[Treatment] ASV settings for treatment of complex sleep apnea

[JoeyWallaby]

I agree, I don't think my issues are purely physiological, as in, caused by anatomical airway restriction (large tongue base as noticed by ENT, narrow and high palate, teeth crowding, etc).

I noticed something trying to control my breathing with the CPAP on, before falling asleep. When I stopped controlling my breathing and started thinking about something stressful, I started to hyperventilate a bit.

During the day, particularly when stressed, I've noticed I sometimes will hyperventilate then hold my breath for a bit, like a CA during the day lol. It happens most often when I'm stressed.

Maybe I need to do some breathwork, buteyko or something.

I'm definitely going to try to get another sleep study.

[Geer1]

Just got my sleep study results and think they do a great job of showing the power of PSG data. I only slept for 132 minutes and had no REM sleep, I left extremely disappointed thinking the entire sleep study was a waste. Turns out it wasn't. In 132 minutes of sleep I had 119 arousals, 118 of which were due to bruxism. 54 arousals per hour... No wonder I feel tired and have strange physical symptoms in TMJ area (numbness like feeling, not pain so always got ignored by doctors).

Stress is a killer and in learning what I have about digestion it is a double killer. Stress triggers sympathetic nervous system which shuts down digestion. Digestion shutting down causes SIBO/dysbiosis. SIBO/dysbiosis screws up hormone levels, immune function, intestinal permeability (which influences food sensitivities) and neurotransmitter function which worsens the stress/anxiety/depression throwing you further down the never ending spiral.

The first thing I worked on and improved was stress/depression/anxiety. Medications helped a bit, time off work helped a bit, psychologist and CBT helped a bit. Combination allowed me to gain control of anxiety but it was still there and could run rampant easily if I didn't stay on top of it. Then I treated gut symptoms and it improved my anxiety etc significantly, I have had a couple digestive relapses (after trying to reintroduce certain foods) and when that happens anxiety spikes as well.

The bruxism is probably a noticeable part of my tiredness and tmj symptoms but I have a feeling it is still a symptom of something else (either neurological or perhaps related to digestion since I still don't think that I have fixed it but again could be a symptom rather than cause). At least treating the bruxism should provide me with further improvement and perhaps I will be able to diagnose more symptoms etc after doing so. That is what I have found in my journey, it is baby steps forward and easy to relapse but eventually you start figuring things out and see improvement.

[JoeyWallaby]

Really, your bruxism was causing arousals rather than arousals causing bruxism?

This is my data overview for the most recent sessions. I haven't used CPAP for two days because I've been away from home.

Aerophagia has been generally good and pressure cycling seems to have decreased slightly. The 11th of April my aircon wasn't working so I was too hot and on the 15th I was really stressed before bed.

[Geer1]

Really, your bruxism was causing arousals rather than arousals causing bruxism?

I am trying to figure that out (emailed clinic asking for clarification). The PSG report says 

A total of 119 arousals (54.1/hour) were observed during the analysis period as follows, 1 respiratory arousal, 118 bruxism arousals.

I would interpret that as arousal caused by bruxism rather than calling them spontaneous arousals and saying bruxism was present. The tech showed me a couple examples the night of PSG and I want to say the EEG arousal followed EMG data in what she showed me but I don't have the experience to interpret that data accurately. 

If it was causing the arousals that seems like it would be clinically relevant as the majority of my research indicates that bruxism usually occurs post arousal.

[JoeyWallaby]

Haven't posted for a while, I spoke to my doctor. He didn't refer me to a sleep doctor for a sleep study. 

I don't know if I should get a sleep study or a CPAP titration study. I don't know if they'll do a CPAP titration without a recent sleep study.  Either way, I need to see if my insurance covers them. 

I believe only sleep doctors can order sleep studies in Australia. If my insurance covers them, I'll ask my doctor for a referral to a sleep doctor again. I could always get a WatchPAT done, they're pretty affordable, although obviously not as good.

I've under a lot of stress lately and has probably been adversely affecting my sleep. Aerophagia is not bad but have tiredness, as usual. Been waking up during the night...

In terms of treatment, I really think I need MSE (palate expansion) in the long-term. Nothing else will help with my non-allergic rhinitis or narrow and high arched palate.

I've been taking some probiotic pills I was given (life space broad spectrum probiotic). I saw a study about how supplemental anti-oxidants don't improve inflammation markers, while food that contains anti-oxidants do. I presume that the same true is for probiotics, it's better to have a good diet that supports the gut biome rather than supplements. I'm sure that's an obvious conclusion and I'm the beating the bush here.

I haven't been doing any myofunctional exercises although I should probably try them. I don't know what ones to do. I want to fix my sleep cycle, light in the morning and minimal light at night but it's hard.

The natural droopage of my face during sleep is a problem, jaw always dropping on my back and somewhat even on my side. Just makes my airway even smaller and even harder for CPAP to overcome the resistance.

I just feel like my anatomy is the problem and I'm trying to put a band-aid on it...

[Geer1]

I don't see anything that makes me think obstructive breathing is an issue. You don't have apnea, you don't have hypopnea, you don't have flow limitation, your ventilation numbers are good. Nothing points to an obstructive breathing issue. Your recent charts still look better then they used to, the most recent night looked a little rougher for some reason but that happens.

I think you are like me. Poor disrupted sleep quality, perhaps due to an underlying neurological or physiological reason, possibly at least at times worsened by stress etc. Unless you can find a doctor that will somehow guarantee you that your airways are the issue I would not go under the knife as I have read more cases of making things worse than better by doing so and it isn't reversible. Most surgeries are not recommended anymore and if you can't find a doctor to do a sleep study good luck finding a doctor to do surgery (and if you do I would question his motives).

Watchpat is pretty much useless imo and I bet it would show a number of false positive events in your case as it largely uses readings of blood flow which I bet in your case are affected but not by breathing as watchpat assumes. Another recent member had a watchpat test that showed high rdi but PAP data and a later PSG do not support the theory of SDB.

An oximeter if you don't have one is the best home test you can try. I don't know how Australia's medical system works or if there are private options for sleep studies (like Canada has), if they do have private options all you probably need is to find any doctor to refer you. If your doctor has given up on trying to figure out your ailments then it is time to start knocking on other doors.

As for digestive side of things. Probiotics make it worse for me and their use is kind of controversial as they help some people and make symptoms worse in others. I think food intolerances and bacterial overgrowth are fairly common issues and the only way to fix food intolerances is to find the troublesome food and remove it (can only be done with elimination diets, low allergen and low fodmap are best imo) and treating bacterial overgrowth often requires antimicrobial or antibiotic treatments (I do one every 3-6 months). This is all that I have done that has been helpful for me over the past year and my sleep quality improved significantly. I recently bought a better night vision camera and without a doubt my sleep is not as disturbed as it used to be, still some room for improvement though.

I already knew dairy was an issue for me and I started to question gluten (since there is known cross reactivity between gluten and casein). Since doing so my geographic tongue (considered a benign autoimmune disease) had pretty much healed (it had already been doing much better then before dairy though). Then one night I decided to test my luck with dairy again and ate some ice cream, the next day my tongue had blown up again and there was a good square inch of geographic tongue back. It just finally is done healing again.

All of this stuff is connected and I really am starting to believe digestion is our most important function. There are numerous studies proving its importance in autoimmune diseases, parkinsons etc. Unfortunately it is tricky to figure out what the problem is and most doctors don't even try because it is so complicated (everyone is different, has different triggers, needs a different diet etc). Most of the good research is fairly new and I am betting 50+ years from now we will have a lot more understanding about this stuff but unfortunately that doesn't help us now.

[JoeyWallaby]

Yea I didn’t think WatchPAT would be very useful.

I think LPR might be messing me up. I don’t know if you any experience with reflux or LPR.

I only had a stomach endoscopy years ago.

I want to get another and another sleep study.

You can do other stuff too like barium swallow, 24-hour multichannel pH and impedance testing and manometry. https://www.refluxgate.com/laryngeal-sensory-neuropathy

LPR is hard because both eating and not eating can both cause reflux lol

[Geer1]

I have LPR as well. It was much worse before diet changes and antimicrobial gut treatment. I had a chronic cough and hoarse voice because of the inflammation. I still have inflammation present (confirmed by ENT) but not to the point it bothers me anymore other than odd time if flares up a bit.

Doctors tried me on PPIs but they didn't help which is not surprising when you research LPR. PPIs haven't been found to be more helpful than placebo in most studies unless GERD is also present.

Based on my research LPR is more of a neurological issue tied to autonomic dysfunction. Your esophageal sphincters open when they aren't supposed to allowing pepsin into upper airway which then reacts with water and damages upper airway that isn't made to withstand pepsin. My LPR most likely happens when I sleep as I have all sorts of odd twitches throughout the night. I just got a good video last night showing diaphragm twitches during REM sleep which explains my odd shaped REM breaths (I think everyone has this to some point so hard to know if it is considered abnormal or not).

You like I have multiple "functional" aka unknown probably neurological symptoms. Non allergic rhinitis, LPR, IBS, bruxism. That is why I am pretty sure we have similar issues. I don't know what it is, chronic fatigue syndrome, fibromyalgia, in myself I wonder about pre parkinsons, autoimmune something or other who knows. When you research all of these you find the best help with improving symptoms is treating gut issues. They have even theorized that many of these issues and autoimmune diseases are actually due to dysfunctional digestive issues (in many cases due to some genetic predisposition).

Here is an example for Parkinsons. I have a lot of interest in Parkinsons because I have had essential tremors since university, have multiple (if not most) early symptoms and my Grandmother has it. I think some of my twitches in rem might be early signs of rem sleep behaviour disorder (I don't act out dreams but I think they might be signs of loss of atonia), was hoping my sleep study would answer some of those questions but alas no rem sleep...

https://www.nature.com/articles/s41531-021-00156-z

[JoeyWallaby]

I'll see my doctor soon and request a sleep study and gastroscopy, and won't take no for an answer. Because I believe these are the avenues that will be most helpful to seeing what's wrong.

My oral anatomy bothers me. I can't "mew" properly (if people don't know what that is... just look up Mike Mew and mewing). If I put my tongue on my palate, there isn't really enough room. My comfortable resting state is having my teeth slightly apart with my tongue kind of between my molars.

I wonder about getting MSE often. Curing my narrow and high arched palate would be nice, even if it didn't magically fix my sleeping issues.

On another note, ASV does seem to help my grinding because I've noticed when I don't use any CPAP devices... I sometimes dream about my teeth cracking, shattering or being extremely worn.

Having these issues suck because there isn't much sympathy. People just see the results (tiredness and such) and see it negatively.

[MrSpeed]

Central Apnea Due to Hyperventilation (most common and likely your issue)

- Central apnea best conceptualized as sequence of events
- First any variety of stimuli induces hyperpnea (deep breathing)
- Hyperpnea causes ventilatory overshoot and hypocapnia (low CO2) inducing a central apnea
- Central apnea causes CO2 levels to rise until mild hypercapnia (high CO2) restores respiration at which point there may or may not be an arousal.
- Cyclical repeating nature of this hyperpnea, hypocapnia, central apnea, hypercapnia.

Thanks for this Geer1. Very insightful. I guess technically an ASV device could detect such heavy breathing and limit that to control the hyperventilation. Ever heard of a device that can do that? ASV really helps me a lot but it is far from perfect.