[UARS/Mild SA] Nearly perfect OSCAR score but still waking up exhausted

[SteveIsTired22]

Been on APAP for around 3 months and switched to BiPAP probably about a month ago, my AHI is practically zero at this point (wasn't super high to begin with) but I still wake up every morning feeling like I got hit by a truck. 

Current BiPAP settings are updated in my profile/in the oscar screenshots.

I'm wondering if its just that the events I'm having just aren't being detected by the bipap, or if maybe there's something else causing my terrible sleep quality. 

Currently taking/doing besides BiPAP:

• Bed inclined by ~6 inches
  
• Cervical neck collar to keep neck straight
  
• 40mg of Pepcid before bed for GERD
  
• Saline spray to keep nose clear before bed (Had a septoplasty/turbinectomy ~5 months ago)
  
• Mouth Tape
  

But even if I decide not to do any of these things my sleep quality is still the same. I don't take any sleep medication, I've been prescribed a bunch (hydroxyzine, trazodone, gabapentin, doxepin, clonazepam, and most recently ambien) but I still wake up in the middle of the night/early morning when I took them, and feel much worse in the morning after going to bed medicated. 

I put some screenshots from last night and zoomed in where my flowrate seems to get a little funky.

Edit: Also just to clarify, the room that I sleep in is always quiet, cool, and dark. When I wake up in the middle of the night sometimes I have to get up to pee, sometimes not. When I wake up in the morning despite being super tired it is impossible to fall back to sleep.

[jcoleman]

I'll take a stab here...

The first thing that jumps out at me is the total hours of sleep. At 5.5 hrs I would feel terrible not matter how optimized my therapy was. Was that your whole night sleep? And, if so, do you have to wake up that early? With a 3:30am wakeup, the circadian disruption alone would flatten me. Plus, for me, that would prevent most of my REM sleep. Is this a normal night of sleep for you?

Secondly, those flow curves do indicate flow limitation. Do you have any idea where this is coming from? Does it feel nasal/sinus? You mention that you treat for nasal dryness/congestion and GERD. Have you ever found any dietary changes (what/when/how-much you eat) that have helped with this? In addition to the nasal spray at night, has any combination of machine humidifier/heated-hose settings ever made much of a difference, either better or worse?

Lastly, your machine isn't doing much, pressure-change-wise. How did you land at these pressure/PS settings? Could it be that they are too high? I would zero in on those leaks if I were you (which sounds like you are doing with the collar, tape, etc.), and personally, I find that there is a delicate balance between pressure (especially IPAP) and leaks. For me, sustained pressure over 12 can go a bit wonky, especially with a PS of 4 or more.

Anyhow, that's what jumps out at my amateur eyes, at least on review of this one night. I hope that helps.

[SteveIsTired22]

Thanks for the reply, 

As far as the total sleep, I forgot to put my mask back on after I woke up ~4am and slept for about another hour, so about 6.5 hours in total, typical night is probably around 6.5-7.5. After that time despite being still very tired I just physically can't fall back asleep, I typically spend like 20-45min trying to get back to sleep but at some point decide to just get up.

As far as I can tell I don't think the flow limitation is coming from my nose, after I had my septoplasty/turbinectomy my nasal breathing has been lightyears better than before. When I'm lying on my side the nostril that is facing down tends to get a bit congested but I can still breathe through it fine. I've been playing around with the humidifier settings but I haven't noticed any difference yet. 

As far as GERD goes, while I haven't tested it out enough yet to know for sure but it almost seems to me like the later I eat before bed the less I tend to wake up at night. I've obviously been told by my doctor to do the opposite but I don't find that stopping eating 4-6 hours before bed makes any real difference.

Pressure-wise 6.4 for EPAP is what I've landed on to get rid of the couple OA's (Or at least what OSCAR detected as OA's) I had every night, but for IPAP and PS I've just been slowly increasing (starting at 4 PS) to see if there would be any difference (which there has not). I can try going back down to a PS of 4 for the next week and see if that fixes up the leaks.

[KeepSmiling]

SteveIsTired22,

Your pressure settings are ok. May change upper setting later.

The famotidine (Pepcid) may cause sleep issues. I suggested you see a gastro, for your issues, GERD symptoms can have different sources. Pepcid is not as strong as other meds, which I am not recommending. 40mg, is not recommend long term. Find what foods causes issues and monitor how much you eat. Coffee (2 cups in 24 hours) and cinnamon causes issues.

The 4-6 hours to prevent acid. The sleep may be better because you are not digesting.

When you get deeper sleep you may have more events then change setting.

[SteveIsTired22]

Yeah I had an upper endoscopy done ~5 months ago and was told that I just had mild gastritis and mild esophagitis, a saw an ENT more recently and when he looked down my throat the he saw signs of LPR and recommended 40mg of pepcid the next 6 weeks til I see him next.

He also saw that I had 'prominent' lingual tonsils, but I'm not sure how much those could actually be affecting my sleep (if at all).

But yeah I'll start listing down what I eat each day and see if certain things spike my reflux more than others. Don't drink any coffee but I used to put hot sauce on damn near everything, but I've stopped that like 6 months ago.

Thanks for the response.