PSG - Mild OSA and Severe PLMD

[gohoos1998]

            Hi everyone - first off, I want to thank everyone that takes the time to reply to people here on this forum, including anyone who replies to me in this thread. Extremely helpful navigating unknowns. I didn't think I'd have sleep apnea as I am a 6'3", 215 pound male in decent shape.

Anyway, I was diagnosed with mild OSA with an AHI of 9 and an RDI of 11. I was also diagnosed with severe PLMD - a PLMS index of 63/hour and a PLMS arousal index of 20/hr.

Some other tidbits that may be helpful:

- I had a minimum oxygen sat. of 85%.
- I had an arousal index (AI) of 35/hr
- I spent 7 percent in stage N1, 51 in Stage N2, 7 in Stage N3, and 34 in Stage R
- I had no obstructive apneas - only hypopneas. I did have 10 central apneas, good for 2/hr

I have also attached the full PSG interpretation report as that may be helpful.

Overall questions - Despite what the report says, my doctor wants to start off with medicating for the PLMD first before going the CPAP route. He is confident that the PLMD is the reason for my issues - extreme fatigue, extreme brain fog, extreme anxiety. Do you think that I should push for CPAP? I've read that mild sleep apnea is only considered mild as it relates to AHI, not actual symptoms experienced such as the above.

Do I have to worry about the 10 central apneas or are those benign?

I am wondering if there are any other things in the report attached that are important for me to know/other things to glean from this? My doctor went through it very quickly without much explanation.

Again, thank you to everyone who provides a response. I have been struggling for years and have finally found a potential reason. I want to remedy this.

[Sleepy Quixote]

@gohoos1998

Welcome to the forum!!!

"Overall questions - Despite what the report says, my doctor wants to start off with medicating for the PLMD first before going the CPAP route."
Absolutely pursue treatment for PLMD at the soonest possible opportunity. Be very thankful you have a Dr. who recognizes it as a serious problem.
Don't ignore the CPAP avenue either, even mild sleep apnea needs to be treated, those hypopneas are a source of sleep disturbance. The centrals in the numbers you are having aren't much to be concerned about, but do deserve attention too as they may increase when you start CPAP therapy, known as treatment induced. Mine tripled after starting PAP therapy.

Others far more knowledgeable than I concerning PSGs and OSA will be along soon.

On the PLMD treatment, make sure to thoroughly investigate your Drs suggestions for treatment, there isn't a set avenue and the options are scarce and many have some possibility of fairly serious side effects. Don't be surprised is the first round isn't successful.

SQ 

[gohoos1998]

Thank you so much. I am a bit wary of ropinirole because it works through the dopamine pathway (already have bad anxiety), but I will absolutely give it a chance. My doc is pretty renowned and I am thankful for that.

Interesting bit about CAs increasing with PAP therapy - definitely something that I will look at. 

I was super excited to have these diagnoses as I had no answers for years, but I am now realizing that it will not be an overnight fix. And that's okay - a good attitude will be important here. I am in a much better place now than I was in before these diagnoses. 

Thanks again!

[Sleepy Quixote]

@gohoos1998

You are very welcome, fellow longtime PLMD sufferer here. Please keep us posted on how well the Ropinirol works for you. I avoided it because it is know to cause augmentation in PLMD patients to the tune of up to 24%. Its normal augmentation incidence for use in other cases is only around 3%. 24% is not a dice I want to roll. Having some luck with Clonazepam right now, just giving it a months trial. For me it's span of effectiveness is too short, it stops working after about four hours. So it moved my clusters from early sleep cycle to late cycle.

Since you have severe PLMD I highly recommend getting a Sleepon Go2Sleep SE. It monitors Hearth Rate, Oxygen Levels and toss and turn (has an accelerometer). To a lesser extent it tries to report on sleep stage, sleep quality and AHI. (Tries as in its not up to PSG capabilities, it can only estimate these others) The nice thing about the device is it comes with both a ring to wear on a finger (I found it too unstable) and three different sizes of finger cot attachments that also works on toes, I've used it on all four limbs and found my left foot to be the main culprit. Unlike other sleep monitors that measure various parameters every few seconds, they measure at 50 HZ, that's about every .02 of a second. The out put is amazing. You can actually see if the medication is working beyond daytime feels.

If you are interested I will point you to another thread here that has screen shots of the output graphs.

SQ

 

[gohoos1998]

Totally get why you're shying away from the ropinirole - my doctor didn't mention augmentation. I only found that it was a possible issue from my own research. Basically how I got to this diagnosis in the first place - no one thought it was a sleep issue. No one looks at a 25 year old male in decent shape and thinks it's a sleep issue - just got to advocate for yourself. I'd rather not use clonazepam as it's a benzo and I'd rather not go that route - sounds like it's not a perfect solution anyway. Maybe you can take another dose in the middle of the night? I'm not a doctor, obviously.

I was wondering if there was a reliable tool to see my progress with PLMs - AWESOME advice. I want to start testing now so that I can see with meds, and with meds and CPAP. Going to buy it today.

This place has already been more helpful than my doctor.

[Sleepy Quixote]

@gohoos1998

Same here, I suffered 17 years because Drs dismissed my severe PLMD back in 2006 as inconsequential as the going establishment assessment is that in most patents aren't affected by them. Which is true, but for a small percentage about 2% it is very consequential. When a PSG reports 78 arousals in six hours due to PLMs for some reason those arousals aren't weighed as heavily as OSA arousals, even ignored. Unfortunately I didn't have the resources to do my own research soooo I believed the Drs so 17 years of crap sleep. Fast forward to last year was nearly disabled from exhaustion was given another PSG, again PLM index of 50, again Drs ignored 70 arousals in six hours and focused of the AHI of 13 with 53 reparatory arousals and acted like getting on CPAP was the cure to all that ails. After a couple of months went back in and said the CPAP has helped some but I am still exhausted. Their answer... stop changing settings on the machine, even though I explained that due to using OSCAR to analyze I was making informed decisions on settings changes. I even asked if PLMD wasn't at least half the problem the answer was a condescending and final NO.

Went out and found my own Neurologist and we started medicinal trials of various medications to either improve sleep quality or control the PLMs or both. After several month long trials of various meds, herbals, exercise and stretching I was desperate, had Benzos on the no go list for the obvious reasons one doesn't want to go down that road, the Dr finally said we are out of options please consider a trial run. That's where I am best results so far, by far. Am contemplating as you suggest setting a midnight alarm for a second dose.

I am so happy for you that your Doc is sympathetic and responsive.

Goodluck with the Go2Sleep SE (important to get the SE version) The mobile app is excellent, recommend using it on a tablet vs phone just due to larger size of charts, the desktop software is pretty useless for our needs due to the way it graphs the movement.

If you are Android be aware of the location glitch when rebooting the phone, easy enough to fix, just turn off location permission for the app then turn it back on and restart the app works every time. If you are iOS haven't heard of any glitches.

[gohoos1998]

Terrible. Just from reading a few posts about PLMD here, it seems that it has often been overlooked or deemed inconsequential. I'm sorry it took so long, but I'm glad you at least know and are doing things to try and remedy it.

Definitely thankful that my doc has deemed them consequential enough to come up with a treatment plan.

Just ordered the Go2Sleep SE - very appreciative of your advice. I am using iOS so hopefully no issues there.

I will definitely be asking questions/starting threads as I am extremely early in my OSA/PLMD journey - I hope to report some progress. I hope that you get some too.

[Gideon]

Definitely get the PLM managed.

Overlooked is your Oxygen Sats.
First, the 95% low ONLY means to look deeper.
The critical number is the time spent at or below 88% which was 1% of both the total time of 470 minutes and your sleep time of 388 minutes.
Sleep = 3.88 minutes
Total (Sleep + Wake) = 4.7 minutes.
What is significant is the Medicare guide for supplemental oxygen is 5 Minutes cumulative. This is approaching significance.
Whether or not you use CPAP get a recording Pulse Oximeter so you can periodically check you nighttime oxygen levels. The other thing I'll add here is that CPAP will typically increase your oxygen saturation.

The study distinguished between Respiratory issues (AHI=9, RDI=10) for a diagnosis of Mild Apnea and the PLMS of 22.

IMHO you should treat both simultaneously.

[gohoos1998]

Thanks Gideon. Really appreciate the advice - I've learned so much for the day I've been on here.

As the medicare threshold for supplemental oxygen is 5 minutes cumulative, and I hit about 4.7 minutes, I would imagine that I often will punch above this threshold if I am sleeping for longer, say 9 hours? This is how I understand it as the guideline is in minutes, not a percentage of sleep.

I will definitely try to manage the PLM and will give the Ropinirole a try. Sleepy Quixote was so kind as to make a recommendation for the SleepOn Go2Sleep SE tracker, which tracks Blood oyxgen. 

I actually called my doctor today and he is going to set up CPAP for insurance...hopefully doesn't take too long.

On the road to taking care of both of these issues and to live a life worth living. Thanks again.

[Gideon]

On a CPAP, insist on a ResMed.