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Daytime sleepiness despite low AHI, low leak, 7+ hours of daily use
#1
Hi all,

I've been on my Resmed Auto PAP for about 6 weeks now. I had some mask issues initially (http://www.apneaboard.com/forums/Thread-...-face-mask) which were sorted out and I have been consistently using the Dreamwear nasal pillow mask with minimal leakage (I landed up using a medical tape to prevent air from escaping from my mouth) and sleeping on my side.

Here's a typical chart:

[Image: tS1sa4ih.png]

The problem is that I have been feeling lousy during the day (in terms of daytime sleepiness). It's as bad (if not worse) than before I started using my machine. 

When I started using the machine about 6 weeks ago, I seem to have felt pretty good for the first few nights (even though I had major leakage issues). One of things that was different then was that I was sleeping on my back. I quit doing that when I found that my AHI was significantly lower by sleeping on my side.

For Saturday night, I went back to sleeping on my back and here's the chart:

[Image: hmWialyh.png]

Even though the AHI numbers are much worse, I actually felt better during the day (less sleepy). I had a couple of drives (where I would normally feel sleepy) and it felt pretty good.

All in all, I am more than a bit puzzled and frustrated.


A few questions:

- how long does it normally take for treatment to have a positive impact on daytime sleepiness? 

- since I found that sleeping on my back seemed to subjectively make me feel better, any thoughts on continuing to sleep on my back but increasing the pressures some more to reduce the events?

- Does anyone have any ideas about what might explain my weird findings? 

Incidentally, I found a medical paper (https://www.ncbi.nlm.nih.gov/pubmed/17580592) that reported that after 3 months of CPAP use, the degree of benefit on daytime sleepiness (as measured by ESS and MSLT) improves with more CPAP use up to 7 hours nightly but 20% of users don't get a benefit from a daytime sleepiness even after using CPAP for more than 7 hours nightly. They provide some theories about why those 20% of users aren't seeing a benefit. I am wondering if I am in that 20%....


Thanks.
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#2
Hi Vas,

I'm hardly and expert, especially with your type of machine. You probably recognize that the increased AHI when you sleep on your back is due to the position. Your airway is more likely to close but also in that position and, as was the case with me, you may be experiencing chin tucks, in which your head tilts forward with your chin towards your chest which partially closes your airway. Your flow limit graph shows a lot more flow limitations while on your back than on your side.

In my case I used a buckwheat chaff pillow, which could be conformed, to stabilize my head while on my side and prevent chin tucks. It is also possible to conform the pillow with a hollow for your head and the a supporting ridge for your neck to prevent chin tucks while on your back. You can get such a pillow at Amazon for $49. Just search CPAP pillows. A cheaper alternative that many on the forum advocate is a soft cervical collar. Either may help improve your AHI while on your back.

I have no idea why you feel better with the higher AHI and I will not comment on your pressures. I will leave that to those with more expertise with your type of machine.

I can tell you you've come to the right place. A month ago my AHIs were between 7 and 15. Since following advice from this forum they are consistently under 2

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#3
Looking at your two charts, the first one looks like the night of sleep that I dream of.   My best guess is that sleeping on your side disturbs your sleep in some way not related to sleep apnea.  Maybe it causes discomfort or triggers restless leg syndrome or is just so different from your usual position that your brain stays alert.  If the latter, I'd expect that to resolve over a week or two.
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#4
G'day Vas. Your first chart looks almost ideal and I would have expected you to wake up refreshed and have an excellent day. The second chart indicates a significantly disturbed sleep with lots of high pressures, flow limitations etc - all the stuff we'd expect from sleeping on the back. Plus there's something weird happening at 6:30.

As to why you felt so much better despite the notionally poor results on Saturday is a bit of a mystery. My guess is that side-sleeping causes you discomfort to the extent that your sleep isn't restful despite the excellent breathing results. I know when I sleep on my side for any length of time I wake up with lower back pain, sciatica and often a sore neck. Consequently I have optimised my settings for back-sleeping and get a pretty good result.

This might be an option for you - sleep on your back if that's more comfortable and adjust your machine accordingly. I'm not familiar with the VAuto but it's obvious the pressure is butting up against the maximum for much of the night so an increase in pressure is probably required.
DeepBreathing
Apnea Board Moderator
www.ApneaBoard.com


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#5
Sleep in the way that feel best and most rested. As Melman was suggesting, you can accommodate back sleeping in two ways; first, keep your head and neck aligned using an ergonimic pillow or soft cervical collar. Second, give yourself a little more room for EPAP to rise, or set a higher minimum EPAP. In other words, let the machine use up to 16-18 for IPAP. The point is to have restful sleep, and for many of us that may mean supine sleeping. No worries, all you need it to avoid the chin-tuck that Melman points to because no amount or pressure can open an airway that is physically shut by your head position; and give your machine a little more room to work.

Good luck!
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#6
It took me awhile to notice a difference between "nights with CPAP" and "nights without CPAP." Initially it was a subtle difference, nowadays (almost 10 years later) it's immediately noticeable. Also, there was a lot of getting used to the "pressure in my nose" (I use nasal pillows) ... headaches, nose soreness, etc. I'd say for the first year it was hardly noticeable, and using the CPAP was probably more of a PITA than a help.

I'm in the process of trying to get a new machine. I'm trying to rent a modern unit for a couple of weeks before I visit my ENT for a scheduled visit ... by using a modern APAP I hope to evaluate newer technology (I have a constant-pressure brick) and also gather data on "breathing events" during the night  (using Sleepyhead or whatever). Maybe it will uncover something about my overnight breathing of which I am not aware. I then hope to present this datat to the doc, and convince him of prescribing a nicer APAP. We'll see how it works out.

**random ramblings**

There may be some other factors:

   What does your vitamin D level look like?

   How about magnesium? It affects your ability to sleep and a bunch of other things.

   How is your hydration? I heard a sleep scientist recommend drinking 1L of room temperature water first thing on waking up. It's helped me a lot.

   How is your fitness? Do you workout before bedtime (when I do, I generally get a bad night's sleep)

Other random note ... my wife and her siblings inherited (from their mother) a "light sleep" thing. She and her siblings, generally speaking, don't sleep well. I don't know what it is, I've suggested to her to get a sleep study (I think it's a brain thing, not apnea) ... but she hasn't decided to follow through.

Regards-
Dave
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#7
It turns out that sleeping on my back didn't really help. I tried it for a couple of more days and my daytime sleepiness was similar to how I felt sleeping on my side.

I just got back from a follow up appointment with my sleep doctor. She theorized that the changing pressures (due to the Auto setting) were potentially causing my brain to be roused with an alpha sleep pattern (or something like that!) thus disrupting my sleep given that I am a light sleeper. The other thing she said is that even though the Auto works well for some people, in some other people it could cause breathing instability.

She suggested turning off the Auto setting and changing it to Bilevel. The pressures she suggested were 12/9 after looking at my pressures over the past 6 weeks. She suggested leaving it that way for 3 months before making any more changes. It seemed like a reasonable suggestion so they made the change.

Any comments about her suggestions?

Thanks!
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#8
Based on your past auto bilevel results posted above, the fixed pressure at 12/9 seems pretty reasonable. I still think your results on 3/11 involved some physical obstruction that may be related to head angle or something that caused obstruction that was not prevented by pressures up to 14/11. If you see such OA clusters with fixed pressure, it does not mean change pressure, but probably to find a way to avoid the cause of the obstruction.
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#9
Thanks, Sleeprider. Last night (chart below) was the first night with the new settings and the numbers were decent though there appear to be a cluster of OA's towards the end. I am not sure they are legit because I woke up quite a few times (probably because of the higher pressures).

I'm not feeling that much better today - I guess I need to give it a few weeks before drawing any conclusions.

On 3/11, I slept on my back. I've gone back to sleeping on my side after concluding that the outcome (in terms of daytime sleepiness) of sleeping on my back was no better.

[Image: AcYmY2Ml.png]
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#10
Looks okay, but you had better days with auto bilevel that had pressures averaging 10/7. As you suggested, give it time and if you don't adapt to this pressure try one a little lower. I'm not sure what the advantage of fixed bilevel is supposed to be, but maybe you can educate both of us after this trial.
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