3 Months on CPAP, still tired despite Dr saying my apnea is controlled

[highwaystar86]

Hello all, I'm new to the forum but like many I've spent time on r/SleepApnea and was referred here.

I've been using CPAP therapy since mid September and have essentially had 2 months of compliant usage with my AHI being under 1 or 2 for that period. My follow up after my second sleep study (titration) my doctor has told me that I shouldn't be experiencing fatigue and daytime sleepiness now but I am. In fact it hasn't really improved much at all.

I'm posting my OSCAR screenshot here to hopefully see if the experienced users here can point anything out. Thanks and let me know if there is anything else you need!  


   

[Dormeo]

Welcome! A couple of questions for you:

Do you feel you sleep soundly during the night? If not, do you know what wakes you up?

In what position or positions do you usually sleep?

What do you use in the way of medications, drugs, and alcohol?

Have you had any testing for other possible causes of daytime fatigue and sleepiness?

One small suggestion: turn off the ramp. You will probably not miss it, and that way we can see what's going on during those periods. (As I recall, your machine will not register events or flow limitations while the ramp is on.)

With more information from you, people here may have some additional suggestions to make.

[highwaystar86]

Thank you for the help.

I'm a 35M, not overweight, active and eat healthy.

I don't smoke, drink or consume recreational drugs. I was prescribed modafinil last week but only used it twice since it causes brutal headaches for me so this screenshot is from a normal night. I gave up coffee in May so caffeine is limited to a green tea in the morning or early afternoon.

I sometimes sleep on my back but usually on my side. I find that I wake up once or twice a night to either a nose itch that makes me wake up and take off the mask to scratch, or a mask leak from improper positioning on the pillow. Other than that I sleep soundly

I am currently undergoing neurological examination since I have been having a bunch of neurological symptoms, my MRI did show non-specific lesions and I will meet with a neurologist next week to discuss. I am aware that this could be the cause of my fatigue especially if it's something like MS.

[highwaystar86]

Welcome!  A couple of questions for you:

Do you feel you sleep soundly during the night?  If not, do you know what wakes you up?

In what position or positions do you usually sleep?

What do you use in the way of medications, drugs, and alcohol?

Have you had any testing for other possible causes of daytime fatigue and sleepiness?

One small suggestion: turn off the ramp.  You will probably not miss it, and that way we can see what's going on during those periods.  (As I recall, your machine will not register events or flow limitations while the ramp is on.)

With more information from you, people here may have some additional suggestions to make.

Thank you for the help.

I'm a 35M, not overweight, active and eat healthy.

I don't smoke, drink or consume recreational drugs. I was prescribed modafinil last week but only used it twice since it causes brutal headaches for me so this screenshot is from a normal night. I gave up coffee in May so caffeine is limited to a green tea in the morning or early afternoon.

I sometimes sleep on my back but usually on my side. I find that I wake up once or twice a night to either a nose itch that makes me wake up and take off the mask to scratch, or a mask leak from improper positioning on the pillow. Other than that I sleep soundly

I am currently undergoing neurological examination since I have been having a bunch of neurological symptoms, my MRI did show non-specific lesions and I will meet with a neurologist next week to discuss. I am aware that this could be the cause of my fatigue especially if it's something like MS.

[Sleeprider]

The outstanding feature of your therapy is the high flow limitation along with long inspiration time. This means if you zoom in on your flow rate chart the inspiration is going to be flattened or even downward sloping. This reflects a significant amount of upper airway resistance or partial obstruction which requires considerable respiratory effort to overcome. We don't know the cause of this upper airway inspiratory flow limitation, but it could be partial obstruction in your nasal passages or upper airway at the pharynx. You are using a Resmed Airsense 10 Elite CPAP, so pressure is fixed. If you were using an Autoset, then the pressure would rise to relieve the flow limits. The only option you currently have is to increase the pressure setting from 8.0 to see if the added pressure can help expand your airway. I suggest you try a pressure of 10, then compare the 95% flow limitation statistic which is at 0.21 with your current pressure of 8.0. I also hope to see inspiration time less than or equal to expiration time.

Most users with this issue benefit from bilevel pressure with more pressure support. Pressure support is the difference between inhale and exhale pressure, and a higher pressure difference can offload inspiratory effort from you to the machine. The fact you still feel fatigued is not surprising considering the effort you put in to getting a breath of air, and it goes on all night long. This respiratory effort leads to frequent micro-arousals as your brain awakes you to i ncrease respiratory effort or you experience shots of adrenaline from the poor respiration flow. One thing that may help is to avoid chin-tucking which can obstruct the airway. If you find yourself sleeping on your side with your chin tucked in a fetal position this is a problem. Pull a corner of your pillow between your shoulder and jaw and see if that helps.

[highwaystar86]

The outstanding feature of your therapy is the high flow limitation along with long inspiration time. This means if you zoom in on your flow rate chart the inspiration is going to be flattened or even downward sloping. This reflects a significant amount of upper airway resistance or partial obstruction which requires considerable respiratory effort to overcome.  We don't know the cause of this upper airway inspiratory flow limitation, but it could be partial obstruction in your nasal passages or upper airway at the pharynx.  You are using a Resmed Airsense 10 Elite CPAP, so  pressure is fixed.  If you were using an Autoset, then the pressure would rise to relieve the flow limits.  The only option you currently have is to increase the pressure setting from 8.0 to see if the added pressure can help expand your airway.  I suggest you try a pressure of 10, then compare the 95% flow limitation statistic which is at 0.21 with your current pressure of 8.0.  I also hope to see inspiration time less than or equal to expiration time.  

Most users with this issue benefit from bilevel pressure with more pressure support.  Pressure support is the difference between inhale and exhale pressure, and a higher pressure difference can offload inspiratory effort from you to the machine. The fact you still feel fatigued is not surprising considering the effort you put in to getting a breath of air, and it goes on all night long.  This respiratory effort leads to frequent micro-arousals as your brain awakes you to i ncrease respiratory effort or you experience shots of adrenaline from the poor respiration flow.  One thing that may help is to avoid chin-tucking which can obstruct the airway.  If you find yourself sleeping on your side with  your chin tucked in a fetal position this is a problem.  Pull a corner of  your pillow between your shoulder and jaw and see if that helps.

Wow.. you just blew my mind. Thank you. This makes so much sense to me because there are times before I fall asleep that I notice it's like the machine isn't detecting my inhalation anymore at the top of my breath. Possibly because of restriction or to be honest probably a baseline level of congestion I always seem to have. I know that using a nasal spray does help but I don't think that's safe to use on a nightly basis?

I'm definitely going to put it up to 10 tonight and see how that goes. I do remember on the original prescription sheet sent to the CPAP supplier the doctor wrote "if BIPAP required, exchange CPAP".

[Dormeo]

It sounds as though you are in the midst of some other diagnostic processes, and I hope they shed helpful light on your fatigue.

Meanwhile, to follow up on Sleeprider's post, in addition to increasing your pressure, you might return to your sleep doctor to ask whether you could be titrated on a bilevel machine like the ResMed VAuto Aircurve. It would be able to deliver greater pressure support than the 3 you get via EPR on your current machine.

Also be aware that you can increase your pressure gradually, in increments as small as .2. Try 9 before you go to bed just to see what it feels like (with ramp off). If it feels OK, then try a few nights at that pressure, then go up as incrementally as you need to. If it's not so good, try starting at 8.4 or so. Feel free to post charts along the way.

[Geer1]

I would also turn ramp off. As Dormeo already commented it just delays treatment and limits machine reporting. It did so for ~ 1 hr in the data you posted due to the machine being turned off and restarting ramp process.

[Dormeo]

Just read your most recent post. Do get a copy of that prescription. I'd recommend trying to get your hands on a VAuto Aircurve, if coverage and/or cost are not an issue.

You're right that some nasal sprays for congestion should not be used regularly, but it is perfectly safe to use Flonase every night. It takes a week or two to build up its effectiveness, so be patient if you try it. Before you start Flonase (not concurrently), you can try something like Afrin for a night or two, just to see what it does to your flow limitations. That could help identify the part of your airway that is causing the FLs.

[Geer1]

But best not to use anything new tonight when trying the 10 cm. One change at a time so it is easy to know what is making the difference, first step is 10 cm to see if the increased pressure helps reduce flow limitations.