[Diagnosis] Symptomatic but Sleep Apnea Negative per WatchPat

[Ninjaa]

Hi all,

20M, 6', 190lbs.

I've been having sleep apnea symptoms for a while now, including little energy, brain fog, inability to concentrate, irritability, dry mouth, etc.  However, I don't snore / snore very lightly. Additionally, going to gym with multiple rest days in between and eating above maintenance per day resulted in me still getting weaker due to lack of recovery even though I block out 8+ hours of sleep a night. About two month ago, I've had to stop going due to that.

Blood tests (CMP, CBC, testosterone, B12) showed nothing to worry about.

No past excess anxiety / stress, but I now get sleep anxiety before bedtime knowing I won't feel refreshed next morning. 

Attached is my WatchPAT One data. 

pAHI 0.7, pRDI 2.8 are both well under the threshold of 5. However, I only have 14% REM sleep, 17 awakenings, and lot of fluctuation on my "Wake / Sleep stages" graph. Those seem problematic compared to what is normal. I do not remember any of these wakenings, and have put a lot of work into making sure my sleep environment is optimal (blackout curtains, no computer light, etc) as well as sleep hygiene (consistent sleep / wake time, no daytime napping, etc).

I am doing an in-lab sleep study (PSG) in two weeks. But in the meantime, any ideas on what could be going on? I'm doing much worse in school, needed leave from my job, etc. Would appreciate any thoughts.

[Apnea23]

Have you had an ECG or any other heart checks, including blood pressure?

How do you feel first thing after getting up out of bed? Dizzy? Heart racing, nothing? Ever wake with a pounding heart, or get one during the day?

The awakenings correspond to your pulse which is to be expected, but holy cow if you're brain is essentially "awake" at every spike on that pulse graph without you knowing that seems pretty crazy.

Note your awakenings and pulse spiking is significantly worse in the last leg of your sleep. You may as well be awake. That cannot be restful. None of that sleep can be.

Whatever it the cause of the constant awakening or pulse spiking, that's what's wrecking your sleep cycles.

I'm sure your PSG will reveal your sleep stages are completely trashed, far more so than WatchPAT suggests.

Interesting that you have barely any respiratory effort related events throughout while all of this is going on.

Shame the WatchPAT doesn't measure nasal flow by nasal cannula.

Could this be central apnea at work? I have no idea.

[Ninjaa]

No ECG, but at my recurring physical (last one was during these sleep issues) whenever I am measured for blood pressure nothing abnormal is called out.

I wake up with a high heart rate before it goes down to resting (50 - 60), but no dizziness. 

A cancellation opened up for this Sunday and I was able to move my PSG to then. Are there any particular questions you recommend I ask / concerns I bring up based on the above results? Or just let them do their thing?

Unfortunate that the WatchPAT doesn't measure nasal flow (I will confirm my PSG does). But it sounds like, based on the lack of respiratory events, you believe that OSA or UARS are very unlikely? 

Thank you for your help.

[Apnea23]

That's great. I'd be very interested to hear what the results are and what happens next.

Do you have uncomfortable urges to move your legs during the day?

I believe WatchPAT is garbage for detecting UARS, so that definitely cannot be excluded with your dry mouth.

[Ninjaa]

No in regards to moving legs, but my sleep study tested for that so doctor will be looking out for it. 

I've done the sleep study, but unfortunately the clinic is refusing to release the data to myself or my primary care doctor since the data has not been interpreted yet. However, they are quoting a 3 week interpretation timeline. I am not asking them for whether I was diagnosed with sleep apnea or something else, just the raw ADI / RDI / etc. Are they allowed to withhold the data until interpretation?

[Ninjaa]

The clinic sent my results to me today. They are attached. The AHI is very low (0.5), so they are very confident I do not have OSA. However, my awakening index is 9.3 / hr, and I'm not aware of any of those awakenings. This is resulting in very fragmented sleep, and little REM duration. Any ideas? My sleep hygiene is the best it can practically be, and I'm already following all the other recommendations. Yet I still feel terrible every day. I'm not sure what to do next.

Note that it took me a while to fall asleep for this study due to all the equipment. Typically, I fall asleep much more quickly.

[Apnea23]

Excellent, so you're suspicions we're likely correct and you probably have sleep disordered breathing that doesn't meet the criteria of sleep apnea.

Welcome to the club.

Was a nasal cannula used - did they measure airflow?

Now you need that referral to a sleep specialist for potentially CPAP to see if that cured it - but also to investigate your nasal pssages, upper airways, soft palate and toungue base, etc for potential sources of obstruction and restrictive breathing.

Does the clinic who performed the study not have a sleep specialist? Who is giving their medical opinion on your sleep study if not a specialist?

[Ninjaa]

This is the description of the study:

There was continuous attended monitoring of: EEG, EOG, sub-mental EMG, anterior tibial EMG, body position, ECG, pulse oximetry, nasal pressure and nasal oral airflow, throat microphone, and chest and abdominal movement. The recording was scored using standard AASM and Medicare guidelines. A hypopnea is defined as >10 second duration with a >30% decrease in airflow. Medicare hypopneas are associated with a 4% de-saturation (VII.1.D.1B). For all other insurance hypopneas are associated with a >3% de-saturation and/or an arousal (VII.1.D.1A). Raw data was reviewed epoch by epoch by interpreting physician.

So it looks like airflow was measured. However, I'm not sure what the metric looks like. Do you see anything on the above report that concerns airflow? If not, I will followup with my clinic regarding access to the PSG raw data, including airflow. The "Impression" and "Recommendation" section were filled out by their in-house sleep specialist, I will see if I can somehow talk to them directly. 

Thanks for all the help.

[Apnea23]

What a garbage sleep specialist/clinic that isn't interested in manually reviewing your nasal flow rate for the night during and around your arousals and fragmented sleep.

I'd get a copy of the full nasal flow breath by breath for the night and post it here.

This is trash medicine, and it is very infuriating.

I will have to assume it is just some technician who interprets studies and then suggests referals on to an actual sleep specialist for further investigation. If that's the case, maybe I'm being too aggressive. ?

In any case, it will have to be a specialist who has access to your full nasal flow rate along with the other data.

[Dormeo]

I'm not so sure you yet have evidence of sleep-disordered breathing. What you *do* have evidence of is way too many spontaneous arousals, along with delayed sleep onset. I think it will be very important for you to talk with a sleep specialist in the field of insomnia, especially maintenance insomnia.

One area to explore with a specialist is medication. This may be more than you want, but there's a lot of information here in these meta-studies:

https://www.thelancet.com/article/S0140-...9/fulltext

https://www.sciencedirect.com/science/ar...9223000023

I'm struck by your mentioning muscular weakness as a daytime problem you're experiencing. I don't think of this as a typical problem accompanying sleep deprivation. I'd recommend fuller blood-test investigation, perhaps including thyroid, B-6, Lyme's, autoimmune diseases, including those in the connective-tissue family, electrolytes, and anemia.