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Only feel good at zero AHI?
RE: Only feel good at zero AHI?
Thank you for your responses.

@Guyscharf: the nights with the lowest leakage are mostly followed by a good day. So there definitely seems to be a relation.

@Corruptalligator: a CPAP did not help me at all. Only once I got my bilevel, I started feeling better than without PAP therapy.

@Geer1: I suppose I have UARS which has developed to hypopneas over the years. I lowered my PS after consulting this forum but I might have cut it a bit to much. At PS of 5+ the curve looks a lot more rounded than it does now at 4.4. I will raise my PS a bit and see what it does.
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RE: Only feel good at zero AHI?
For uars the only thing you can rely on is how you feel unless you have eeg data.

Chasing perfect flow rate curves (rounded inhalations) is unlikely to help. At most you can try to manually count arousals and see at which settings they are minimized.
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RE: Only feel good at zero AHI?
That's a fair point Geer1. However, my Oscar readings are the only tool I have. 
Counting arousals might be an interesting option. Could you elaborate how I can derive them from Oscar data? As far as I know they aren't reported as such.
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RE: Only feel good at zero AHI?
Most arousals can be noted by abrupt changes in breathing pattern that are often larger in amplitude.

If there are obvious apnea, flow limitations etc preceding the arousal then it might have been caused by the breathing issue. If an apnea occurs shortly after arousal breathing it is often a falsely flagged event/SWJ or in some cases (not yours) sleep transition central apnea.

Here are a few examples of severe flow limitations causing arousals (RERAs).


If you had UARS you should see something similar in your data but judging by the one example you posted showing non existent flow limitations it is frankly unlikely to be the case. Imo the only thing you will probably learn from looking at your OSCAR data is how your leaks cause some arousals and to help determine if your odd apnea/hypopnea are real or falsely flagged (pre or post arousal).

If arousal breathing appears to occur randomly it is likely a spontaneous arousal and not related to a breathing issue. The other thing that can be tricky to interpret is rem sleep breathing as it can appear to be inconsistent and look like arousal/swj breathing. The trick with interpreting rem breathing is by noting the typical pattern (occurs roughly every 90 minutes in increasing duration as the night goes on).
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RE: Only feel good at zero AHI?
Thanks a lot for your referral to the wiki page. I've read it all when I first started CPAP therapy, but maybe is was a bit of an information overload at that time. The thing that stroke my eye was PLM related arousals. From my PSG I know I did suffer from PLM, although they seem far less frequent since I effectively addressed the respirational events with the Aircurve. When I asked my wife about it, she said I used to be far more restless at night than I am now.

Take aways for me from this thread are the following:
1. My assumption that feeling better is related to an AHI close to zero is apparently false. In search for leads (preferrably of quantitative nature) in order to fine tune my therapy, I mistakenly presumed a correlation between low AHI and feeling better. The problem with that is that one tends to chase low AHI numbers which doesn't make sense given the fact that some flags appear to be false. Last night I set my trigger from high to very high in order to cut down on CA flagging. Oscar reported 0,0 AHI but to be honest I can't say that I'm feeling so well today. So I think I'll just go for comfort and take any AHI figure for granted as long as it is below 2 or 3.
2. Although CPAP therapy has been successfully dialed in, I might still suffer from non respirational related arousals, i.e. PLM. I have to dive in to this subject a little more and probably have to cut back on caffeine.
3. I need to learn to read my RR curve more profoundly. I'd like to be able to identify arousals and distinguish between real events and false flags.

One last question: is it possible to see PLM related arousals in the RR curve even if the PLM is not the result of a respirational event?
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RE: Only feel good at zero AHI?
You misunderstood some of what I was saying, point 1 specifically is not necessarily false. The point I was trying to convey is that rather than feeling good because you have no recorded apnea it is probably that you feel good because you had a good night of sleep with few disturbances and falsely flagged events leading to a low recorded AHI. That said I am guessing you also have some nights you feel good after AHI of 1 since AHI is an imperfect statistic and not an indicator of sleep quality.

PLM can be an issue and definitely can be triggered/worsened by apnea/breathing. This improving is a sign that CPAP has helped. PLM may also be being triggered by other things (like you say caffeine, bad night etc) or imo may be a symptom of underlying issue that is causing how you feel. PLM will often show up in your data because muscle activation and movement often does affect lungs. If you record your sleep with video you will find it pretty amazing to see how almost all of your flow rate blips and oddities are usually explainable to some physical phenomenon and not necessarily a breathing issue. PLM arousals will show up as arousal breathing, PLM without arousals will probably show up as periodic blips in flow rate. Sheepless is a member that suffers from PLM and has a thread on it with some examples of how it shows up in his data as well as other comments on treatment although I haven't read it all in detail.


The tricky part of improving sleep is how complex it is and then when the main complaint is something like brain fog it becomes even more difficult because that isn't specific to sleep quality.

I myself have been on a journey for the past 4 years now to improve my sleep and health in general. At one point I figured/hoped it was all apnea but I have since realized that is not the case although CPAP does improve my sleep quality. My main complaints have been poor sleep quality, fatigue and I get brain fog as well. In follow up in clinic sleep studies including one with CPAP I was diagnosed with "no obvious sleep disorders" although both studies showed elevated spontaneous arousals at 54 and 37 arousals/hr. Doctor says they have no way of knowing what is causing these arousals or if they are happening regularly or just occurred because of sleeping in strange place with equipment hooked up etc. Their only idea is to trial different medications to see if any of them help.

One of my main improvements over the years was with diet changes (removal of dairy, gluten and reduction of carbs/sugar) and I challenge anyone that suffers from IBS, reflux, nasal congestion etc to try elimination diets to try to find any food sensitivities etc that may be causing/worsening not only these more obvious gastrointestinal symptoms but also sleep and general well being.

Other main improvement was with an SNRI antidepressant which helped my energy levels, brain fog, muscle relaxation and more. Interestingly this makes me feel better even at times when it shortens/worsens my sleep.

I also use a sleep aid that helps me get a good night sleep and counteracts the SNRI's shortening of sleep. I think it helps but maybe leaves me feeling a bit drowsy some mornings.

I am finally getting close to feeling good and think that things will continue to improve as I have more time on these medications (only been on the SNRI for a couple months now). Going to be trying one more medication that is used off label for both insomnia and bruxism (as that is one of my issues) and depending on how I feel if I need more improvement will probably see a psychiatrist to see if they have any more ideas.

Too many people poorly understand sleep quality, depression, brain fog and more because they are hugely complicated interwoven processes/symptoms affected by physical, chemical and psychological effects. I just started reading a book called Behave by Robert Sapolsky that discusses neurobiology and how our thoughts, behaviors, life situations, genetics etc all affect our bodies operation and although it is a fairly technical book (has to be for the topic) I think it is going to be very good and a couple chapters in I have already learned a few things.

I mention some of this because PLM for an example can be caused by numerous things including mineral deficiencies (iron is the main one I am aware of) and is often treated by dopaminergic medications (if it needs to be treated). What causes your PLM could also be causing your brain fog and who knows what else. Unfortunately modern medicine does not yet have the technology/knowledge to accurately test, diagnose or treat these issues yet. Sometimes realizing how things like this can all be intertwined and related is helpful in breaking free from the idea that some basic thing like apnea is the root cause of all your issues and helping further diagnose the problem.

One last note again this stuff is all hugely complicated and intertwined. I am not saying you don't have sleep disordered breathing and even if you don't have it I am not saying CPAP doesn't help. Only you can determine that based on how it makes you feel and based on your comments it has helped in your case by helping you get some nights of good sleep and reducing PLM etc. Even if your sleep disordered breathing is minimal like my own CPAP can still be helpful and you determine this by how it makes you feel, not the AHI number.
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RE: Only feel good at zero AHI?
Thanks a lot for your detailed answer. Much appreciated! I allready started to read the thread you mentioned. It's tough reading to he honest (because of the complexity of the subject). But very informative at the same time.
Your insight that good sleep possibly involves much more than just reaching low AHI/FL, has helped me a lot.
To be continued.
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RE: Only feel good at zero AHI?
For many people, Dopamine Agonist (DA) drugs work very well for PLM/RLS until 'Augmentation' kicks in and the condition is worse than they started with. Gabapentinoids are considered first line treatments in some countries these days although they have risks of their own (as do virtually all drugs). Best to try and get iron/ferritin levels up and identify dietary elements that could be making things worse (e.g. caffeine, alcohol, ...).
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RE: Only feel good at zero AHI?
My understanding of PLM is that they don't bother to try and treat it unless it is a known issue. Same as apnea.

I can only think of two ways to try and determine what is affecting your sleep quality now. Titration study to see how well you sleep on current PAP settings and if or what is still affecting sleep, biggest weakness is that it is only one night in a strange spot so especially if sleep is only poor some nights then it might not catch the issue. Other option is video recordings at home to see if you can see what appears to disrupt your sleep.
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RE: Only feel good at zero AHI?
Hi Permabear!

You said: "My assumption that feeling better is related to an AHI close to zero is apparently false"

As Geer1 says it is infinitely more complex than that.

Many days when I "hit" AHI of 0 is because I had a light or disturbed sleep, didn't sleep deeply enough to create the situation which would precipitate OSA.

My best days are when I have an AHI of < 2. In fact that is what I aim for. With excessive Pressure Support I feel less good: the side effects of PAP therapy kick in: mine include chest inflation, chest pain, heart palpitations, headaches, feeling wrecked the day after, bruxism as well as the more common dry mouth and so on. I aim to avoid over-treatment, and feel better the next day when I have still have a few short OSA and actually do better if I maintain a few true CA. 

Once your AHI is less than 5 it is best to no longer focus on the AHI. Better to correlate how you feel against the PAP settings. Focus more on your side effects and how treatment effects you.

PAP therapy, like all medical treatment, can have and does have side effects. These are individual. It is up to each of us to titrate the side effects against the therapy settings.

That is why is it crucial that we do not allow encryption of machine data. The CPAP clinicians, therapists, as well meaning as they are, are only trained to follow generic treatment pathways.

For example if you have hypertension or diabetes and your doctor brings your BP or sugar levels down too far or too quickly, they may think you are responding well to treatment, but you have to tell them that despite numbers (BP or sugar levels) you are feeling unwell. It is a balance between over-treatment and under-treatment. Only you can be the one that decides that, and you need to be part of the decision making process.

The paradoxical journey you go through with xPAP is an intensely personal one. The sleep clinics can give you a rough guide. The help and shared experiences of others here on this forum will add much value and understanding to your experience.

Once your xPAP has you in the "ball park" as far as AHI goes, it is time to look at other factors that effect sleep quality, as alluded to by Geer1 and others.

Happy traveling!
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