[Diagnosis] Concurrent Conditions and Diagnosis Doubt (Mild OSA)

[slortien]

Hi all, I've read here a bit, especially the longer threads on not feeling rested despite starting therapy. I'm less than two weeks in, so it may not be the best time data-wise to draw conclusions, but I'd like to get things working as well as possible before the 30-day free change and return limit expires.

I have some concerns first about the diagnosis procedure. I went to a sleep specialist and told them I'm having trouble sleeping and staying alert during the day, rated 11/24 on the Epworth Scale, have a BMI of 21.5 and am 36 years old. I have a history of back pain, chronic cough, ADHD, depression, anxiety, and specific sleep-related stress from being woken up multiple times every night at random times from age 12-19. I also have a past diagnosis of non-24 sleep-wake disorder (five night in-lab study) from 2007. Currently, my partner complains about how much I move at night, which makes me wake up more when I move, to try to disturb her less. After telling the doctor all of this, he had me do a single night at-home study and said I had mild OSA. I've attached the data from the study.

I met with the doctor after my study to try to push back on the PAP prescription and OSA diagnosis, but they were firm that I should try the device and they will look at further studies and differential diagnosis only after I've completed 90 days of adherence. Another thing contributing to the feeling that the doctor didn't actually pay close attention to results is that he said that I was snoring, and that sleeping on my back had worse numbers than on my side, but I don't see that in the numbers or graph. When I pushed back, he admitted that snoring likely wasn't an issue, but didn't budge on the positional opinion.

Despite doubts, I picked up my machine and started therapy on the AirSense 11 and P10 mask (pressure 6-15, exhale pressure reduction 2, 82°F and 5 humidity). My events per hour are slightly reduced from the study, but I'm not feeling any improvement from the device yet. I picked up a foam mattress topper and cervical pillow last week, and I've noticed a decrease in conscious waking events with those. My leak rate has been 0 except for the night before last, which was at 2L/m. I have had very slight mouth exhalation, but I'm trying Mewing to reduce those issues. Average oxygen saturation hasn't changed at all according to my smartwatch. The main thing I've noticed is that my throat is a bit sore all day, about at the top of my Adam's apple, but inside the airway.

A friend said that it can take up to 6 months to see improvement. Honestly, if it takes that long, I have doubts that the therapy is actually doing anything for the individual. Maybe he meant some people have a hard time adjusting to sleeping with the device, but that hasn't been an issue at all for me after the first night. He suggested I tweak my settings, get the SD card, and try different masks.

I'm trying to get all of my medical issues untangled and hopefully settle on a combination of the least intrusive/disruptive/number of treatments possible. My health overall has been deteriorating as I was completely untreated for anything for about 10 years due to financial difficulties, but I'm more stable now and have good insurance. It's probably too early to talk about simplifying, but I'd like to keep an eye on that for the future.

Does my diagnosis appear legitimate? Is it normal to be diagnosed with OSA with an Apnic Index of only 1.7?
Should I try another mask, perhaps covering the mouth?
Should I ask to try a MAD, EPAP, or BiPAP?

The more I read and watch, the less I feel like I know  Any comments, suggestions, or feedback at all are greatly appreciated!

[BoxcarPete]

Find an ENT who cross-specializes in sleep medicine and ask him to take a look up your nose. Your combination of age/BMI, few apnea, relatively many hypopnea, equal numbers on your back/side (doc is just in the habit of saying back is worse and didn't look close enough) and minimal improvement from CPAP indicate to me that you may have a structural problem with your airway rather than the "classic" tongue and soft tissue collapse that we think of with sleep apnea. Your timeline chart also shows clustering that may be related to sleep stage, particularly REM sleep (but without a full PSG sleep stage tracking has poor accuracy if it is even available). Your history of depression may be connected to this as well, as there are well known yet poorly understood links between depression and problems with REM sleep.

It's impossible for me to say anything definitively on either topic, but for the first it is certainly worth a consult with an otolaryngologist, and for the second you now know as much or more than your doctor about it.

[SarcasticDave94]

It would be helpful to download OSCAR, the free app in the link above. This in conjunction with the sleep data stored in the SD card would allow you to view all the data and you may attach it here within a post. We would be able to comment on how things are going better.

[Deborah K.]

I suggest that you raise your starting pressure to 7. Most adults don't feel very well at pressures lower than that.

[slortien]

Thank you, I've received my card and upped the pressure. The provider actually started me on 5-12 with auto ramp starting at 4 for some reason, despite my prescription being for 5-15, and I had a lot of suffocating feelings that first night so I changed it to 4-12 and then 6-15 after reading a bit about pressures and how to change it on my machine. I don't have detailed data yet, but here are my summaries.

Pete, I'll check with my primary care about a referral to an ENT with sleep experience. My primary is very dismissive in appointments, but at least she happily refers me anywhere I ask

[BoxcarPete]

In that case, I would do a little leg work on my own. Call some sleep centers and/or ENT offices to see if there's someone they recommend for sleep apnea patients, then you'll make it REALLY easy for your doctor to refer you somewhere that you can get some real help. That's how I got the name of the guy that fixed up my nose, I told the sleep center that I wanted to change my sleep specialist to an ENT (sleep center doc is an allergist/immunologist), and they referred me to a really great surgeon.

[Deborah K.]

What we need to see is a daily chart. It has a lot more useful information.

[slortien]

Here's my data from last night. Felt fairly typical, maybe slightly worse than the last 2 nights.

[SarcasticDave94]

I was going to say getting the sleep study report, but there it is at the top of the thread.

I think you'll want to request the lab sleep study due to the Central Apnea component. Make a fuss, complain about CPAP treatment not going well enough.

Either these CA are real, needing treated, or there's a Positional Apnea aspect involved.

The Positional clusters aspect wiki included just in case.

https://www.apneaboard.com/wiki/index.ph...onal_apnea

You might need to reduce EPR to 1, seeing if CA reduce. However the other events might increase by doing this.

If it's actual CA you're dealing with, it's probably going to require a different machine.

[AndyB]

There are many knowledgeable and helpful people on this forum, so I'll defer to them for specific therapy suggestions, but I hope you understand that it usually takes a while for one's body and brain to adjust to sleeping with a CPAP machine. Even the best advice and optimal machine settings rarely result in immediate treatment success.

You sound like a smart, thoughtful guy who has been dealing with a lot of challenges for many years, so I expect you understand how important perseverance and patience can be when learning to cope with a brand new experience like this. In my case, it took several months to adjust to sleeping with a CPAP machine -- not fun at first but unquestionably worthwhile in the long run.

Good luck to you!