Daytime fatigue w/ lower AHI, higher number of CA

[quartet3424]

Hi Everyone,

I am a Male, 32 years old, 6'0", 208 lbs. I was diagnosed in my early twenties and have been struggling since then. I've been consistently compliant w/ CPAP therapy for the last 7 months.

I have daytime fatigue, which is much worse if I don't use the CPAP. 

Current configuration:

Machine: ResMed AirSense 10 
Mask: ResMed F20 full face mask
Pressure: Fixed pressure of 11 with an EPR of 1
Mouth taped
Try to side sleep

I have a history of mouth breathing and a tongue thrust. I have a beard that a try to keep very short to improve mask seal.
I also started utilizing mouth taping to reduce aerophagia, with mostly successful results. 

I'm looking for adjustments I can make to help improve symptoms. Any advice for me?

Thank you

[quartet3424]

After reading through the forums and wiki some more, I tried adjusting Pressure up to 12 and EPR up to 2. 

Subjectively I feel pretty good this morning, definitely better than recent days. I had initially done the adjustment with the intent to improve flow limitation, but from the statistics, that doesn't seem to be improved. But, the number of clear airway events are down, and the total time in apnea is 1 minute vs ~3 minutes from my last post. 

Will give it a few more days and see how consistent it feels.

I've attached the overview of last night, a zoom in on a limited flow section, as well as a limited exhalation (potential palatal prolapse?) section.

[quartet3424]

Have been trying some adjustments since last I posted. 

I decided to try a cervical collar. I've tried a few different ones, and found the 2.5 inch to be the most comfortable, and it seems to have improved flow limitations as well. I've been feeling more rested, but I'll need to see if it lasts over the next days.

I also got a pulse oximeter, and the rates seem pretty good, with only 1 desaturation.

I've found it hard to get a consistently low leak rate with the full face mask. I might try a nasal mask in the future, but am unsure if I create a good seal with the back of the tongue and soft palate.

[Jay51]

Thank you for posting all of those charts.  Your therapy looks pretty good.  A few things I see are a respirtory rate at the low end of normal range (about 12 median).  From what I have read, 12 to 20 or so is average.  

Your tidal volume median good at 500.  Minute vent ok.  Your inspiration time is a bit higher than average, but ok.  About 2.5 seconds.  Since your median respiratory rate is about 12, you compensate by taking larger, and slower breaths to keep your minute ventilation up.  

Your median pulse rate for the night is 39.  That is pretty low.  Gets down to 31 for the low of the night.  Do you see a Cardiologist?  What have they said about this? What has your PCP said about it?  Not to scare you, but just saying.  

I can't speak to palatal prolapse or not.  I don't have enough experience with that.

[quartet3424]

Thanks Jay! I appreciate you taking a look.

With respect to respiratory rate, I don't take any opioids, and I don't have hypothyroidism. Maybe it is related to the slow heart rate? My blood oxygen looked okay to me. It was 96% when I was asleep, and during waking hours that same sensor reads 97%.

Regarding the pulse, I would like to see a cardiologist about it, because it seems super low to me too. I have talked to my PCP about it in the past, and he doesn't seem concerned, I think because I don't seem to have any negative symptoms due to it (like during exercise etc.), but I still wonder what is going on there.

I had another pretty restful sleep last night, still hard to get a good mask fit, I managed to displace the cervical collar at some point during the night, I think I need one with a slightly smaller diameter. I think that is reflected in the flow limit somewhat, but definitely need a bigger sample size

[quartet3424]

Well, these are the best numbers I've gotten in a long time. An RDI of 0.3! And of course it is the one night I forgot to put the SD card in. 

Given that my apneas were mostly central recently, I decided to lower the minimum pressure from 12 down to 10. And I raised the maximum pressure to 15 (just to see where it would run up to during the night). I woke up with the pressure being 10.7.

I also managed to wear the 2.5 inch cervical collar the whole night. And mouth tape.

I'm feeling pretty good today! I am curious to see if I'll start to feel fatigued in the next hours.



So I don't only post the positive stuff, the second image is from yesterday. The numbers certainly don't look *that* bad with an RDI of only 1.9, but I felt like a zombie most of the day, and took about two naps, even though I slept for 8 hours. I managed to remove the cervical collar at some point as well. 

The relatively small difference in RDI, with the large difference in subjective experience makes me feel like I'm dealing with disordered breathing that maybe doesn't quite meet the criteria for events. Or who knows, and I am very sensitive, and a few additional apneas can really affect how I feel.

[Jay51]

Thank you for posting those charts.  Both look ok.  The 1st one looks great.  In the beginning people can have what is called treatment emergent CA's, or Therapy onset CA's.  Since they are breathing much better, they are also getting rid of more CO2.  CO2 in the blood is the signal to breathe.  So less of it can cause some CA's.   You don't have many CA's, so I wouldn't worry about it much.  If they get worse and your AHI gets over 5, then more changes might need to be made, but you are a very quick learner on how to adjust your settings (and soft cervical collar) to get the best results.  You have pretty much got it figured out IMO.