mtueckcr - Sleep Journal

[mtueckcr]

Hello apneaboard members,

I am mtueckcr a new member on this board trying to find out what is wrong with my sleep and how to fix it. I have a Löwenstein Prisma Smart CPAP machine which I bought used on ebay in order to use oscar to analyze my sleep and find out if I have OSA or UARS. Getting a proper diagnosis here in Germany is taking a long time since there is a lot of need for in lab studies and a long waiting list. I got an in lab study done in the middle of June 2024 and the sleep doctors said my sleep was fine and I am healthy.

My symptoms include: Derealization, Always dry mouth, drinking a lot and urinating a lot, Headaches, body pain after waking, sleepyness throughout the day, fatigue, brain fog, acid reflux, can only sleep on stomach, low libido, low energy, hard to breathe through nose when exercising.

I got a CBCT scan done which shows the area behind my tounge to be very narrow only 34mm² when it should be at least 150mm². My PSG showed 150 PLMs in 5,5hours of sleep which my sleep doctor did not address.

Since I currently suspect UARS and heard that BiPAP works better for a lot of patients with this condition I bought a Löwenstein Prisma 25S-C bilevel machine which works with the humidifier I already have. I also purchased a checkme O2 max pulsoxymetre to lay over the BiPAP data so I can figure out what is causing my sleep to be poor.
I am planning to get a second opinion since I don't think the lab I was at has enough experience with the diagnosis of UARS.

I will use this thread to post screenshots of my data and note down things I observe. I am happy about your input and thoughts on my situation, feel free to comment. I also hope this thread can be seen by people in a similar situation. I have attached some photos of my CBCT scan.

[mtueckcr]

Here are my in lab short reports since they are in German I have translated the text on the images. The first night I slept without a mask using the sheets they provided. I woke up a lot and was sweating a lot because their blanket was made from polyester which is not very breathable. On the second night I brought my down blanket from home and they gave me a CPAP mask. My sleep was a little better on the second night since my pillow and blanket where more comfortable.

Analysis Date: 11.06.2024 (21:20:35 - 05:51:26)
Light out/In bed time: 11.06.2024 21:20:39 to 12.06.2024 05:51:26 (08:30:46)
Total Sleep Period (TSP): 07:42:56
Total Sleep Time (TST): 05:31:56

Sleep Stages:
Sleep Efficiency: 65 %
Stage 1: 7.8 %
Stage 2: 51.8 %
Stage 3: 20.9 %
REM Stage: 19.4 %
Sleeplatency Stage 2: 00:50:20
REM Latency: 146 min
Awakenings (Index): 8 (1.4/h)
Wake Time [ % TIB]: 35 %

Arousal:
Arousals (all): 37
Arousal Index: 6.7 (/h)

Breathing:
AHI Index: 3.4 /h
RDI Index: 3.6 /h
AHI Index (Supine): 2.8 /h
Apnea Index: 0.4 /h
Hypopnea Index: 3.1 /h
Central 0 /h
Hypopneas: 17 /h
Central Apneas: 0
Average Duration SBAS: 18.8 (sec)
Longest Apnea: 14 (sec)
Average Respiratory Rate: 15.7 /min

Snoring:
Snoring Episodes: 8.2 % TST

Oxygen Saturation:
Desaturations (Index): 23 (4.2 /h)
Minimum SpO2 [%]: 90
Basal SpO2 [%]: 94
Number of Desaturation < 90% [% TST]: 0 %
Deepest Desaturation: 90%

Heart Rate:
Average Heart Rate: 64 bpm
HR Acceleration: 0/h
HR Decrease: 0/h

Leg Movements (PLM):
PLMs (Index): 150 (17.6 /h)
PLMs with Arousal: 5 (0.6 /h)

Analysis:
Sleep analysis was done according to AASM.
Sleep efficiency: 65% (Normal >85%) with a total sleep time (TST) of 05:31 h.
The sleep latency to stage 2 is 50 min (Normal <30 min), the REM sleep latency is 146 min (Normal 70-110 min). The REM sleep portion is 19% (Normal 17-22%), the deep sleep portion is 21%.
Arousal Index: 7/h, Periodic Leg Movements (PLMS): 2/h.
There were a total of 2 obstructive, 0 central apneas, and 0 central apneas.
Apnea-Hypopnea Index: 3/h (Normal <5/h), supine position: 3/h, in side or prone position: 3/h. Cheyne-Stokes breathing 0% of sleep time.
The desaturation index is 4/h, the median oxygen saturation is 94%, the lowest is 90%.
Episodes of snoring: 8% of sleep time.
Average heart rate during sleep: 64 bpm, average blood pressure (pulse transit time) 116/88 mmHg.


   


SECOND NIGHT:

Analysis Date: 12.06.2024 (21:36:03 bis 05:26:27)
Light out/In bed time: 12.06.2024 21:36:03 to 13.06.2024 05:26:27 (07:50:24)
Total Sleep Period (TSP): 07:06:27
Total Sleep Time (TST): 06:02:57

Sleep Stages:
Sleep Efficiency: 77.2 %
Stage 1: 3.6 %
Stage 2: 48.5 %
Stage 3: 20.4 %
REM Stage: 27.6 %
REM Latency: 68 min
Awakenings (Index): 3 (0.5/h)
Wake Time [% TIB]: 22.8 %

Arousal:
Arousals (all): 50
Arousal Index: 8.3 /h

Breathing:
AHI Index: 1.7 /h
RDI Index: 1.7 /h
AHI Index (Supine): 0.0 /h
Apnea Index: 0.2 /h
Hypopnea Index: 1.5 /h
Central 0.2 /h
Hypopneas: 9 nominal
Central Apneas: 1 (n)
Average Duration SBAS: 23.2 (sec)
Longest Apnea: 22 (sec)
Average Respiratory Rate: 11.4 /min


Snoring:
Snoring Episodes: 0.1 % TST

Oxygen Saturation:
Desaturation (Index): 12 (2 /h)
Minimum SpO2 [%]: 89
Basal SpO2 [%]: 94
Number of Desaturation < 90% 1
SpO2 < 90% [% TST]: 0.0%
Deepest Desaturation 89%

Heart Rate:
Average Heart Rate: 63 bpm
HR Acceleration: 0 /h
HR Decrease: 0 /h

Leg Movements (PLM):
PLMs (Index): 86 (11 /h)
PLMs with Arousal: 6 (0.8 /h)

Analysis:
Sleep analysis was done according to AASM.
Sleep efficiency: 77% (Normal >85%) with a total sleep time (TST) of 06:02 h.
The sleep latency to stage 2 is 46 min (Normal <30 min), the REM sleep latency is 68 min (Normal 70-110 min). The REM sleep portion is 28% (Normal 17-22%), the deep sleep portion is 20%.
Arousal Index: 8/h, Periodic Leg Movements (PLMS): 0/h.
There were a total of 0 obstructive, 0 mixed apneas, and 1 central apneas.
Apnea-Hypopnea Index: 2/h (Normal <5/h), supine position: 0/h, in side or prone position: 2/h. Cheyne-Stokes breathing 0% of sleep time.
The desaturation index is 2/h, the median oxygen saturation is 94%, the lowest is 89%.
Episodes of snoring: 0% of sleep time.
Average heart rate during sleep: 63 bpm, average blood pressure (pulse transit time) 104/81 mmHg.


   

[mtueckcr]

Here are some screenshots of my night from OSCAR. I slept from 23:17 to 08:08 waking up at 05:32 and taking off the mask for 1 minute but then deciding to try to sleep longer and putting it on again. After waking without an alarm at 08:08 I felt groggy with a headache and body aches I did not feel rested at all. I had set my machine to static pressure of 9cmH2O for IPAP and EPAP since previously I had set it to lower pressures and the irregularities in my breathing suggested my body might be fighting the machine which a higher pressure might fix.
Tagging @CPAPfriend

[mtueckcr]

On the 22nd I got stomach cramps after putting the CPAP and I fell asleep without it. Slept 8.5hrs and felt a little better than the night before but still pretty run over.
The night of the 23rd of July I slept with an EPAP of 6.5 and IPAP of 9.5 with PS of 2.5. It was the night with the highest AHI to date of 8.40 and I had a lot of mouth leaks throughout the night which woke me up a couple of times.

[Jay51]

Welcome to ApneaBoard, mtueckcr.

A few things I see:  1.  Lots of leaks still.  I hope this link helps.  Mask Primer

2.  Some clusters of H's (hypopneas).   Try lowering your pillow height, possibly side sleeping and not back sleeping, or even a soft cervical collar if those 2 suggestions don't help.  

3.  Your tidal volume is low for a male (even if you are of short stature).  280 is low, but I have a little knowledge of the Prisma's algorithm and wonder if the EEPAP is the cause of this?  If I understand it correctly, the EEPAP switches from exhale pressure to inhale pressure rather quickly, and can possibly sometimes cut short a normal full exhalation.  Other members more familiar with the Lowenstein might wish to comment about this.

[mtueckcr]

Hello Jay51, 

thanks for your input. The leaks are all mouth leaks which I have been having since I upped the pressure above 7. I am using a nasal pillow mask since it is the most comfortable for me as I am always sleeping on my stomach. I am using a light down pillow and my head is rested about 10cm (2.5in) high. Usually my head is facing left.

From what I understand Löwenstein is pretty good with getting the pressure right at the right time. I have the same tidal volume with a fixed pressure. 

Last night on the 24th of June I had an AHI of 7.22 with APAP 9.0-11.0 and PS 2.5. I woke up from a mouth leak and to pee once during the night.

[Jay51]

You are welcome mtueckcr.  Sleeping on your stomach could cause the mask to shift at times, but if you like that sleeping position best, that is your choice. 

Your inspiration to expiration ratio is inverted.  Normal is usually at least equal (I:E) or inspiration time is less than expiration time.  I think the algorithm of the prisma machine may be responsible.  Not bad therapy in spite of this though. 

You still have some clusters of H's at times.  Have you tried wearing a soft cervical collar (even though you sleep on your stomach).  It is up to you if you want to give it a try.  And it may not work since you sleep on your stomach.  

I hope it goes well in your therapy.

[mtueckcr]

I have received my bipap machine and set it to EPAP 7 & IPAP 11. I also got a pulsoxymetre which shows frequent heartrate spikes throughout the night. I don't feel rested when waking up without an alarm.
I have included the heartrate reading from 29th of June.

[Jay51]

Thank you for posting those charts.  These charts look better with this Prisma Bipap.  Tidal volume is up close to normal.  That's great.  Your I:E ratio is improved also.  15 median respiratory rate or so is normal.  

Your SPO2 levels look ok to me.  One time you drop below 90, but bounce back up very quickly.  

The leaks are still a major problem.  Spikes on the leak chart mean a mask leak (from movement, etc.).  You have some of those.  You also have some very long leaks (mouth leaks).  These are when the leaks go up and stay up a long time (unlike a mask leak that just spikes and usually comes back down quickly).  It may be time to do something about these mouth leaks (your profile says that you use a nasal pillow mask).  Some members here use mouth tape.  For some, a soft cervical collar does the trick of keeping the mouth closed with a nasal mask.  

If their are any Lowenstein experts or anyone else who sees anything, please feel free to post.

[mtueckcr]

Hello Jay,
thank you for taking the time to look at my case and your suggestions. I used mouth tape last night but subcontiously ripped it off in the night and still had mouth leaks. I have ordered a cervical collar and will try that when it arrives. I will also keep trying mouthtape as I know it takes some time to get used to.

My settings are currently EPAP 8 & IPAP 12. Do you think these settings make sense and I should get the leaks fixed or do they need tweaking?

I still feel very fatigued in the morning and wake  up with a headache. My heartrate spikes often throughout the night which coincides with the breathing events I am having. I have included two screenshots of a more detailed view of my breaths.