Struggling to improve sleep quality. Please help!

[janitor500]

Hi I have been using my Dreamstation APAP for about 3 months now. My AHI has dropped from 25.8 during the sleep study down to about 4 to 7 recently (adjusted the APAP myself based on the advice provided to other users here). While I started dreaming more, I noticed I still feel as tired as before. I am not sure I am doing anything wrong. May I get some advice from you experts please?   

Also, after an endoscopy, my doctor informed me that I have a floppy epiglottis. Not sure if it would affect my use of a CPAP

[Jeremy H]

How did you feel before you started on CPAP? Do you feel as tired now with it or is it about the same as before, or different before?

[SarcasticDave94]

Welcome,

Here's a few things that will help, turn off flex for a night and note how your CA respond. Flex can add CA which is Central Apnea to us but clear airway on the PAP. Either way, CA means your CO2 is being flushed out too much causing you to pause breathing. Also note that CA are consistently inconsistent, meaning up and down frequently with no reason.

I know Ramp isn't on at this time and that it's a manual button, but let's avoid it due to similar reasoning as flex.

Due to Hypopnea I'd increase Min pressure to 11. Note if they decrease.

Last item, did you get a detailed sleep diagnostic study? If not you need to request it from the doc. Then you can post it here redacted of personal info. I'm fishing for the data that includes your event type and count during that diagnostic.

[janitor500]

How did you feel before you started on CPAP? Do you feel as tired now with it or is it about the same as before, or different before?

Hi Jeremy. I would say it would be about the same or slightly better. Sometimes, I still want to sleep longer hours (9 hours) so I can feel more rested.

Welcome,

Here's a few things that will help, turn off flex for a night and note how your CA respond. Flex can add CA which is Central Apnea to us but clear airway on the PAP. Either way, CA means your CO2 is being flushed out too much causing you to pause breathing. Also note that CA are consistently inconsistent, meaning up and down frequently with no reason.

I know Ramp isn't on at this time and that it's a manual button, but let's avoid it due to similar reasoning as flex.

Due to Hypopnea I'd increase Min pressure to 11. Note if they decrease.

Last item, did you get a detailed sleep diagnostic study? If not you need to request it from the doc. Then you can post it here redacted of personal info. I'm fishing for the data that includes your event type and count during that diagnostic.

Hi Dave. I tried your recommendations and my AHI went up to 8+ and I had more mouth breathing and a bit of dry throat. I have also attached my study results. Thank you

[SarcasticDave94]

Well according to the test results, these CA would very likely be treatment emergent. There were a small amount of CA, a bit more mixed, and then even more Hypopnea and Obstructive Apnea. You'll have to play the "Avoid CA Game" with the APAP.

If you felt better off with the prior settings, change it back.

[Jeremy H]

Please explain C02 being flushed out to much. That does not make sense to me. If you didn't use a PAP machine, you would not exhale the same amount? I thought the whole idea was to keep the air way open for (normal) breathing. How could you exhale more with PAP than without?

[Ratchick]

The PAP helps you to breathe more effectively and more regularly than your body is used to at night while you sleep.

Your body tends to get used to the level of carbon dioxide in your blood over time and this reduces your brain's respiratory drive - because the urge to breathe is actually most often caused by high carbon dioxide levels, not low oxygen levels. So if you now suddenly start breathing more effectively, your brain is used to needing far higher levels of CO2 to trigger you to take a breath than "normal" and so now, because you're breathing more effectively and blowing off more carbon dioxide than you do without the PAP, your blood levels don't get so high, so your brain produces less drive to breathe.

As a result, your breaths get smaller and/or further apart, and then eventually you have a central apnea which lasts until your carbon dioxide level gets high enough to trigger a breath again... so you start breathing again, starting off slowly and then getting bigger breaths as the carbon dioxide takes a while to wash out of your system again, and then the cycle repeats.

In some people, they can get that pattern of breathing without it triggering a full-on apnea, if their respiratory drive is good enough, but that's why treatment causes people to (sometimes) have central apneas. It's also why they can improve over the first couple of months if you keep your therapy settings at the point just about where it triggers the treatment-emergent centrals, because your brain and body adjust to having the lower levels of carbon dioxide again, and so your respiratory centre in the brain becomes more "sensitive" again.

That's also why you can tell "waking" centrals because they start with a larger than normal breath right before the apnea, which does the same thing. It flushes out your carbon dioxide and so your brain just takes a little longer to trigger a breath urge again, but that's entirely normal for that to happen sometimes while you're awake.

Ironically, this same principle is behind shallow dive drownings. Don't hyperventilate before holding your breath under water, people.

[Dormeo]

To follow up on Ratchick's excellent post, your CAs may be the sequels to brief arousals.  In that case, the problem is less the CAs themselves and more the arousals.

Try zooming in on some CAs to see what the flow rate looks like.  I'm attaching an example of a CA after a brief arousal.

[CorruptAlligator]

@Ratchick. I don't know if that idea holds up when the CA drop drastically with cervical collar. Anyhow, I've seen CA from when I was fully awake trying to fall asleep. So, the detection isn't accurate.

For me, reduction of temperature maybe reducing my AHI values, so I wonder if we fully understand the causes to really define what to detect for CA.

I'd advise to check the Oscar results on the duration when you were fully awake and look for CA within that duration.

[DaveL]

Ratchick excellent post.

I've used cpap for over 30 years. I've wondered how it affected my daytime breathing, considering I've been breathing through a supercharger so long.

Some time ago I was in the hospital after breaking my tib and fib in 5 spots. They said my lung capacity was way too low. Insisted Iuse my cpap while in hospital that week. Funny most people in the hospital didn't know what it was. March 23 2003 was the day I broke my leg. I learned a lot.