Physical exertion recovery time after CPAP for a few months

[buzallen]

Quick intro to my situation --

Diagnosed summer 2021 with OSA (AHI 17 at sleep test) and REM Behavioral Disorder (mild).  Took a while to get a machine but around November 2021 I got an Airsense 11 with a full face mask (mouth breather).  Took a couple weeks to adjust but since then I have adapted well to the device.  The 'myAir' app has me at 100 out of 100 probably 80% of the nights and I am rarely below 90 with an AHI hovering between 1 and 2, but closer to 1 on average.  Sleep doc says my numbers are as good as she has seen in the time I have had it. Looking at Oscar results also seems to confirm I am adapting well.

Although I adapted to the device well it wasn't until recently that I began to actually feel more rested.  The first two months of using the CPAP there were often days that were worse than before I started with the CPAP (questioned giving it up) but over the last few weeks I seem to be turning a corner and pretty regularly have days that might feel about 80% or more of where I used to before this all began.  From what I have read this is common and I might actually be doing better than many others have.

For full disclosure on treatments,  the REM Behavioral Disorder is being treated with Klonopin & Prazosin (experimentally) with the goal to come off it shortly to test if most if the issue was OSA related and the REM DB might not need treatment.  Prior to the OSA diagnosis I was prescribed Seroquel to help with insomnia (what I first thought was causing the sluggish days), I still take 25mg nightly with the intent to stop soon since it's clear that OSA was causing the issues.  Also have taken Luvox for about 10 years for OCD & Depression.


Now the issue..

When I started to feel better I began to do some of the things that had been put aside, primarily rock climbing.  The odd thing is, even somewhat moderate levels of physical exertion cause a massive (seemingly disproportionate) disruption to my 'recovery' from OSA.  For instance I climbed last on Saturday morning for a few hours, enough that I was a bit sore the next day and there was a some of catching of my breath in the process but nothing crazy. 

It's about the 3rd time I've tried this and the same thing happens each time.  I am completely wasted for at a minimum 2 days after.  And by that I mean similar to the worst days I had prior to treatment.  Brain fog, exhaustion doing simple tasks (i.e. taking out the trash), headaches. Today is Monday and I just squatted to pick up my pack and stood up breathing heavy.

A few months back I started to lose some of the weight I had gained since the first signs of all this started (early 2021).  I put on about 20 lbs, I've lost 10 and another 10 will put me back in the range of reasonable (200 lbs, 6' 2", 50 years old).  Cut out most fast food, eat a more balanced diet, etc. as an attempt to be more fit.  I've never been super fit but was a pretty active guy in general.

Am I being greedy?  Is more patience required to recover to the point where I can be active.  My thought now is to very slowly introduce exercise back into my life as opposed to trying to jump right into more moderate levels of activity.

I read a lot of posts and it appears as if I am actually doing OK (if not great) for the length of time I've been using the CPAP (for which I am grateful), I'm just really surprised at how what I would consider moderate physical activity throws me off.

Anyone relate?

Thanks,
Brian

[2SleepBetta]

A few things may be among explanations, Brian:

1> In your "down time" away from climbing, the obvious thing you are no doubt aware of, overall deconditioning of your base condition.

2>Some underlying health issue has crept in.

3>Intensity of climbing exertion or Rx de-tones critical airway passage muscles.

4> Very low AHI may be accompanied by high and persistent enough flow limitation to cause arousals disrupting restful sleep.

5> Rx changes.

Any one, two or all three of items 3, 4 and 5  strike me as most plausible, given your awareness of past performance level.

 Just ideas worth what you paid for 'em.

[sheepless]

it might be that your sleep isn't good enough to facilitate more rapid recovery from exercise. we can review your apap charts but you mention rem behavioral disorder (that alone might wear you out), ocd, depression and the meds for them, all of which may be beyond pap concerns and most of us on the forum.

[2SleepBetta]

Brian, you need to present OSCAR charts. SleepRider lists, as I should have, links to the source for OSCAR and how to provide charts that are needed for you to get help.

Check the links at the bottom of this post of his, which does not otherwise apply to you. Advice on changing pressure | Apnea Board

[buzallen]

Brian, you need to present OSCAR charts. SleepRider lists, as I should have, links to the source for OSCAR and how to provide charts that are needed for you to get help.

Thanks, I have been keeping the data from the  machine and have it in Oscar.  Here are the last couple nights.  The times on the charts are off, must be off on my machine.  I'm not sleeping from 2pm until 11pm.  Probably doesn't matter anyway.

   

   

[buzallen]

it might be that your sleep isn't good enough to facilitate more rapid recovery from exercise. we can review your apap charts but you mention rem behavioral disorder (that alone might wear you out), ocd, depression and the meds for them, all of which may be beyond pap concerns and most of us on the forum.

Agreed about the meds, I plan to wind down off most of them but my doctor and psychiatrist want to do one at a time.  I've been on the Luvox for 10+ years without issue but who knows what it is reacting with. Oddly, despite the frustrations with OSA over the last year I  have managed to avoid any serious lasting depression (the depression and OCD have been managed for 10+ years and I feel they are something I understand well).  

The REM BD has also been suspected for a while (years) by my psychiatrist (symptoms are obvious to wife who sleeps with me) but I hadn't had any tiredness issues from it.  The suspected diagnosis was confirmed in the sleep test so the sleep doctor wanted to treat it. 

My sleep doctor's opinion is a few things aligned combined with age (loosing of certain muscles?) and that's why my tiredness seemed to come on so suddenly.  Apparently the physical structure of my throat is very prone to OSA.

Couple months and I should be on much less medication and have a better idea of my 'baseline' without as many meds.

Thanks for responding.

[2SleepBetta]

Groping, I don't know what to make of your charts at all, other than to think such  sleep was not restful as you report. Let's hope someone else  sees the obvious I don't see. If the  charts were mine I'd probably switch to APAP and raise IPAP pressure to 15 with EPR 3--and might get aerophagia, being used to less than 14. I'd try to reduce the FL flag signals.

Your charts present distinct high respiratory rate episodes with usual attending lower tidal volumes and inspiration times. The first chart periods 18:33-19:27 and 16:33-16:44 show alternating periods of higher flow limitation with low flow limitation in association with continuously lowered tidal volume and a lowered band of more excursive/grassy inspiration times.

From end of first break, 17:30, to end, 23:30, the flow limitations are nearly all associated with lower   tidal volume and periods of lower inspiration times. The exceptions being 19:53-20:14 where tidal and minute volume rises during higher (grassier) respiration rate and 21:55-22:13 where the chart shows tidal volume lower but, strangely, minute volume higher--the latter inversion shows up at 18:30 as well (possibly scale and line-pixel-width artifacts?)

Earlier, before the first break, 15:18-16:22, flow limitations are more concentrated, with slightly lower severity, but tidal volume rises and inspiration time is mid-level and not grassy. 

If the chart were mine, I'd look at expansions/zooms  of two or three things. A couple 5-10-minute views at sudden rises and drops of RR and a 2-minute view, say, starting at 19:15, to show inspiration wave tips.

First, I'd shrink the vertical dimension of pressure, leak and snore to near nothing, make flow rate amplitude and inspiration time twice as high, drag the expiration curve below but next to the inspiration curve and double its height. Then I'd scroll all down to push the green event bars upward and off screen view.

Take a look at your green cursor location (first chart). The readings of curve values at that cursor location are shown at upper left of each graph, see tidal volume of 526.64, for example. Then look at the inspiration and expiration time curves in the high respiration rate and flow limited areas where curves diverge widest apart. If there is much time where the I and E values are about equal, I/E=1, it can mean your breathing takes extra effort which may cause arousals which fragment your sleep without your knowing it until awakening still tired.

Sheepless, may well have it right. Your needing time to adapt, to recover conditioning or to sort out Rx and Dx factors. 

I looked at some REM BD  hits. This one  https://pubmed.ncbi.nlm.nih.gov/20217359/  does not mention REM breathing disorder. I don't know if it could apply or be the direction to look. It does mention doubling of respiration rates.

[SarcasticDave94]

The recovery question: I don't expect you to know exactly when your Apnea began robbing you of good sleep, but let's suppose it was a few years like the rest of us. Because it has to accumulate badly enough to get our attention. A few months of perfect Apnea therapy cannot fix years of bad sleep. That's reason one.

Reason two is your therapy isn't perfect. You have some Obstructive Apnea and flow limits that hinder this. They aren't very high events but they exist, and it can always be made a tad better. We're not after true zero event perfection however, just better than now.

The settings should be edited IMO. You have an AutoSet so why not run it that way? Most members come to find that their doctor shuns the Auto mode because they feel it takes control away from them, while hindering you from best possible therapy. This may be true here as well.

Right now, your pressure is 12 with EPR 3 giving overall 12/9. Change it to AutoSet mode 7-15 to give it a bit of range to find out where your optimal numbers are. Take off the Ramp to allow all time available for therapy too, and to remove a variable, unless you feel you need it. But set a goal to wean yourself off Ramp.

With medication being the joker in your deck, you need to account for this, and realize there's more to your situation than just a CPAP and Apnea.