Chronic Insomnia

[mawaw1992]

I have been on cpap therapy for around 20 years treating a severe case of sleep apnea. My therapy was doing good until this past June when one night I could not fall asleep. Up until then I would take 1.5mg of Melatonin before going to sleep and would get a consistent 7 hours of sleep with a Total  AHI of 1.0 or below. Then in June I had dental surgery and that night I could not get to sleep. This continued for 4 nights until my doctor prescribed me Trazodone to help get to sleep. After 2 weeks I finally got to where I could fall asleep pretty quick but started waking up during the night almost every night. At first it was always around 3:00a.m. and has changed to different times of the night. I started thinking it might be a hormone imbalance. I figured it might be caused from a high level of cortisol (a stress hormone) produced by the adrenal gland due to the stress from the dental surgery. So back in November I had my cortisol checked and it came back normal. I have been doing whatever I can to try and get a decent night's sleep. I now take 2mg of Melatonin (Extended Release), 100mg of Trazodone, 2 Magnesium before going to bed to try to sleep all night. Then the nights when I wake up I will take 5mg of Ambien. I am a person who hates taking pills to sleep. It makes me feel like a drug addict.  I have kept a daily journal where I document my blood pressure once in the morning and then in the evening, my AHI reading from each night and also a sleep log of what medications I took that night, how many times I woke up during the night and at what time I woke up. So this past week I downloaded Oscar to see what it showed about my sleep therapy. I do not understand how to read all the charts but did notice that at the time I woke up last night that there was a gap in my Flow Rate of about 3 minutes.  So I looked at my sleep log at another night I woke up and the same thing, another gap at the same time I had written down as to when I woke up. I was hoping that someone here might be able to look at my charts and tell what might be happening. I just saw my sleep doctor back in October and her idea is that as long as my AHI is below 5 that I am doing great. But I am not apparently. I was using a Resmed S9 up until November with a set rate of 12. I purchased a Respironics Dreamstation Apap machine and have it set to 10 min to 14 max. I need help. 

Thanks,
Mark

[OpalRose]

Just use the link below to Organize your chart from the daily page of OSCAR, then use the Attachment Feature to post a chart here. Someone will be along to advise.

[mawaw1992]

[attachment=28872][attachment=28873]Here are a couple of screenshots from my sleep on Dec 7, 2020. According to my sleep log I woke up around 11:45p.m., 12:48a.m., 3:00a.m., and finally at 5:15a.m..

[Sleeprider]

I must have missed this new thread posted on Christmas day.   You are using a Dreamstation Auto CPAP at 10.0 minimum 14.0 maximum pressure, Flex 3, and seem to experience considerable arousals during the night that are disrupting your sleep. I think on your chart, we can visualize the arousals where larger spikes are present in the Flow Rate. In the graph below from Dec 7, we see spikes at 23:00, 23:20, 23:40 and intermittent spices from 00:30 to 00:50 where the first break occurs. There appears to be a quiet period from 01:00 to 02:00 where se see more of these spikes leading to a break at 03:00, and a very disrupted third session.

To better understand what is happening, it would be helpful to post some charts that are zoomed in to 2-3 minute segments immediately before the spikes and during the  suspected arousal. We want to see the individual flow wave shapes to make an interpretation of your respiratory flow and how it changes during these arousals.  The main suspect is flow limitation which will be evidenced by flat-topped inspiratory peaks, but lets see what is in the graphs at a closer zoom and go from there.  At this point, only need the standard view zoomed rather than the Advanced view with resp rate, tidal volume etc. The purpose of our review will be to identify respiratory disturbance as a possible source of sleep disruption. I'm not well-acquainted insomnia and hopefully someone better at that topic can also contribute. I do know that "periodic limb movement" PLM can be a source of the kinds of flow disruption we are seeing in the chart. Are you aware of a PLM disorder or has your wife/bed partner ever commented on movement during sleep? Based on my own experience with Dreamstation machines, I think a Flex Level of 2 may be helpful in syncing with your breathing better.

[mawaw1992]

[attachment=28890][attachment=28889][attachment=28888]I don't know if this is exactly what you needed. If not, just let me know what other information you need. As far as the PLM question I don't know. Because of my sleep disorder my wife and I have been sleeping in different bedrooms. Hopefully you can help me figure out what my problem is and I can find something to help me so that my wife and I can start sleeping together again. Like I mentioned in my original post, this problem started on the day I had dental surgery. I am wondering that when I started taking the Trazodone, which is an antidepressant that is also used as a sedative to help with sleep, has it had an effect on my respiratory airway in some way. I am currently trying to wean myself off of it.

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[attachment=28891][attachment=28892][attachment=28893]Here are some more additional charts.

[mawaw1992]

[attachment=28894][attachment=28895][attachment=28896]Here are some more additional charts.

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[attachment=28897][attachment=28898][attachment=28899]Here are some more charts.

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[attachment=28900][attachment=28901][attachment=28902]Here are some more charts.

[mawaw1992]

[attachment=28903]One last chart. The period from 3:00 to when I finally woke up was after I took an Ambien to help me get some sleep. 

I am to a point to where I will do whatever I need to do to fix this problem. Is this problem something that could be classified as Complex Sleep Apnea or UARS? Also hopefully someone knows about the effect of sleep medications on a person with sleep apnea.

[Sleeprider]

I'm not accustomed to seeing the flow rate at this exaggerated vertical scale, and using the standard view would have been fine. I see periods of continuing flow limitation, and what I can't say is whether it is related to the Trazodone, but the logical approach would be to assume we found effective machine settings for your sleep apnea and flow limits, and that the Trazodone is the new variable causing problems. I would suggest finding an alternative since the problem started with the onset of that therapy. If you're using Ambien as a supplement, and have experienced increased sleep disturbance since starting Trazodone, there seems to be a logical cause and effect here. Talk to your doctor about stopping that therapy and if needed, try something else. I really don't want to mess up what was working great to accommodate a drug with side-effects known to affect this aspect of your sleep.

[mawaw1992]

I am trying to wean myself off the Trazodone. Hopefully I can get off of it for good. I had adjusted my Flex setting to 2 two nights ago and had a great nights sleep . Slept solid from 10:00p.m. to 5:00a.m. and fell back a sleep around 5:20 and woke up at 7:00. Felt good and rested. Then last night I woke up at 12:00 and stayed awake till 2:00 and then took an Ambien to get back to sleep. I woke up at 5:00 and felt bad all day. Is there any thing else I might try that would help? After my last sleep study years ago my doctor put me on Cpap with a pressure setting of 12. When I switched to the Dreamstation Auto Pap I set the settings from 10-14. I have noticed that on most nights my pressure rounds about 10.5. Should I go back to the 12 on Cpap and see what happens. Would higher pressure help my problem. Also I have read where others who have flow limitations find help with Bipap or the newer ASV machines. Also, others have mentioned the use of soft cervical collars that help them with flow limitations. Is this something that may help my problem if getting off Trazodone does not help my problem?

Thanks,
Mark

[Sleeprider]

Mark, I would try a Resmed Airsense 10 Autoset or Aircurve 10 Vauto before going to the extreme of ASV. I’m sure you would find either to be an improvement over the Dreamstation. I don’t see positional apnea in your charts. My assumption was we should work with what we have here. If you are willing or able to go to a Resmed solution then I doubt you would regret it.