[Treatment] Looking for guidance on adjusting treatment settings

[aspiesleep]

Hello everyone. This is my first time here. I came across the board after I finally decided I need to get a good handle on my sleep apnea treatment. I've done a good bit of reading, and it seems like my sleep issues point more towards central apnea. I'm hoping you can give me some pointers to adjust my treatment settings and start taking control of my sleep therapy. My AHI has been consistently low while using the machine, but looking at the data with OSCAR, I am concerned about the central apneas.

I'm 35 years old, weigh about 165 lb, and I am not overweight by any measure. I have had fatigue problems going back into my early 20's as long as I can remember. It took getting married and my wife pushing me to get things checked out.

I had my first sleep study in a sleep lab in 2015. Following that I was prescribed a CPAP and used it off and on. I couldn't get used to it. After having sinus surgery for a deviated septum, I did a second sleep study at home in 2017. At that point I committed myself to sticking with the CPAP. I consistently use it now, but I feel like my treatment could be better.

An interesting side note, I find I have dysfunctional breathing throughout the day too. I often hold my breath without thinking about it, especially if I am really focused on my work. When I was a kid, I would hold my breath when I got hurt. I only take shallow breaths throughout much of the day. I have Aspergers and know a couple of other people with Aspergers that have also been diagnosed with sleep apnea. They too don't fit the typical physical profile for obstructive sleep apnea. I am curious if there is some sort of link between Aspergers and central sleep apnea.

One of the big hurdles to sticking with CPAP therapy was aerophagia issues. I still struggle with aerophagia on a regular basis. I have tried full face masks and a chin strap with my nasal mask.

Anyways, that is a little bit of an introduction for me. I will include some screenshots of my OSCAR data below. I can also provide screenshots of the data from my sleep studies if that would be of benefit. Please let me know if any additional views, zoomed in areas, or cleaning up of the screenshot format would be helpful.
A big thank you to anyone who is able to help me get started in the right direction.

Example sleep data from a recent night:
   
   

Overview of trends since the last time I reformatted my Resmed card:
   

[Gideon]

Welcome to the forum

Based on your chart I see no issue with your central apneas, They are very low and should not be significantly impacting your sleep.
I know of no connection between apnea and Aspergers.

On Aerophagia, set your max pressure to 9.6 and let's see how that helps it. The Idea is to eliminate aerophagia by lowering max pressure and then slowly adding it back in as your body adjusts.

[aspiesleep]

Thank you for the quick reply.  

I had come across a post in the wiki by Sleeprider (about changing trigger sensitivity) and the graph looked very similar to my AHI pattern and I thought maybe there was some room for optimization with settings or perhaps a different machine.

I will adjust the max pressure as suggested and give it a few days to see how it goes. Then I will report back.

[Dormeo]

Hello, aspiesleep! You've gotten some good reassurance and advice from Bonjour, who has incredible expertise.

I notice that the GENERAL trend with your CAs is downward, albeit with a lot of variation. This suggests that your body is adapting to the subtle changes that PAP therapy can make in the neurochemical regulation of breathing. The variation is itself pretty typical -- "consistently inconsistent," as people here say -- so don't worry at all if you see the CA Index bounce around. Keep an eye instead on the general trend. (By the way, on the Overview page, you can look at a graph that includes CAs only. Nice for tracking the trends.)

Daytime breathing is much more irregular than nighttime breathing. Holding one's breath while concentrating or physically exerting oneself during the day is very common.

I have several friends with Asperger's so you got me curious. I see online some trustworthy studies connecting Autism Spectrum Disorders with insomnia in children, and one study connecting Asperger's with insomnia -- but nothing about apnea. If you find anything, I'd be interested to know about it.

[aspiesleep]

Hi Dormeo! Thanks for the encouragement. I haven't found any studies yet either. It's mostly just a hypothesis I have formulated based on the anecdotal evidence I have experienced or heard. There's plenty of studies showing how people Aspergers or ASD have disrupted sleep (insomnia or frequent awakening). I have all kinds of other weird things that also affect my sleep, besides just the sleep apnea stuff.

• Restless legs
  
• Grinding teeth (wear a night guard)
  
• Acid reflux (it's worse when laying down. I sleep on a foam wedge, which helps)
  
• And then the weird one. When I close my eyelids, my eyeballs don't stay still and rest. My eyes involuntarily move around all over the place behind my closed eyelids. It freaks my wife out to look at it.
  
  

I have also noticed that the aerophagia exacerbates my acid reflux. My reflux is much worse when my digestive track is full of air. This is logical to me, but not sure if anyone else experiences that.
Unlike many with Aspergers or ASD, I have no trouble falling asleep. I'm usually asleep within two minutes of lying down. Even if I'm not in bed. I've read that's a sign of sleep deprivation. I am also a very light sleeper and wake easily with noises (or prodding from my wife to fix my CPAP because it's too loud or to roll over).

[sheepless]

aspiesleep, like you, I fall asleep quickly but wake too easily. when I first started apap I slept in fragments of less than an hour. it took a while after getting my ahi down to realize restless legs and periodic limb movements are the main reason why.

if your ahi is under 5, you're still tired, fall asleep easily & wake too often, restless legs &/or periodic limb movement could be the reason. around here, sleep docs seem to concentrate on obstructive apnea & we have to push them to address much else. it might be worthwhile to pursue treatment (meds) for it.

also, if your rls is occuring in sleep (which I understand to be plm, but the label doesn't matter as to my knowledge the treatment is the same), & it's anything like mine, your machine pressure may rise ineffectively and disturbingly against our flow limited response to movement (I moan groan grunt & otherwise protest the movements, resulting in a partial breathing restriction or flow limitation). this can easily cause aerophagia, leaks, arousals & full awakenings. limiting max pressure is necessary to avoid this.

for me, relief from acid reflux was the first notable 'how-I-feel' benefit of apap, coming within 2 or 3 months after starting treatment. aerophagia doesn't help the situation so reducing pressure, especially max pressure, should, even if at the cost of a few more apnea events. it can be a balancing act.

it sounds like you are pretty well informed & taking an active interest, so important to sorting this stuff successfully.

[Dormeo]

I'll be curious how the new maximum pressure works for you, aspiesleep, for both the aerophagia and the kinds of disturbances sheepless describes.

I looked up eye movement during non-REM sleep, and here's an interesting little note:

https://www.thoracic.org/professionals/c...-sleep.php

Here's the summary: "In one study, 78% of patients with NREM eye movements were taking an SSRI at the time of the study and an additional 6% had taken an SSRI in the past. NREM eye movements may also occur, though at a much lower prevalence, in individuals using other classes of antidepressants, neuroleptic agents, and benzodiazepines. The presence of NREM eye movements has not been associated with any symptomatology."

Have you by any chance ever taken these kinds of medications?

You are right to sense there's a possible connection between aerophagia and GERD. Lots of detail here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576329/

I hope that capping your maximum pressure will help to minimize the aerophagia and, with it, lessen the reflux at night. At one time my doctor thought I had GERD (though it turned out I didn't), and he strongly advised me not to lie down for 3-4 hours after eating. Did you get that advice too?

[aspiesleep]

Hello all. I'm just checking back in. It has been three days since I lowered the max pressure. The aerophagia was significantly reduced all three nights, although still present. Attached are the screenshots for each day.

I'm also starting to keep a sleep journal to make note of anything I can think of before bed:

• reflux (also see if I can link that to particular meals)
  
• legs feeling jumpy
  
• if any antacids/supplements taken
  
• if I drank any alcohol, how long before bed
  
• food close to bedtime
  

Hopefully I will be able to identify some patterns affecting my sleep.

One thing I see is that I average 7 hours of sleep but have closer to 6 a lot of nights too. I'm pretty good about using the PAP all night, so my usage time is a fairly accurate representation of my sleep time. I think I need to focus on bumping my sleep up to 8 hours.

sheepless, thank you for sharing. I agree the RLS/PLM may be an avenue to explore. It's hard to get access to doctors for sleep apnea in NZ, so I will have to research things on my own and try to work with my primary care doctor to get approvals for stuff. All the doctors I have seen only focus on obstructive apnea. And none of them have reviewed any of my PAP data with me.

Dormeo, thanks for digging up the articles/studies. I've never taken any SSRI or anti-depressant. The only prescription medication I have taken for any length of time would be a PPI (lansoprazole) for reflux. I took that for a little over a year around 2017. I generally eschew prescription medications, because of the side effects and the fact they are often masking symptoms rather than fixing causes. But sometimes they help to give temporary relief for the body to balance out. And sometimes they are just the only answer.

I have not received specific advise to avoid laying down 3-4 hours after eating, but it sounds logical. I often find I want to eat a snack before bed because eating suppresses the discomfort I feel from reflux. My reflux is often worse when I haven't eat in a while.

I have often used natural calm magnesium powder before bed and it is a big help with the restless legs. Recently, I have been trying some black strap molasses before bedtime too.

[aspiesleep]

Also, I dug up my two sleep studies. Attached are the screenshots of the summaries. I thought they might be helpful to review.

The first one in 2015 was in a sleep lab. If I recall correctly, the official diagnosis the doctor gave was "moderate obstructive sleep apnea". About two weeks later, insurance provided the Resmed AirSense 10 Autoset.

The second one in 2017 was at home using a Alice NightOne. This was following sinus surgery to see if the surgery had any positive affect on my sleep. I used to wake up most days with a stopped up or stuffy nose. Since surgery, that almost never happens.

Data from 2015 sleep study:
   
   

Data from 2017 at home study:
   

[Dormeo]

I'm glad to hear the aerophagia is better. Your pressure is for the most part going up in response to flow limitations, which are changes in your airway that somewhat restrict the flow-rate of air when you inhale. Often they are caused by relaxation of tissues in your airway.

The sleep journal is a GREAT idea, and it will help you understand whether tweaks to your settings are helping you sleep better and more restfully, or not.

The FLs may or may not affect the quality of your sleep. I would suggest you stick with your current settings a few more days and then do ONE of two things. (1) Increase the EPR to 3. That might help some with the FLs. If it does, you can assess whether that helps you sleep better or more restfully. (2) Reduce the maximum pressure a little bit more, maybe to 9.2. Then you can assess whether that helps decrease the aerophagia further and also whether it increases your obstructive events.

One change at a time, though; that way you can have a better understanding of what is and isn't working. Stick with new settings (unless they're awful) for a week or so before considering additional changes.

About GERD: from a trusted web site (Mayo Clinic), here's the advice many people in the U.S. with reflux will get:

Lifestyle changes may help reduce the frequency of acid reflux. Try to:

Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
Stop smoking. Smoking decreases the lower esophageal sphincter's ability to function properly.
Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can't elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn't effective.
Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
Avoid foods and drinks that trigger reflux. Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.