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[Diagnosis] Negative sleep study, still ordered a CPAP
#1
Negative sleep study, still ordered a CPAP
Hello folks,

For the past 3 years I've been dealing with insomnia, nightmares, choking at night, waking up extremely tired, etc - you know the drill. I've had 2 doctor appointments 2 years ago which told me to improve my sleep hygiene, but they left it at that. This year I was better informed and in March I had a doctor's appointment where I requested a sleep study to make sure no sleep disorders are present. In September this year I finally had a PSG home sleep study done after picking up my gear at the hospital. Last week I received the results. 

TST 6 hours and 33 minutes.
Normal amount of N3, 1 hour and 54 minute 29%
Low REM, 55 minutes 14%
SOL 40 minutes
WASO 29 minutes
AHI 1,5
Average O2 Saturation 95,2%, minimal O2 Saturation 92%
PLMnr_I 4,72 & 1.98 arousal

Doctor said there is nothing indicating OSA. Suboptimal sleep hygiene (this because of afternoon naps) and fragmented sleep. No somatic sleep disorders registered.

Doctor's assistent called me offering to make an appointment at their sleep psychologist to check for possible PTSD because of the nightmares that sometimes involve a traumatic past. Told me it'll take 9 months minimum before I can speak to the psychologist. I told her this way too long, but to sign me up anyways. I ordered a cpap online myself (resmed airsense 10 autoset) and the gear aswell. Someone I spoke to online told me he has UARS and had 3 sleep studies (2 PSG and 1 PSG+PES) to rule out OSA/UARS and the final sleep study with the PES finally diagnosed him with UARS. Now this tuesday my own GP is calling me to discuss the results and I'm going to request a WatchPAT study aswell as another psychologist who can make an appointment earlier than in 9 months, this all to rule out other sleep disorders than OSA and to be certain I don't have PTSD or something alike. 

I know it was a bold move to order my own CPAP and just try it out, but I had to know if it was going to make me feel any better. So far I slept 3 nights with it on and I haven't noticed that much of a difference, aside from waking up less than normal. The first night I slept with CPAP mode with pressure at 6 and EPR off, I could barely sleep with those settings so the next night I turned EPR to 3 and set the pressure to 7 and turned ramp off. I have my OSCAR results aswell posted below. Tonight I plan to try APAP mode set to 7-20 to see what my optimal pressure would be. If it doesn't help me, then I sadly spend a hefty sum of money for a young man, but I have to get to the bottom of this.

I'd greatly appreciate any advice, own stories, opionions, whatever just so I'm better informed.

In chronological order I have placed the 1st, 2nd and 3rd night from OSCAR.
The first night I didn't sleep, but laid still for 2 hours. The 2nd night I woke up only once around 12 to readjust my mask. The 3rd night I woke up around midnight panicking I had to go to work and my mask was leaking aswell, so I took it off and went to sleep.

imgur.com/a/tSjt3Qj (The 3 pictures are located here, can't place them yet as I'm a brand new member)

Thanks in advance.


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#2
RE: Negative sleep study, still ordered a CPAP
I think you might be more comfortable in Autoset mode with a little bit of exhale pressure relief (EPR). I would set a range of 7 to 10 with EPR 1 or 2 based on comfort. I don't think a range up to 20 is needed, and with this limited range we will quickly know if you are hitting the maximum pressure and get some better idea on where you need to be. You are experiencing some CA events and it's hard to know if that is sleep disruption or just adapting to CPAP. The only OA occurred in a cluster, and may have been positional.
Sleeprider
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#3
RE: Negative sleep study, still ordered a CPAP
Hello, Anargy. When you change your settings per Sleeprider's advice, check carefully to make sure you've locked them in by pushing the round button after you turn it to the desired setting. (You report that you introduced EPR of 3, but I don't see that on the charts you posted.)

Also, it'd be helpful to see your flow limitation graph. To squeeze it into the screen shot, just grab the horizontal gray bars separating the graphs and push them up.
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#4
RE: Negative sleep study, still ordered a CPAP
I too see the adjustments mentioned as being a good idea, to both machine therapy and to OSCAR charts. Realize that you're almost there with good therapy, just that it needs a bit of tuning. Welcome to Apnea Board BTW.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: Negative sleep study, still ordered a CPAP
(11-14-2020, 11:19 AM)Sleeprider Wrote: I think you might be more comfortable in Autoset mode with a little bit of exhale pressure relief (EPR). I would set a range of 7 to 10 with EPR 1 or 2 based on comfort. I don't think a range up to 20 is needed, and with this limited range we will quickly know if you are hitting the maximum pressure and get some better idea on where you need to be. You are experiencing some CA events and it's hard to know if that is sleep disruption or just adapting to CPAP. The only OA occurred in a cluster, and may have been positional.

Thank you, I have set it to 7 to 10 with EPR on 2.

(11-14-2020, 12:48 PM)Dormeo Wrote: Hello, Anargy. When you change your settings per Sleeprider's advice, check carefully to make sure you've locked them in by pushing the round button after you turn it to the desired setting. (You report that you introduced EPR of 3, but I don't see that on the charts you posted.)

Also, it'd be helpful to see your flow limitation graph. To squeeze it into the screen shot, just grab the horizontal gray bars separating the graphs and push them up.

I double checked and the EPR was really set to 3. Where on the chart can you read if EPR is active? I'm going to sleep in a few hours with the new settings, I'll post an updated OSCAR stat with my flow limitation graph in the morning.

(11-14-2020, 12:58 PM)SarcasticDave94 Wrote: I too see the adjustments mentioned as being a good idea, to both machine therapy and to OSCAR charts. Realize that you're almost there with good therapy, just that it needs a bit of tuning. Welcome to Apnea Board BTW.

Thank you. I hope it's going to help me get a decent amount of sleep, using a CPAP without being diagnosed with OSA doesn't sound very promising, but alas I have to try.
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#6
RE: Negative sleep study, still ordered a CPAP
Oh, I just realized your pressure chart's minimum is at 6, so it isn't showing anything less than that. Could you rescale it so the minimum is 4? Just right-click on the graph label to access those settings.

In general, you can see the EPR under machine settings in the panel on the left. That line isn't visible in your screenshots, but you should be able to see it yourself.
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#7
RE: Negative sleep study, still ordered a CPAP
There are some good Cognitive Behavior Therapy - Insomnia (CBT-I) apps and programs online. Also online, PTSD self help may hold you until your appointment with the doctor. Search the USA Veterans Administration sites.

You have the right idea regarding getting things straightened out while you are young. It doesn’t get any better with age.
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#8
RE: Negative sleep study, still ordered a CPAP
I have been suffering from the exact symptoms you have mentioned in your first post. I am a psychiatrist and can tell you that the line between PTSD and Breathing Related Sleep Disorder have been blurred significantly in the last decade. However, nightmare is far from being only symptom of PTSD. What you may have been suffering from is significant flow limitations accompanied by arousals during your rem sleep ( your muscles are most relaxed during rem and your airway shrinks). As you experience these brief arousals during REM most of which do not reach to complete wakefulness yet enough to activate your memory retention, you end up remembering wild and crazy dreams. We remember the dreams from which we are awaken.

This is how I explain it. PTSD or any type of significant anxiety disorder leads to hyper-vigilance, which in turn leads to exacerbated response to external stimuli. Your brain believes that you are under constant threat. Thus, a flow limitation that would not cause any arousal for most of the population, may be enough to disrupt your sleep.

Now, this is where the tricky part comes. 99% of sleep specialists will not diagnose you with breathing related sleep disorders because most labs do not count flow limitations. I am not a sleep expert. However, I am not convinced that the machine you have is specifically good at addressing flow limitations while not causing further vigilance in your highly hyper vigilant state of mind.
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#9
RE: Negative sleep study, still ordered a CPAP
Marasmus, it is wonderful to see this post from a psychiatrist who also understands the world of breathing-related sleep disorders.

Anargy's traumatic past suggests that PTSD should be on the diagnostic table for him, but more broadly, many people who post on apnea forums experience daytime anxiety and have trouble sorting out the relationship between that and their sleep problems. It sometimes seems two-way, and anxiety medication seems often not to help.

Your speculation about the role of flow limitations is especially helpful. I do know that some people find they sleep more soundly after reducing FLs (usually with the help of a bi-level machine). Others don't seem bothered by FLs, even fairly heavy ones. Your take on this -- with a starring role for anxiety-related hypervigilance -- helps to make sense of this.
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#10
RE: Negative sleep study, still ordered a CPAP
"PLMnr_I 4,72 & 1.98 arousal"

I'm not quite sure what this means, presumably 72 periodic leg movements averaged to 1.98 plm arousals/hr?

if so, not a lot of plm, but in my experience it doesn't take a lot of it to disturb sleep. plm is also quite variable so your test results may or may not reflect your typical night. at any rate, plm is rarely addressed so I'm mentioning it here for you to keep in mind as a possible factor contributing to fragmented sleep, daytime sleepiness, possibly choking, maybe nightmares, etc. respiratory response to plm includes flow limitations. be aware that resmed machines raise pressure ineffectively and disturbingly against plm induced flow limitations. this can be as or more disturbing than the plm itself. if you experience this, keep your pressure range to a minimum & limit max ipap to avoid swinging and runaway pressure.
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