[Diagnosis] Fractured sleep: Spontaneous arousal or breathing related?

[Twoshade]

       
Hi Everyone,

I´m a new CPAP user (1.5 years now, 54 years old). In the original sleep study an AHI of 20 was measured. The original pressure range for APAP was set by the clinic from 6 to 11 mbar. I have followed the advice in this forum a lot, but I have reached a bit of a brick wall in terms of sleep quality. I have always been struggling with stress related insomnia. In the last two years I have made many changes (stress reduction, sleep hygiene). For the first time now I have no more problems falling asleep. However, my sleep is still fractured and not restful. I have also used a mandibular advancement device, which solved some of the problems. In a home study it turned out that with the MAD my AHI was 2.5, while the RDI measured as nerve impulse in the finger tip was still 11. So I went back to CPAP with the idea of reducing flow limits. I´m now using an EPR of 3 at 11 mbar fixed pressure which reduced the flow limits (99.5 percentile usually below 0.1, 95 percentile always at 0), but increased the CA events to about 4 or 5.

Could you have a look at my charts and provide an opinion on the following questions:

1) Would you regard the CA event at 01:07:30 as a spontaneous arousal (movement, tossing and turning) or is it the breathing that wakes me up? Oftentimes before the event I also see a pulse rate spike.

2) Is a bi-level device an option for me in order to further improve my breathing? Or is the EPR of 3 already enough? What about a comfort improvement with bi-level in order to further reduce EPAP (my OA events would allow a lower EPAP)?

3) Or, of course, any other suggestion!

Your input is most appreciated! Cheers!

[TiredTom111]

Try dialing your EPR back to 2 for a few nights to see if it reduces the CA's.  If that doesn't have an impact, you can reduce to 1 or turn it off.  I know in my case, going from 3 to 2 significantly reduced my CA's without having any impact on my 95% FL.  Sometimes EPR 3 can be overkill depending on your individual situation.  Just keep a close eye on your flow limits to make sure they don't jump significantly.

[Twoshade]

Hi TiredTom, thanks for your reply!

I come from EPR = 2, and it´s exactly like you said. It reduces the CA and increases the FL a bit. In both cases my sleep remains fractured. Or in other words, if I run a lower EPR I have a bit more FL and less CA, and if I run a higher EPR it´s the other way around. Either way, I wake up way too many times a night. What I can not understand is what actually kills my sleep: Is it the CA event, the flow limit or is it a spontaneous arousal not breathing related at all? What do you think?

Cheers!

[gainerfull]

1. No, you can see the associated flow limit so my guess it was a hypopnea.

2. Yes, I think bilevel could improve your sleep but realize the Aircurve 10 VAUTO has way more settings so be prepared.

3. Can you zoom into 2a-230a so I can see what those spikes look like?

4. Have you considered going to sleep earlier consistently? I'd recommend no later than 10p for 7 days and for 7 days in a row be strict.

5. Are you taking any medications or have any other issues with your breathing?

[Sleeprider]

You are currently at 11.0/8.0 pressure (inhale/exhale) and it looks pretty good, with steady pressure other than some stray CA events. You could reduce EPR to 2 and that might reduce CA and increase FL a bit. The idea of reducing the minimum pressure by 1.0 to 10, may also reduce CA without compromising therapy, and I think that may be worth a try. You have done a good job of optimizing pressure settings and EPR. Your sleep time is only 6.5 hours and that may be part of the problem. Your continued fatigue may be an argument to move to bilevel therapy. The Aircurve 10 Vauto has some setting adjustment (trigger sensitivity) s that can knock out the CA events and further optimize pressure support (EPR) as it is adjustable in increments of 0.2 cm. We have had a couple other members, Deborah K and Fixit50 that recently got prescriptions to move from CPAP to bilevel therapy without a sleep test or titration. If this is something that interests you, reading those threads will give you a lot of tips on how the process works.

[Twoshade]

   

You are currently at 11.0/8.0 pressure (inhale/exhale) and it looks pretty good, with steady pressure other than some stray CA events.  You could reduce EPR to 2 and that might reduce CA and increase FL a bit.  The idea of reducing the minimum pressure by 1.0 to 10, may also reduce CA without compromising therapy, and I think that may be worth a try. You have done a good job of optimizing pressure settings and EPR.  Your sleep time is only 6.5 hours and that may be part of the problem.   Your continued fatigue may be an argument to move to bilevel therapy. The Aircurve 10 Vauto has some setting adjustment (trigger sensitivity) s that can knock out the CA even,  and further optimize pressure support (EPR) as it is adjustable in increments of 0.2 cm.  We have had a couple other members, Deborah K and Fixit50 that recently got prescriptions to move from CPAP to bilevel therapy without a sleep test or titration.  If this is something that interests you, reading those threads will give you a lot of tips on how the process works.

Hi Sleeprider, thanks for your time and advice.
I´ve tried 10 mbar fixed and EPR = 2 last night (see chart above). CA went down on cost of FL. I´ve slept quite well for my standards. But it might also just be a rebounce sleep after many bad nights. I will keep this setting for a while, see what happens. So again, thanks.

What 95 and 99.5 percentile of FL do you find acceptable, as a rule of thumb?

I really want to give bi-level a chance. I hope to decrease EPAP. Who knows, maybe I can even get rid of the mouth taping?

Cheers.

[Twoshade]

   

1. No, you can see the associated flow limit so my guess it was a hypopnea.

2. Yes, I think bilevel could improve your sleep but realize the Aircurve 10 VAUTO has way more settings so be prepared.

3. Can you zoom into 2a-230a so I can see what those spikes look like?

4. Have you considered going to sleep earlier consistently? I'd recommend no later than 10p for 7 days and for 7 days in a row be strict.

5. Are you taking any medications or have any other issues with your breathing?

Hi Gainerfull, thanks for your reply!!

your item 3. I´ve added a typical CA event preceeded by a pulse spike (see chart). The synchronisation between my Viatom ring and the Airsense device might not be perfect. But I start the CPAP machine once the O2 rings starts measuring, and I rename the Viatom/Wellue file according to the CPAP start time. I see this very often: First (!) a pulse spike and then the CA event. This makes me think that the event might not be breathing related, but might be triggered psychologically or might just be tossing and turning (oftentimes, but not always, the O2 ring also indicates movement).

your item 4. I´ve worked on my bedtime schedule. But you are right, there is room for improvement. I will give that a trial.



your item 5. My overall breathing is alright. I don´t take any medication that acts centrally. I do take statins, hypertension meds and Ibuprofen (on demand against osteoarthrosis pain). Sometimes, I think that the moderate osteoarthrosis pain also contributes to my fractured sleep. I also like to have a few pints of beer, but I stop drinking before the evening, say 18.00.

Again, thanks for your input! Cheers!

[Sleeprider]

Twoshade, your therapy was objectively improved at a pressure of 10 with the new settings. I agree with continuing to use them, and we can revisit this and try taking things down by 1-cm when you're ready.

[Twoshade]

Twoshade, your therapy was objectively improved at a pressure of 10 with the new settings.  I agree with continuing to use them, and we can revisit this and try taking things down by 1-cm when you're ready.

Thank you! I am really looking forward to that. It definitely feels good to have some experienced support here.

Cheers!