Junebuggy - Therapy/Education

[junebuggy]

Hi, I am new here. I am glad that this resource exists, and am delighted to learn more about how all of this works.

My main question: Can someone tell me what I am looking at here, in the first screenshot? Is this for real? For about 30 minutes this looks like a total mess, and I want to learn how to read and understand it. I will not be messing with any settings just yet, as I have not had my follow up with my sleep doctor since starting CPAP a month ago. Is this just dreaming/REM? Some of these OAs look very much like the CAs, and some very similar sections are not flagged. I have searched for characteristic wave morphology of breathing that looks like this and I'm not finding much, but I am sure someone here has seen something like this before. 

My sleep doctor diagnosed me with mild OSA, but I want to know how to dig into this with her meaningfully during my follow-up in a couple of weeks. In my sleep study and almost every night on CPAP, my CA events have outnumbered my OA events, often 2:1 or more. Negligible flow limitations if any, very low leak, sometimes as low as 0-1 l/min. I only have 4 nights of detailed data as I didn't learn about OSCAR till last week. My sleep doctor has declined to provide me with the details of my sleep study, I just have a brief overview and prescription. I am going to request the full study from the hospital soon, though I don't know how useful it will be. They collected 7 hours of data and I only slept 3 of them.

If you need to see a different selection or zoomed section, please let me know.

Background/Additional Info If Relevant

• 54, female, normal BMI (24), generally good health and good sleep hygiene.
  
• Never diagnosed with seizure disorder and never conscious of a seizure, though I recently had an "abnormal" EEG (the neurologist said it showed some "irritablility" and referred to an epileptologist; am scheduled for a 96-hour EEG next month.
  
• No evidence or history of heart or lung problems. Apple Watch data for the last 2 years shows no significant abnormalities in heart rate.
  
• No recreational drugs, alcohol, or smoking.
  
• Prescriptions: At night: Lamotrigine, atorvastatin; During day: wellbutrin; Weekly: HRT for menopause; As needed: rescue meds for migraine (nurtec, tizanidine); took ambien for insomnia for 10 years (nightly) but have discontinued for several months and don't plan to resume. No other CNA depressants except maybe benadryl at bedtime for allergies, more severe in winter.
  
• Normal/low blood pressure: typically 105/70 ish with occasional dips and spikes. I measure every day. Had a short, situational period of high blood pressure in 2022.
  
• Conditions: 
  
• -- chronic, severe insomnia since childhood (which is the whole reason I got the sleep study. I did not suspect or imagine I had apnea.). 
  
• -- depression/bipolar depression first diagnosed in the early 90s; currently well controlled; 
  
• -- generalized anxiety, well controlled with therapy, medication, & breathing exercises;
  
• -- chronic migraine and chronic episodic migraine, presently well managed and MUCH better since starting CPAP; 
  
• -- diagnosed with multi-domain, non-amnestic mild cognitive impairment at age 49 after mysterious cognitive decline, extreme brain fog, executive dysfunction, and some mild atrophy in left temporal and parietal lobes on PET scan. I have largely recovered. No neurodegenerative disease is suspected. Brain MRIs all clear.
  
• Snoring rare/mild
  
• Sleep study: My sleep study was done at home but by the Sleep Institute of a major hospital. My API in that study was 6.5, with a min 02 of 65%, (which I find alarming). HR in study ranged from 53-220 (!) with an average of 72 (which is my normal waking BP).
  
• Therapy results so far: Since CPAP I have had a few nights of API 13, 9, 8, etc. but generally low. Have never had CSR flagged. My average since therapy began is 3.78 (OA 1.2, CA 2.19). I have grown to love CPAP in a very short period of time. I have a great deal more energy and less fatigue, a clearer head, and stable mood. I find it soothing and my mask is so comfortable that I forget I have it on. I have ramp off and EPR on 3 and I LOVE EPR. I do not use the humidifier. I am happily compliant and don't want to "fail CPAP" but if I am headed towards Bilevel or ASV, I want to understand why.
  

[Jay51]

Welcome to ApneaBoard, junebuggy.  Two things you can try immediately to help your therapy is:  1. You have EPR set to 3 full time.  Try turning it off (or even experiment with 2, and 1, and 0).  EPR can increase central apneas.  It helps obstructive - type apnea (flow limits, hypopneas, etc), but can cause some central apneas.  2.  You have some "cluster" of obstructive apneas.  This can be helped by lowering your pillow height, changing sleeping position, or even getting a soft cervical collar to wear during sleep.  If you choose to get a collar, just measure the distance between your chin and sternum (chest).  They have many different sizes of soft cervical collars.  

You low SPo2 of 65 is very concerning.  Insurance will usually pay for supplemental oxygen if a person spends 5 minutes total time during sleep under 88%.   Not sure how long you were close to 65, but that needs to come up for sure.  

Your max heart rate of 220 is concerning also.  Have you seen a Cardiologist?  You may either be going into tachycardia from the apneas, or you could be experiencing something like POTS.  Postural Orthostatic Tachycardia Syndrome.  If a person sits up or stands up with POTS, then heart rate skyrockets to compensate.

[junebuggy]

Hi there and thank you for replying. Here is the section of the sleep study that references saturation and heart rate. Am I reading it correctly that I spent 12 minutes under 88%?

I have been considering a soft cervical collar. I can't go to sleep in any position except the side, so my pillow (buckwheat) is a little high to make room for my shoulder. I have spent an absolute fortune on various pillows at every height over the years. I can take some of the hulls out and try that.

I will try turning off EPR, though I really love the feeling of it. Which is pretty rare because my pressure is virtually always at 4 when I am awake unless it has me on blast and I wake up from that. 

I haven't seen a cardiologist and my sleep doctor hasn't recommended one or referred me. If my watch data is accurate, these high spikes are really rare. When I am exercising, my heart rate is very slow to rise and I don't have any trouble with an hour or more of moderate eliptical activity. I do frequently get lightheaded when I stand up, but I've always been like that. I thought it might be low blood pressure, but I don't know. I will look into that.

[Jay51]

I read it the same way you do.  It looks like you spent 12 minutes below 88%.  Tell you care providers about this next time you see or talk to them.  

You may very well have POTS if you get lightheaded when you stand up.  A word of caution, rise to standing very slowly.  This is every time you stand up (or even sit up in bed).  That way your heart rate will have time to accommodate to a change in position better; and so you don't pass out and fall!  We don't want that!

You can experiment with anything you have to keep your chin tucking towards you chest during sleep.  When the chin tucks downward (towards the chest) it can "kink" or even completely close your airway.  Some people have used a small travel pillow and turned it backwards.  Or you can try to tuck a part of your pillow under your chin to try to keep your chin from tucking.

[junebuggy]

If I was having positional apneas, wouldn't I see an increase in the flow limitation in those areas? I'm new at learning to identify these things, and many of the OAs look very similar to the CAs to me. I hope to get better at telling them apart. This is a section that has a cluster of OAs and there doesn't seem to be movement in flow limitation. But maybe that's not significant?

I do actually sleep with a body pillow jammed under my chin, but I never stay in one position. I turn side to side and sleep on my back as well, so I may have to look to something other than pillow manipulation if the OAs can be controlled with positioning.

Edit: Better screenshot

[junebuggy]

An additional example from last night, in which i had a really low AHI, but a few flow limitations. The opposite of what I experienced the night before. One nostril was clogged all night long though. Pressure never really got high enough for EPR to kick on. Maybe that is a clue, I don't know.

[Jay51]

Thank you for those charts junebuggy.  I don't know why the flow limitations did not show in the 1st chart when you had all the OA clusters and CA clusters.  That is positional apnea in the 1st chart.  A soft cervical collar would definitely help this.  And if you change sleeping positions frequently, the collar will benefit even more.  Flow limitations extremely high in the 1st chart at 4.8 for your 95% median.  

The bottom chart looks good.  0.0 flow limitations for your 95% median.  No clusters of anything in this chart.  Great chart.  Maybe you need to work on the breathing with your nostrils (you said one was completely clogged).  ENT's are the specialists that look at these (Ear, Nose, and Throat Dr.'s).  

If you like the EPR and can keep the central apneas low, then by all means keep in on 3 full time.