive sleep apnoea (OSA) when I was 25.  I've also been prescribed pregabalin for ongoing chronic pain.  I'm finding it increasingly difficult to perform daily tasks and take care of myself, feeling very unproductive.  At this point, I have a high suspicion that my issue is related to worsened breathing while trying to sleep.  Despite being under the care of my doctor for diagnosed (probable) iron deficiency with borderline anaemia, taking pregabalin 75mg morning and night, and being 41 years old and in the middle of the healthy range for BMI, I still seem to be experiencing issues during my sleep.  I've noticed that there doesn't appear to be any change in my CPAP data when I'm not taking pregabalin.  I've recently noticed an interesting anomaly in my CPAP data: although I consistently use mouth tape and a chin strap, my I:E ratio tends to be inverse, except for my last few nights where my I:E was 1:1.  Usually it is usually between 1:0.5 and 1:0.7 ratio.  Once I turned on EPR, it seems to have brought my I:E ratio closer to or at 1:1 (TMK this is still not quite ideal).  I use a Resmed AirFit P10 nasal pillow mask and F&P SleepStyle Auto CPAP machine.  I annually have my machine checked to see if it's holding a given range of pressures, and so far it seems to pass these tests, but I understand anything is possible and perhaps my machine could even be faulty (It's 2 years old).  I tend to have a 95% percentile pressure around 6.5

I'm hoping that by sharing my CPAP data, some of you might be able to help me identify any potential issues or patterns that could shed light on what's happening while I'm asleep.  Your expertise and insights would be immensely valuable to me in navigating this situation.  Thank you all so much for your kindness and support!  

 

   
   
   

[PeaceLoveAndPizza]

How did you end up with your current settings? Doctor/sleep tech prescribed or self titration? 

Inverted I:E is usually related to flow limitations, so as you noted when you added more pressure support it was corrected. I:E is different from person to person, so don’t dwell on it too much right now. It is just another data point.

[PerplexedTom]

I appreciate your reply, PeaceLoveAndPizza

Trial and error, by following the overall 95th percentile pressure readings I would get from my data over time.  Usually, I just had it sitting on APAP mode between 5.5 and 7.5, no EPR.

My actual sleep tech prescribed setting as of 2017 (the most recent exam I had) is 5 mmHg

I have been trying my best not to worry, but this level of fatigue is very concerning and I'm not seeing much motivation from my GP in terms of trying to figure out what's going on.

Not all overnight data seems to flag Flow limitations, but I understand they can be there if reviewing other data.  I can't understand what would be causing them.  My index for FL is usually 0.50 or thereabouts.  

I'm wondering if another sleep study is the way to go, or if something more sinister is going on and it just hasn't been discovered for the moment. 

Last night
   

[PeaceLoveAndPizza]

Your settings in that chart are very different from your previous ones. The early ones are all fixed pressure, last night was variable. Definitely moving in the right direction.

I do not see any major concerns in that chart. AHI, flow limitations, pressure, respiration rate, tidal volume, I:E, leaks, etc, are all within desired ranges. AHI could be a bit lower, but that should reduce as you adapt to the new settings.

Your feelings of malaise may be related in both the earlier charts and last nights to the arousals seemingly caused by leaks. I cannot tell if they are mouth leaks or from mask movement. If it is mouth leaks you can reduce or eliminate them by using a soft cervical collar, mouth tape, or possibly moving to a full-face mask. If from mask movement, it likely is due to you turning your head into the pillow or pulling on the hose, both of which cause the mask to move. 

I suggest changing things a bit, something like:

Min pressure 8
Max pressure 15
EPR 3 full-time
No ramp

You will likely never reach the max of 15, but it provides room if needed. Moving the minimum to 8 may help with the remaining OA and H events, and hopefully will not increase CA’s, but we’ll have to see how you respond to it.

Think about overall sleep hygiene as well. Sometimes we miss the bloody obvious looking for complexity.

https://www.sleepfoundation.org/sleep-hygiene

I do not know if another sleep study is indicated, but regarding your machine it seems to be doing its job. I am schooled in the SleepRider school of CPAP and always suggest a bilevel as it has the most options to tweak. But I do not see anything wrong with your current one that makes me think there is a change needed. At least not yet.

[PerplexedTom]

You're correct; I have been researching and experimenting out of desperation to help myself.

I still feel terrible today, FYI. Based on your suggestions, I have decided I will buy the F&P Brevida nasal mask, which has an interesting design that essentially doubles up on nose seals (inside the nose and around the nose).

Regarding leakage, I use tape on my mouth and a Seatec head strap with a mouth cover, effectively attempting to double up on mouth sealing. I could certainly position my CPAP machine better for the tubing, so it doesn't pull on my face at any point. Placing it on my nightstand with the tubing up and behind my pillow would likely help, ensuring there's plenty of slack to prevent tugging when moving around. Thank you for bringing this up.

I have adjusted my CPAP to your suggested settings. Here's hoping for a better night's sleep tonight! I will definitely monitor any potential changes in CA events following the setting adjustments.

A good reminder about sleep hygiene. Managing this aspect is complicated for me due to chronic pain, which I struggle to find much relief from. I perform a stretching routine before bed, but I don't find it consistently effective for overnight pain relief compared to regular paracetamol and pregabalin (which probably just helps me relax more than anything). Once I've tried a week with these settings, I might experiment with skipping pregabalin before bed to see if it affects CA events. Perhaps I've been overlooking factors while trying to interpret my machine data.

I'm glad to hear that it seems like my machine is doing its job. When this machine reaches the end of its useful lifespan, I anticipate purchasing a bilevel machine, which should hopefully become more affordable over time.

I underwent nasal surgery in 2022 to address my nasal breathing issues, which has been a tremendous help. However, I'm now contemplating whether it was a mistake not to address my tonsils, lingual tonsils, and adenoids at the same time. My ENT suggested these procedures, but I declined and focused solely on my nose. Do you have any opinions on worthwhile procedures for improving breathing? What are the commonly recommended options nowadays?

[PeaceLoveAndPizza]

I have no knowledge of prescription or surgical options. Others more knowledgeable will hopefully chime in with thoughts.

I know my nose was broken at least twice, if not more, and just ignore it. I do use Flonase for allergies, which does help quite a bit. Like you I have chronic pain from poor choices in youth, same way my nose was broken. Ah, to be young again…

Focus on sleep quality, not numbers. With the number of inputs we now have available from smart watches, smart rings, CPAP machines, various and sundry monitoring devices, we are flooded with data. 

I know our tendency is to analyse and micro-analyse our sleep. Too often in our quest for perfection we miss the just good enough. 

Deep thoughts for the day…

[PerplexedTom]

Hopefully someone who's learned a thing or two about surgical procedures for sleep apnoea can share their knowledge and experience here.

How bad is your nose?  Maybe consider getting it looked at by an ENT and discussing your options, depending on your identifiable pathology and symptoms.

I agree there is plenty of data to be had these days.  My problem with it is that sometimes it's not showing the whole picture of what's going on, not without thorough investigation anyway.  I also consider the possibility of differential diagnosis.

I am driven to analyse my own health data for purely selfish reasons... I am very concerned about what's happening with me.  It's not normal, or liveable for that matter. 

There's definitely a lot to think about and discuss, sleep apnoea related or otherwise, on this forum.

On another visit to my Doctor, there has been some discussion about a finding in my lower abdomen, an incidental finding from something unrelated.  I am not going to worry, but I am being sent for a gamut of tests.  A suspicious fluid filled mass, found during a lumbar MRI.  The issue has been that it was overlooked several months ago.  I have had doctors arguing about whether or not I had a true iron deficiency, and that being offered an infusion was unnecessary and basically unwarranted.

The last two nights with min 8 and max of 15 with EPR set to 3:

       

[PeaceLoveAndPizza]

I’ve had my nose looked at and surgery was recommended. I decided to just live with it using as needed nasal sprays, nasal rinses, and allergy meds. So far, it is acceptable.

Regarding your last few charts, I think with your 8-15 range the flow rate looks good, so would leave it there and possibly drop the max to 12. No harm in doing so as you do not get above 10.

You could try increasing pressure by 0.2 every few nights to see when the hypopnoea’s and obstructives are reduced or increased. We are looking for the right EPAP/IPAP pressure to balance comfort, AHI, and arousals. Small, incremental increases are less disturbing than a big jump in pressure.

Best of luck with the docs. Hopefully just a storm in a teacup.

[PerplexedTom]

Just a quick update:

I've had a bunch of updated blood tests ordered, including:

- FBC
- E/LFT
- Iron Studies (including serum iron, TIBC, transferrin, ferritin and possibly soluble transferrin receptor / sTfR)
- B12 (and possibly MMA)
- Folate

The clinical notes indicate "low iron." I'm undergoing these tests after 48 hours of abstaining from supplements to ensure accuracy.  Additionally, a second look at a lower abdomen ultrasound has been scheduled.

Regarding CPAP pressures, I'm managing with a minimum pressure of 8.5. However, I do feel like I'm somewhat struggling against it until I fall asleep.  I'll monitor this for a while.

As for my fatigue, there's been no change.  I don't feel any better, but I'm not feeling worse either.  Dealing with all of this is quite taxing, making it challenging to function normally.

It's worth noting that whenever I take B12 (1000mcg sublingually), I experience increased fatigue/tiredness and tend to sleep more deeply and consistently.  After conducting some research online using scholarly sources and AI, it appears that this reaction could be normal for someone deficient in B12.  However, certainty is elusive.

Another factor to consider is my dietary habits.  I've been intermittently following a vegetarian diet for the past couple of years, which I believe may be contributing to my symptoms. As a result, I've decided to incorporate some form of animal protein into my meals at least once a day to address this.

Thank you for your assistance thus far, PeaceLoveandPizza.  I'm leaving these notes here in the hopes that they may help someone else going through a similar experience, seeking data for their own situation.

[PerplexedTom]

I haven't slept well the last few nights, but I got some form of sleep last night.  It's been a couple of hours since I woke up.  So far, I don't feel horrible, but I still have fatigue.

I was very fatigued yesterday, but I managed to keep it together and get some things done.

I had my blood test yesterday, so I'll leave it a couple of days until I follow up with my General Practitioner.  Let's see what comes of it.

Now that my tests are over with, I'm taking this stack of supplements and medications:

1000mcg of active B12 - daily (I plan on this for 30 days, then 1x per week thereafter)
800mcg of Active Folinic Acid - daily (as above)
B complex with enough from each vitamin to at least support dietary intake - daily or every 2nd day
Vitamin C 250mg - taken in 125mg doses, two times a day
Iodine - just the RDI per day (seaweed tablet)
Vitamin D - 1000 to 2000 IU per day MAX (I usually use Dminder app and aim for about 2000 IU from sunshine, daily, besides taking a D3 supp)
Iron 65mg elemental - I was taking this, but stopped, due to unbelievably increased fatigue from it's consumption, which would not ease until about 24 hours later (I may swap to a different form of iron and only take 20mg elemental per day at some point.  *depends on what my blood test shows)
Magnesium 100mg - Taken 2x times daily to support dietary intake
Zinc 25mg - 1x daily or every 2nd day
Vitamin A 5000 IU - 1x every 2nd or 3rd day (to stay within healthy intake limits)

Pregabalin 75mg - taken once a day, 12 hours apart (jumping up to my old dose of 150mg twice/thrice per day, soon)

Last night (some half decent sleep)