PSG Results: Could this be UARS?

[deebob]

So I've been experiencing sleep problems since about May of last year (probably longer but that's when I really started to notice it). I would feel tired after 8-9 hours of sleep every night and no idea why. Then it got progressively worse until about October, and then one night at the end of October I had something important to do the next day and I became very anxious about not getting a good night sleep, which seemed to spark something that's been happening ever since, which is I wake up about every 60-90 minutes, almost always during REM sleep.


There definitely seems to be a component of anxiety that exacerbates it, which is why I have some suspicions it could be insomnia related as well, but I also have so many symptoms and physical characteristics of UARS that I can't help but think that's what it is, even though all the doctors I've talked to seem to be leaning away from that. I should mention I have quite a narrow, high arching palate, a slightly recessed mandible, a Malampati score of 4, and an ENT found my airway and nasal passages to be a little on the narrow side. The home tests I've done have shown good oxygen saturation, and pretty much no apneas, but increased heart rate throughout the night, and increased flow limitation.

This PSG report was rushed from the sleep clinic because I needed it for another appointment, so it's supposedly not 'signed' and finished, but the doctor I spoke with said everything looks mostly 'normal', and he was kind of suggesting my problems might be insomnia related (which isn't impossible since I am quite anxious/neurotic, and the awakenings seem to become worse and more frequent when my anxiety or stress increases). But I have read that anxiety and sympathetic nervous system activity can contribute to UARS just as much so it's really hard to tell.

Two things in the report that stood out to me that the doctor didn't even mention is: “The total arousal index was severely increased at 29.5 events/hour and the spontaneous arousal index was 17.6 events/hour”. They didn't say anything about RERAs or RDI but it seems like these arousal stats could still suggest UARS?
Any help is greatly appreciated.

[slowriter]

Two things in the report that stood out to me that the doctor didn't even mention is: “The total arousal index was severely increased at 29.5 events/hour and the spontaneous arousal index was 17.6 events/hour”. They didn't say anything about RERAs or RDI but it seems like these arousal stats could still suggest UARS?

Maybe you should ask about the RERAs; whether those non-spontaneous arousals they reported were, in fact, RERAs?

[Geer1]

Total arousal index was 29.5 per hour, subtract 17.6 per hour for spontaneous arousals leaves 11.9. PLM arousal index was 6.8 leaving remaining unlabeled arousals at 5.1. Probably safe to assume this correlates with your RDI value. RDI over 5 is considered mild. The other spontaneous and PLM arousals appear to be having a more significant effect.

The heart arrhythmias and possible PVC's might be worth looking into if not doing so already. You mentioned elevated heart rates during sleep study and that could be related to these same findings.

The thing about trying to treat UARS is that CPAP causes its own set of disturbances and if it is insomnia etc causing the issue then CPAP might make things worse.

If you want to try CPAP you could ask doctor about doing a trial just to see if there are any improvements. Waking up during rem sleep and reduced rem sleep could possibly be signs of breathing disturbances during rem. Would have been nice to see RDI values for rem vs nrem.

[Sleeprider]

UARS has a signature appearance of mostly hypopnea events and RERA, and this report suggests AHI is 2.7 and is silent on RERA and any discussion of SpO2 other than "mild oxygen desaturations to 88%". Since a hypopnea requires a desaturation of 3-4% to score, there could be a persistent flow limitation or low oxygen saturation that can certainly add up to poor sleep quality. This summary is missing any of the details that would let us conclude UARS or any other condition is present.

[Geer1]

Arousals due to breathing is at most 5.1 and AHI was 2.7 indicating RERA's were somewhere between 2.4 and 5.1 (likely in the 3-4 range as some of the apneas/hypopneas probably caused arousal).

[deebob]

Arousals due to breathing is at most 5.1 and AHI was 2.7 indicating RERA's were somewhere between 2.4 and 5.1 (likely in the 3-4 range as some of the apneas/hypopneas probably caused arousal).

So does that just mean it's not that severe and maybe isn't UARS?

This test was also not the best example because I only slept for like 3 and a half hours, and I also took Trazodone to help me fall asleep which I don't normally do (though I'm not sure if that changed my sleep experience that much). On a regular night I stay in bed for around 10 hours and maybe sleep for 8 hours of that. And I frequently wake up every 60-90 minutes. The only time I usually sleep for 2 hour stretches or longer is at the first part of the night when I am in deep sleep, and the rest of the night I start waking up frequently as I go through REM cycles.

I'm trying to consider the possibility that it's not UARS, but it just happens so consistently, like clockwork, every night during REM sleep. I feel like if it was some kind of insomnia, it would be more sporadic and wouldn't occur so consistently every single time I enter REM sleep...like maybe once in a while it wouldn't happen. But it's just the exact same every night.  I've had random nights in the past couple months where I slept 'better', and maybe managed to sleep 3 or 4 hours without waking up, but it's hard to pin point what caused that, other than I was in a slightly better mood and less anxious. But that could occur in UARS and insomnia.  It's all really mysterious and frustrating. 

[Geer1]

As I mentioned above there is a possibility. You don't really have the data to support it but part of that is like you say because of a poor night of sleep during the sleep study. If you want to test it out ask doctors about doing a cpap trial just to see if it helps.

Out of curiosity do you have any symptoms of fibromyalgia?

[deebob]

As I mentioned above there is a possibility. You don't really have the data to support it but part of that is like you say because of a poor night of sleep during the sleep study. If you want to test it out ask doctors about doing a cpap trial just to see if it helps.

Out of curiosity do you have any symptoms of fibromyalgia?

I can't say that I have any symptoms of fibromyalgia.

I have an appointment next week with a sleep clinic to try out a CPAP. My hope is that I will see a reduction in my awakenings.  If I don't notice that happening within a few days I will definitely start to think that maybe it's not a SDB problem. I know most people need to give the CPAP a decent amount of time before they notice any results...but my problem seems to be quite different than most people who have regular OSA and generally have headaches and feel crappy during the day etc. My problem is very simply that I wake up very consistently and frequently, resulting in daytime fatigue, and depression/anxiety. If a certain treatment method like CPAP or MAD opens my airway, is there any reason why it should take a long period of time for me to see a reduction in awakenings? Shouldn't it theoretically happen right away if the airway resistance that is causing increased respiratory effort is eliminated?


Thanks for the advice.

[Geer1]

Actually I believe the opposite. Due to your anxiety and other sleep issues I think it may take you longer to adapt to CPAP and notice potential benefits. Trying it is a good idea but you need to go into the experience with the belief that it will work and you need to commit to it for the length of the trial.

The reason I say this is that I am somewhat similar. My first week on CPAP was horrible and I was getting worse sleep then without it. If I had gone into it thinking that I would see results within days I would have written it off. It was my 2nd or 3rd week before I started to believe it was helping. It takes time to get used to having to wear the mask, the noise the machine makes, the air being pushed into you etc and I expect this will disrupt your sleep to start. You need to give yourself time to overcome that and then at that time you will start to notice if it is beneficial or not.

I believe your sleep disturbances are likely due to a number of factors. CPAP will not solve all of them but there is the potential that it may help enough for you to get better quality sleep.

[Dormeo]

"If a certain treatment method like CPAP or MAD opens my airway, is there any reason why it should take a long period of time for me to see a reduction in awakenings? Shouldn't it theoretically happen right away if the airway resistance that is causing increased respiratory effort is eliminated?"

It takes most people some time to get used to sleeping with a CPAP machine. For some it's just a week or two; for many it is a more gradual adaptation over a period of 2 months or more. During the time of adaptation, wake-ups are common. If you decide to try CPAP, the people here will be very happy to work with you on problem-solving. And if your machine is supported by the OSCAR software, you will learn a fair amount by reviewing the charts that provide information about what is going on with you at night.

I don't know how relevant this is to your thinking, but I wanted to mention that people commonly dream in non-REM sleep, and that a brief arousal at the end of a sleep stage is pretty normal. What is NOT normal is to wake up fully and stay awake for a while, over and over during the night.

It might be worth reviewing the rules of "sleep hygiene." Out of desperation I tried following them, and I found that really made a difference.

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.