[Treatment] Non-restorative sleep?

[seekingbettersleep]

I have been on CPAP for 7 years, but after the initial honeymoon period, my sleep is terrible.  With CPAP I can at least sleep through the night, but I never feel fully refreshed, and many days I'm a complete zombie. My AHI is great, but I'm not.

My doctor is very helpful and involved, so we've tried a few different things.  Most recently he was able to observe my restless sleep based on my at-home oximetry, in particular the pulse spikes throughout the night:

   

My O2 doesn't usually drop much, staying between 93-96 all night.  The one big drop above is a sampling glitch due to movement.  Also, the CPAP doesn't see any events for most of the spikes.

The other day I happened to zoom in on a pulse spike and noticed a strange waveform shortly before it:

   

I can't guarantee the oximetry is perfectly synchronized, but it should be close.  Looking further through the night, I see more waveforms like that near most pulse spikes: 

   

I thought maybe it could be EPAP being too low, since I was on BiFlex 3, so I lowered it to 2, but still get similar spikes after blips in the waveform.

What does this look like to the experts here?

I know I have a really weak LES, since I can feel it being splinted open whenever I'm on CPAP (even at 7 cm), and my mouth tastes terrible in the morning.  Could these be moments where I'm swallowing to keep things down? Or something else?

[Sleeprider]

You are using a Philips Dreamstation Auto SV in CPAP mode. WTF? Your settings are EPAP min 7.0, EPAP max 7.0, PS min 0.0. Why in the world are you using and Auto SV for CPAP therapy? Please let us know what you are trying to treat. It appears you are using the wrong machine for the job, or the wrong settings.

I think we can tell more if you will switch the view in OSCAR to the Advanced view. That will show us the Respiratory Flow Rate, Mask Pressure, Pressure, Tidal volume, Minute vent and more relevant charts to your particular problems. Your Oximetry data seems good for now, so let's focus on your respiration and the machine response.

[SarcasticDave94]

That is an odd switch. You're issued an SV Auto to run in CPAP? Hmmm I'm thinking the doc must have checked the wrong box. You're on straight 7 cmH20 on the PAP king? Incredible! An actual CPAP would treat this better if you only need just CPAP.

[seekingbettersleep]

I know, I know.  We started out on ASV because of complex apnea in my sleep study.  When I told my doctor about non-restorative sleep after several years, he felt that ASV might be disrupting my sleep, so he reconfigured the machine to CPAP and modified my mask with some putty and tubing.  It seemed to work as far as my AHI goes.

I just noticed these blips on my waveform corresponding to pulse spikes, so that brought me here.  You asked for the advanced view, so here are those screenshots:

           

---

And one more:

   

[Gideon]

you said " and modified my mask with some putty and tubing. " Can you sho us a picture of the modifications.
Was the putty for the mask vents? Was another vent added, some extra tubing?
We have worked with a number of users with a system called EERS. Something like this? http://www.apneaboard.com/wiki/index.php...ace_(EERS)

[SarcasticDave94]

Same page bonjour. The EERS is what I envisioned immediately. Attempts to treat CA with ASV didn't work or seemingly so, then Doc actually is on top of his/her game and made an EERS to attack CA a different way! Wonders never cease. This Doc must be a one in a million.

[seekingbettersleep]

Yes, that looks like what he did.

   

So any ideas why I'm still sleeping badly?

My AHI is fine, but I keep getting these spikes in my pulse that indicate a disturbance in my sleep.

[seekingbettersleep]

So does anybody know what to make of these disruptions in my breathing right before a spike in my pulse rate?

As I mentioned in my original post, I know I have a really weak LES, since I can feel it being splinted open whenever I'm on CPAP (even at 7 cm), and my mouth tastes terrible in the morning.  Could these be moments where I'm swallowing to keep things down? Or something else?

       

[SevereApnea]

LES = Lower Esophageal Sphincter?  (just guessing here)

I noticed some of your earlier charts had pO2 and PR readings. 

Many times on my own charts mouth leaks correlate with sudden spikes in PR.

Something to look at on your own charts perhaps?

[seekingbettersleep]

LES = Lower Esophageal Sphincter?  (just guessing here)

I noticed some of your earlier charts had pO2 and PR readings. 

Many times on my own charts mouth leaks correlate with sudden spikes in PR.

Something to look at on your own charts perhaps?

Yes, lower esophageal sphincter.  I'm not sure what I have is technically aerophagia, because I'm not exactly swallowing the air.

The charts don't reliably show leaking near the PR spikes.  I don't think I should have mouth leaks with a hybrid mask anyway.  I did mouth leak a lot when I tried a nasal mask, so I'm not using that now.

I normally breathe through my nose, but I can tell that I do sometimes mouth-breathe.  Could the occasional mouth-breathing events be related to the PR spikes?