Central Sleep Apnea, CPAP, and rough early mornings

[middleraven]

Hi! I’ve always been a light and turbulent sleeper; frequent awakenings, vivid dreams, and sleep paralysis, for starters. I definitely need around eight hours to feel well rested, though I could get by on seven.

About a year ago, I started waking up suddenly after about six hours of sleep no matter when I went to bed. A few months after that, I started jolting awake right after falling asleep. My wife noted how my snoring had gotten worse.

You know the drill: got referred to a sleep doctor and an in-lab study. I was diagnosed with mild central sleep apnea (~8 AHI). It was a tough environment to sleep in so I only got ~4.5 hours of sleep and my doctor assumed there was also an obstructive component that maybe just didn’t rear its head there.

Still, he was a little surprised and I had an MRI to verify nothing on my brainstem was causing central apneas - all good there. I did the CPAP titration study and they said a CPAP at a pressure of 7 seemed to keep things around ~1 AHI. That said, I only slept 6 hours in the study before I woke up and they ended the study…put a pin in that one.

The CPAP immediately improved the first 6 hours of sleep every night. No more tossing and turning, no sleep paralysis, no issues falling asleep at all. Ten minutes in bed and I am out. No concerns about compliance here! Took a while to find the right mask, but I settled on an F30i.  I’ve been using a CPAP for almost 6 months now. Cool, right?

Well…the CPAP hasn’t done anything to help my early awakenings. No matter what time I go to bed, no matter the day, how tired I am, what supplements I take, I wake up after almost exactly 6 hours of sleep in a sudden start. My heart is racing and I feel…kind of odd?

Nowadays, I can fall back asleep after ten minutes…but then I wake up again, about 15 minutes later. I fall back asleep five or so minutes later but then I wake up again after 15 minutes. This continues until final wakeup. 

I feel very odd every time I wake up like this. My breathing is shallow and sometimes I wake up to notice that my pressure is oscillating because I’m not inhaling. It’s like I breathe out and then forget to breathe in. I’m not imagining my heart racing, either - I see on my watch that it spikes right before I wake.

My doc said maybe I just need six hours of sleep or that it’s just anxiety. He’s been pretty dismissive – my average AHI over the last few months is low (~3) and my compliance is high. But…I’m dead tired every day. Exhausted and groggy, especially in the mornings. I can hardly stay awake at nights; it feels like I’m always not getting enough sleep, even if the quantity is 8+ hours.

I’m not anxious, either (I swear!) - this wakeup happens every single day and I’m not waking up stressing about getting back to bed. I have no problems falling asleep. If I wake up earlier in the night - like a kid comes into the room - I have no issues getting back to a sound sleep until that six total hours mark. It happens on weekends, holidays, you name it.

Something isn’t quite right here and I don’t know what to do. I made an appointment with a new doctor, but in the meantime, pulled OSCAR data. While my average events are low…they get high and spike around the time I get jolted awake and remain high when I fall back asleep, too. They’re a mix of CA, Hypopneas, and RERAs. Very few are obstructive.

This doesn’t feel quite normal. Is it possible that my pressure is enough to get me asleep but not through the morning where - from what I’ve seen online - sleep apnea can be at its worst? 

Thank you. Any thoughts or suggestions would be greatly appreciated. I included screenshots of three representative days in the past few weeks.

[PeaceLoveAndPizza]

Next time please remember to hide the calendar and pie chart. The more we can see on the left hand table the better.

From the chart, I think we can say you do not have enough pressure to handle the hypopnoea and obstructive events. The dilemma is the solutions may create more centrals, but we will not know until you try them.

Your wake-ups are likely from the bursts of flow limitations that in an APAP mode would cause a pressure rise to deal with them. It will go back down when they are managed, but we will minimise the range to make it more comfortable.

Consider trying something like:

Mode APAP
Min pressure 7
Max pressure 12
EPR 2 full-time
No ramp

That may be enough to help get a better sleep quality. A few nights should tell us which way to go from there. Next steps would be to increase or decrease EPR depending on how the flow limitations respond, and to revisit the pressure range depending on how much it takes to handle the flow limitations.

If you want to stay with CPAP mode, you can increase your pressure to 8 and set EPR to 2. The challenge with this is we do not have a sound basis from titrating pressure, so it is a bit of guesswork.

I suggest giving the APAP mode a try for a few nights and let us know how it goes.

[TechieHippie]

I know that early morning feeling so well. Very similar except mine is not fixed at 6 hours, sometimes it starts early and sometimes later. I have had a few theories (chemical sensitivity, thyroid, tongue fatigue, you can find my recent thread if your are curious, it has my user name in the title), but what I'm realizing is the morning pattern is a symptom of the rest of the night as well recent sleep history, rather than it's own disorder so I'd encourage you to hang in there and optimize the whole night using Peace's and others advice and see if this improves. Mine improved a lot by doing this, I'm still getting swings into that pattern but not nearly as bad, after only 5 weeks of therapy.

[staceyburke]

The last night 30th - you had positional apnea.  The other 2 nights you may have had a little bit.  

You can see positional apnea where either H or Oa events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.

[middleraven]

I owe y'all one. I was a little nervous to make adjustments to the machine myself, but I did set it to AutoSet and slightly opened up the pressure - min 7, max 9. I left EPR off - it caused a ton of Central Apneas for me previously and the pressure doesn't bother me.

It's only been two nights, but holy cow - what a difference. I slept better and my AHI dropped - all the way down to 0.6 last night. I slept about 8 hours and I feel like I could run through a brick wall today. No more RERAs and a much smaller amount of hypopneas and centrals.

Attached a few screenshots here. I'm amazed such a seemingly small change made such a huge difference. I'm guessing that, with how frequently the pressure increases, it was definitely not at a level enough to keep my asleep during the worst parts of the night. I'll probably give it a few days and open up the max to 10.

Cheers!