REM or Positional?

[prp1714]

Hi,  

I've been using my AirSense11 for a little over a month now.  Before and still during CPAP-use I will wake up with a "hangover" and fatigue ~80% of the week. Some days are completely normal.  Occurrence seems completely random week to week.  I usually can pinpoint the stretch or stretches of sleep that caused the fatigue/hangover feel.  By the late afternoon it usually goes away.  Based on OSCAR it seems these distinct periods of flow limits, erratic Resp Rate, and 2-3+ OAs are what's causing it.  See attachments.  Is this REM or positional clusters?

[Sleeprider]

I don't see a problem with these charts. Very low flow limits and events. Minor changes in respiration or flow limitation do not suggest a cause, and it seems unlikely this would be the cause of fatigue. You can try EPR 3 to see if it makes any difference in comfort or restfulness, however your PAP therapy looks great. If you have an Apple Watch you could monitor sleep to see if these minor disruptions correlate to any sleep stage or awakening.

[BoxcarPete]

It's hard to be certain without more to go off of than just the respiratory waveforms, but it looks like your sleep architecture is not very robust. By that I mean you are onto something when you have identified REM as the culprit, and your charts show some regular REM cycles, but they are spaced out weirdly.

In your first chart, you have a shortened REM onset. I don't know if you chopped off the beginning of the chart because you tried to eliminate the time you were awake, but your REM1 starts really quickly if you had done that accurately. It's also an hour long, which is highly unusual. Then you have an hour until your apparent awakening where the machine is off and starts back up, then another REM segment, this one a much more normal 25ish minutes, then bouncing back and forth between light and REM sleep for the rest of the night, which is normal. What's not normal is that REM1 segment, it is early and lengthened compared to a normal sleep architecture.

Your second chart is also unusual. REM1 looks like it is completely missing, and you have numerous awakenings and machine restarts that make me hesitant to guess what, if any, of that sleep is REM.

Based on the limited data I have to go on, I'd say you may be experiencing a mix of REM deprivation and REM rebound. A variety of medications and recreational drugs can have sleep architecture impacts affecting REM including antidepressants and alcohol, so I would start there and see what you can change and what you are stuck working with.

[prp1714]

Thanks for the replies.

I have no other health problems, also no alcohol or medicines. No stress either, besides figuring out the source of random fatigue. These are snippets of the last ~2/3 of the night but I agree my REM feels funky. I'm not sure if that's due to adjusting to machine or not. I am still waking up more often because of the machine. Maybe I am a light sleeper and sensitive to minor disruptions of sleep. Maybe more time with the machine will help.

[BoxcarPete]

Well, that makes it a little harder to try and find the root cause, if we can eliminate the obvious possibilities right out of the gate. I think you would do well to try and delve a little deeper into sleep architecture disturbances and how to solve them, but I'm sorry that I can't be more helpful than that. As Sleeprider said, your charts look pretty good overall, but I personally know how tough it is to deal with REM trouble, as my original sleep apnea diagnosis was nREM 0, REM 25+

[prp1714]

Wow interesting. Thanks for the input. It’s very nice what you guys do on this forum. I will keep troubleshooting. I know my numbers are mild and symptoms are intermittent compared to most but I can’t find the fix!

[Deborah K.]

Listen to SleepRider.  He knows more than all the rest of us.  Did you raise your EPR to 3, as he suggested?  That might help.  Also, if I were you I would turn ramp off altogether.  You get better therapy without it.

Also, you are still in the adjustment phase of pap use.  Give your body and brain the time they need to adjust to your treatment.  It will get better.  

[arch]

This looks like REM predominant to me, which will make you need a higher pressure to treat your apneas and restrictions during REM than any other stage of sleep. It can make things weird, my numbers are fantastic even at low pressures as long as I don't hit REM sleep. The faster I am woken out of REM, the better my charts look, but the worse I feel. Changes in pressure can cause microarousals that seem to stop REM as well. The trick for me has been to find the ideal minimum pressure that will treat my airway into REM sleep. It seems to get messy if I start having obstructions in REM and the pressure has to increase drastically on auto. For me that seems to be Min 10 with EPR 3 (it'll probably be different for you). For now I've tightened up the auto settings, but my goal is to be on CPAP mode to reduce any awakenings from changes in air pressure.

I suspect your REM is structured is so strange because you're REM deprived but not sleep deprived and we're trying to estimate REM sleep from charts showing respiratory rate and airflow, which are not very accurate.

As others have said, your charts already look great, but you should focus on finding settings that let you sleep through the night. I would assess any changes you make based on that. Start with EPR 3 for a few days to a week, then consider bumping up your minimum 1 cmH2O per week or so to see if it gets you to sleep all night.

[prp1714]

Okay, thank you! I will start with trying EPR 3. I’ve slowly ramped up min to 8. Maybe I need to go higher. I will take baby steps. AHI has mostly averaged consistently ~2. 95% pressure numbers are consistently averaging ~8/10 min/max. Maybe that will be my sweet spot. I’ve also had suspicions it’s my fat tongue going backward into my narrow airway. I often wake up with that sensation. Sometimes during the day a random breath will make me snort from a same/similar sensation.

[EddyDee]

@BoxcarPete, @arch
You are saying that you can divine sleep stages from the above OSCAR charts. Could you explain how you do this? Are there any references? Thanks!