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2.5 years on CPAP, still very tired
#1
2.5 years on CPAP, still very tired
Hi all,

I am new to the board and need help.

I have been on CPAP for 2.5 years now. I used it religiously and on average I sleep about 7 hours every night. Still I am fatigued during the day. 

My AHI has a wide range (from 1 up to 10, the average is about 5). It seems totally random. Sleep positions may be a factor, but then I can't control them.

I rarely have a night of restorative and refreshing sleep. A night with a high AHI will definitely lead to a very tired day, but a good night (AHI 1 or 2) does not necessarily give me energy for the day either. 

I have seen my sleep doctor many times and have done two sleep tests during the last two years. I have tried all kinds of masks, and the doctor have changed the pressure multiple times. Nothing helps.

I am attaching a few screenshots. I really appreciate your help!

Ahunix


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#2
RE: 2.5 years on CPAP, still very tired
Typically the first step is to post your recent sleep studies, not just the summaries. You need to remove any personal information before you post them.

The obvious issue are the clear airway (central) apneas. I fought central apneas for years, kept them pretty much in check (1.5 per hour), but then I started having numbers like yours where they would be low and then hit double digits. I ended up with an ASV machine.

The other concern is the Cheyne-Stokes Respiration. I don’t know how well (accurately) the Airsense 10 identifies them. But that is a concern.

Have you shown these charts to your doctor? It will be interesting what the sleep studies found.

John
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#3
RE: 2.5 years on CPAP, still very tired
Have you tried reducing the EPR to say 1?
It should reduce the centrals, worth a try.
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#4
RE: 2.5 years on CPAP, still very tired
Welcome to the forum.

I would like to see your overview chart.  I want to see your AHI history

Also I want to see a couple of 2 minute segments of your Central Apnea areas, including one that says CSR,  We need to see what your breathing looks like during these events.

Also post redacted full copies of your diagnostic and titration studies.  This means the charts and tables and not just the summaries.

Central Apnea is extremely variable as you are seeing.  THIS is the reason why your AHI is all over the place.

Some surprises here in that you are a CPAP user for 2.5 years.  After this period the Centrals shouldn't be Treatment-Emergent as they should normally disappear in 2-3 months.

Treatment:
Step 1:  Reduce EPR to 1.  In your case this may or may not reduce Central Apnea.  It could increase obstructive events.  Either way it will tell us important info about your apnea.

Possibly may require a new CPAP machine, specifically an ASV.  But let's see what we learn going forward.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: 2.5 years on CPAP, still very tired
As SanO says, it'd be very helpful to the experts if you could post a full redacted sleep study. If you don't have a copy, you can request one. (You have a right to have it.)

Two other things would be useful.

(1) Could you change the y-axis on your pressure graph so we can see where the pressure goes? Over at the left of the graph, where it is labeled, right click to find the y-axis adjustment, then select Override and set the maximum to your maximum pressure of 15.

(2) In one of the green areas for CSR, could you provide a 10-minute zoom-in? Select the green area, then hit the up arrow on your computer until you get to a graph for around 10 minutes. Use the right or left arrows to find a segment where you have a lot of CAs. The experts will want to look at the pattern they exhibit.

And one question for you: do you think your leaks wake you up or disturb your sleep? Do you know what causes them -- mask shifting, mouth leaking, some of each?
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#6
RE: 2.5 years on CPAP, still very tired
Forgot to ask.

Because Centrals are your primary issue currently, and to eliminate causes

any of the following
Drug usage, especially opiods and recreational drugs.
Heart conditions, including CHF.
Breathing issues other than apnea, such as COPD, Asthma
Seizures, strokes, Brain injuries
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: 2.5 years on CPAP, still very tired
Thank you all! Let me put together more info.

First, bonjour's questions:

Drug usage, especially opiods and recreational drugs.

No.

Heart conditions, including CHF.


No. My sleep doctor ordered some tests, including a Stress ECG Test, a Holter monitor test. Everything seems to be fine.

I do have hypertension for 7 years now.

Breathing issues other than apnea, such as COPD, Asthma

No.

Seizures, strokes, Brain injuries

No.

Overview charts: Last 3 months, 1 year, and everything.


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#8
RE: 2.5 years on CPAP, still very tired
2nd Sleep Test (5/22/2019)

ATTENDED CPAP/BILEVEL POLYSOMNOGRAPHY REPORT



PATIENT'S NAME: 
DOB:
MRN: 
WEIGHT: 171 lbs
HEIGHT: 5'7"
BMI: 26.8
DATE OF RECORDING: 5/22/2019
REFERRING PHYSICIAN:

Monitoring Tech: 
Scoring Tech:
Reporting Tech:
Interpreting Physician:
Medications:


Clinical Background:
47 year-old patient is here for an Attended CPAP\BiLevel titration procedure.

PROCEDURE:  
This attended polysomnogram montage using Compumedics Profusion 3 Software included recorded video, 6 EEG electrodes for frontal, central, and occipital monopolar recordings, 2 EOG electrodes, ECG, and chin EMG electrodes, snoring microphone, thermistor, airflow pressure, thoracic, and abdominal respiratory effort, pulse oximetry, leg movement, body sleeping position, and body movement. Please note that the AHI greater than 4% in this report is consistent with the current Hypopnea definition according to Medicare Criteria and is consistent with the current Hypopnea definition according to AASM criteria.  The 30 sec. epochs were scored according to the AASM Manual for the scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications edition (Ver. 2.3).


CPAP settings of 5 to 11 cm of water were used during the titration. It appeared that the patient needed higher pressures to adequately treat his sleep disordered breathing during REM stage sleep, especially while sleeping in supine position. There were very occasional post-arousal central apneas noted during the sleep-awake transition times during the night.

SLEEP SCORING DATA:  
Lights Out / On (clock times): 21:59:25 / 05:23:56
Total Recording Time (TRT) (min): 445.5
Total Sleep Time (TST) (min): 342.5
Sleep Efficiency: 77.1%
Sleep Latency (min): 8.0
Stage REM Latency (min): 45.5
Wake after sleep onset (WASO) (min): 94.0

Stage N1 Sleep (min, % of TST): 18.0  (5.3%)
Stage N2 Sleep (min, % of TST): 152.0  (44.4%)
Stage N3 Sleep (min, % of TST): 99.0  (28.9%)
Stage R Sleep (min, % of TST): 73.5  (21.5%)
Supine Sleep (min): 121.5
Arousals (index, #): 6.7  (38)

RESPIRATORY ANALYSIS:  (index = #/hr)
Apnea/Hypopnea Index (AHI): 7.0
*AHI 4% or greater: 1.2
NREM AHI: 5.8
REM AHI: 11.4
Non-Supine AHI: 4.3
Supine AHI: 11.9

Respiratory Disturbance Index (RDI): 7.4
NREM RDI: 6.2
REM RDI: 11.4

Apneas (index, #): 0.2  (1)  
Obstructive Apneas (index, #): 0.0  (0)  
Mixed Apneas (index, #): 0.2  (1)  
Central Apneas (index, #): 0.0  (0)  
Hypopneas (index, #): 6.8  (39)  
RERAs (index, #): 0.4  (2)  

Mean Awake SpO2: 97%
Mean Sleep SpO2: 96%
Minimum Sleep SpO2: 90%
Sleep Time with SpO2 < 88% (min, % of TST): 0.0  (0.0%)

Cheyne Stokes breathing: No

CARDIAC ANALYSIS:
Mean Awake HR: 51
Mean Sleep HR: 51

Bradycardia: No
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (index, #): 0.0  (0)
PLMS with arousals (index, #): 0.0  (0)

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure activity was noted.

CLINICAL INTERPRETATION:
1. Patient was previously diagnosed as having severe obstructive sleep apnea, and it appears that he would be best treated with nasal Auto-CPAP at an airflow pressure range settings of 8.0 to 14.0 cm of water.  This pressure may need to be adjusted after the patient is habituated to the equipment and after review of Smart Card download correlated with clinical symptoms.
2. The patient should avoid sleeping in supine (on his back) position.  Side-sleeping or elevation of the head at 30 degrees would be preferred.
3. A prescription for CPAP supplies was done.

Sleep study raw data was manually reviewed and the report
reviewed, edited, and electronically signed by me. Please feel
free to contact me if you have any questions.

1st Sleep Test (9/20/2017)
 
split night report 2017


SPLIT NIGHT POLYSOMNOGRAPHY REPORT


PATIENT'S NAME:
DOB: 
MRN: 
WEIGHT: 163 lbs
HEIGHT: 5'8"
BMI: 24.8
DATE OF RECORDING: 9/20/2017
REFERRING PHYSICIAN: 

Monitoring Tech: 
Scoring Tech: 
Reporting MA: 
Interpreting Physician: 
Medications:


Clinical Background:
45 year-old patient is here for a Split Night Polysomnography.

PROCEDURE:  
This split night polysomnogram montage using Compumedics Profusion 3 Software included recorded video, 6 EEG electrodes for frontal, central, and occipital monopolar recordings, 2 EOG electrodes, ECG, and chin EMG electrodes, snoring microphone, thermistor, airflow pressure, thoracic, and abdominal respiratory effort, pulse oximetry, leg movement, body sleeping position, and body movement.  Please note that the AHI greater than 4% in this report is consistent with the current Hypopnea definition according to Medicare Criteria and is consistent with the current Hypopnea definition according to AASM criteria.  The 30 sec. epochs were scored according to the AASM Manual for the scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications edition (Ver. 2.3).

DIAGNOSTIC PORTION:
Lights Out / On (clock times): 22:02:11 / 00:16:12
Total Recording Time (TRT) (min): 134.0
Total Sleep Time (TST) (min): 111.5
Sleep Efficiency: 83.2%
Sleep Latency (min): 9.0
Stage REM Latency (min): 103.5
Wake after sleep onset (WASO) (min): 13.5

Stage N1 Sleep (min, % of TST): 14.0  (12.6%)
Stage N2 Sleep (min, % of TST): 78.0  (70.0%)
Stage N3 Sleep (min, % of TST): 0.0  (0.0%)
Stage R Sleep (min, % of TST): 19.5  (17.5%)
Supine Sleep (min): 95.5
Arousals (index, #): 24.8  (46)

RESPIRATORY ANALYSIS:  (index = #/hr)
Apnea/Hypopnea Index (AHI): 56.0
*AHI 4% or greater: 53.8
NREM AHI: 56.7
REM AHI: 52.3
Non-Supine AHI: 52.5
Supine AHI: 56.5

Respiratory Disturbance Index (RDI): 56.0
NREM RDI: 56.7
REM RDI: 52.3

Apneas (index, #): 52.2  (97)  
Obstructive Apneas (index, #): 35.5  (66)  
Mixed Apneas (index, #): 0.0  (0)  
Central Apneas (index, #): 16.7  (31)  
Hypopneas (index, #): 3.8  (7)  
RERAs (index, #): 0.0  (0)  

Mean Awake SpO2: 93%
Mean Sleep SpO2: 89%
Minimum Sleep SpO2: 70%
Sleep Time with SpO2 < 88% (min, % of TST): 18.8  (16.9%)

Cheyne Stokes breathing: No
Snoring: Mild

CARDIAC ANALYSIS:
Mean Awake HR: 53
Mean Sleep HR: 53

Bradycardia: Yes
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (index, #): 0.0  (0)
PLMS with arousals (index, #): 0.0  (0)

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure activity was noted.

CPAP/BIPAP PORTION:
CPAP settings of 5 to 14 cm of water were used during the titration. Bilevel settings of 15/10 cm of water were also explored during the titration. It appeared that the patient needed higher pressures to adequately treat his sleep disordered breathing while sleeping in supine position, in comparison to sleep in other positions.

SLEEP SCORING DATA:  
Lights Out / On (clock times): 00:16:11 / 05:58:42
Total Recording Time (TRT) (min): 342.5
Total Sleep Time (TST) (min): 262.0
Sleep Efficiency: 76.5%
Sleep Latency (min): 5.0
Stage REM Latency (min): 100.5
Wake after sleep onset (WASO) (min): 75.5

Stage N1 Sleep (min, % of TST): 13.5  (5.2%)
Stage N2 Sleep (min, % of TST): 152.0  (58.0%)
Stage N3 Sleep (min, % of TST): 15.0  (5.7%)
Stage R Sleep (min, % of TST): 81.5  (31.1%)
Supine Sleep (min): 161.0
Arousals (index, #): 16.3  (71)

RESPIRATORY ANALYSIS:  (index = #/hr)
Apnea/Hypopnea Index (AHI): 26.8
*AHI 4% or greater: 24.7
NREM AHI: 34.2
REM AHI: 10.3
Non-Supine AHI: 5.3
Supine AHI: 40.2

Respiratory Disturbance Index (RDI): 26.8
NREM RDI: 34.2
REM RDI: 10.3

Apneas (index, #): 22.7  (99)  
Obstructive Apneas (index, #): 9.6  (42)  
Mixed Apneas (index, #): 0.0  (0)  
Central Apneas (index, #): 13.1  (57)  
Hypopneas (index, #): 4.1  (18)  
RERAs (index, #): 0.0  (0)  

Mean Awake SpO2: 97%
Mean Sleep SpO2: 95%
Minimum Sleep SpO2: 81%
Sleep Time with SpO2 < 88% (min, % of TST): 1.0  (0.4%)

Cheyne Stokes breathing: No

CARDIAC ANALYSIS:
Mean Awake HR: 54
Mean Sleep HR: 54

Bradycardia: Yes
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (index, #): 1.8  (8)
PLMS with arousals (index, #): 0.0  (0)

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure activity was noted.

CLINICAL INTERPRETATION:
1. The diagnostic study documents severe Obstructive Sleep Apnea with significant oxygen desaturations during sleep. The RDI was 56.0 events per hour of sleep.  The lowest oxygen saturation was 70 %, and 16.9 % of the sleep time was spent at saturations below 88 %.  Snoring was present per technician's notes.
2. A very few periodic limb movements of sleep (PLMS) were noted but overall frequency was not significant.
3. Based on the titration part it appears that he would be best treated with nasal Auto-CPAP at an airflow pressure range settings of 8.0 to 20.0 cm of water.  This pressure may need to be adjusted after the patient is habituated to the equipment and after review of Smart Card download correlated with clinical symptoms.
4. The patient should avoid sleeping in supine (on his back) position.  Side-sleeping or elevation of the head at 30 degrees would be preferred.
5. A prescription for nasal Auto CPAP initiation at above pressure range settings was done.
6. Patient should schedule a follow up appointment to be seen in sleep clinic a month after starting CPAP therapy.  

Sleep study raw data was manually reviewed and the report
reviewed, edited, and electronically signed by me. Please feel
free to contact me if you have any questions.
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#9
RE: 2.5 years on CPAP, still very tired
Help: I need to post more charts (2-min, and also the result of EPR=1) but I was told I am out of quota already. What do I need to do? Thanks!
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#10
RE: 2.5 years on CPAP, still very tired
EPR = 1

Last night's result after reducing EPR from 3 to 1. I'm very tired today, as usual.

https://imgur.com/a/xCeIjch

2-minute zoom in

https://imgur.com/a/2iR4alZ

https://imgur.com/a/JxuD6N7

https://imgur.com/a/DI4LeN0


Thank you all very much for your help!
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