PSG Results: Could this be UARS?

[Geer1]

Well the thing is I don’t have effective therapy with BIPAP/CPAP. It’s only effective in terms of AHI. But it seems like flow limitation or something else is still causing me to wake up every REM cycle, and sometimes more. And in order to treat the flow limitation/RERAs, I need to increase pressure and PS, but because I currently can’t really tolerate that without getting centrals, I thought ASV might be able to address that problem. I’ve seen Barry Krakow recommend ASV for all kinds of complex cases. And if I am in fact dealing with SDB, I may be one of those complex cases.  There’s probably still some experimenting to do with the other machines, but I don’t think ASV is out of the question.

It is too easy to get caught up on thinking sdb is the issue and what has been tried just isn't effective. 

The only difference ASV makes is increasing PS. If you cant stand higher than 3 with aircurve wait till ASV tries to blast you with 10 ps. 

I'm with Sleeprider. It is unlikely SDB is your issue or that you will find relief with a different machine/setting. There are a lot if things that can affect sleep/fatigue to think it can only be SDB is short sighted. 

With regards to flow limitations, flow limitations are only an issue if they are an issue. They must create too much of a restriction that then causes an increase in co2 which then causes an arousal. Only way to treat such a situation is higher PS but you claim that makes things worse not better indicating it likely isn't the issue. 

Imo I would focus on treatment other than pap. Pap likely does help to some point but likely isn't the answer to your problems.

[Dormeo]

Deebob, you say that the trazadone "actually helped me sleep a bit better, and my mood felt a bit better the next day." So why did you immediately start cutting back on it? Yes, it can have side effects, though you don't mention having any, but I know how bothered you are by sleeping poorly, so maybe it is worth sticking with something that helps.

You ask whether treatment emergent central apneas can go away over time. Yes, they can. It can take a while. Start where the pressure support is low enough not to trigger any but a few CAs. Then increase it by .2 and see what happens for a few nights. Proceed in this way until you start triggering a lot of CAs. Then back off by .2 or .4 and stay there for several weeks. Try going back up by .2. You get the idea -- small increments of increase, letting things settle in. For me, after 2 months at PS of 4.8, with the CA index bouncing around between .4 and 2.4, CAs have finally become consistently negligible.

Finally, if your Ouros is reliable, then the big variable in the amount of REM you get comes with the first part of the night. When you get some REM then, your percentage for the night is good. When you don't, it is a bit low.

In case it matters -- people dream in other sleep stages than REM.

[Geer1]

Also if my memory is correct your main period of sleep disturbances based on PSG was during nrem.

[deebob]

I currently don't have any kind of RLS feelings. If it's not SDB I really don't know what else could be causing this. Is it possible for mental issues to cause me to wake up so consistently every night? It doesn't vary at all. It feels very mechanical as though it's happening as certain bodily functions like sleep cycles and breathing changes occur. Even if I take Ativan or Trazodone, which could theoretically overcome mental issues, I still experience the same disturbances, they are just dulled a bit and happen slightly less frequently. Which makes me think all that the drugs are doing is dulling my arousal threshold a bit and improving insomnia when I try to get back to sleep, but the breathing issues still exist so it doesn't solve the problem completely.

Last night was another very typical (bad) night for me, where I woke up almost every hour during REM. https://imgur.com/a/JIJZ12e
In the early morning I almost couldn't go more than 30 mins without waking up.  What makes me think it's breathing related and not something else like PLM, is that I often wake up with my heart racing and a feeling like I had just been holding my breath.  To me, it seems to feel very much like a RERA when it happens. It is my understanding that when there is breathing difficulty, the body releases norepinephrine or adrenaline or something like that which increases the heart rate in order to wake you up because your body perceives this as danger.  This seems to match my experience exactly.

The only problem is that my OSCAR charts almost always look fine. Last night I had nothing except 1 central. Flow limitation looked okay, leak rate was fine. There were a couple of funky breathing instances that may have been RERAs, but it isn't very clear, and most of my breathing curves look fairly normal, and there doesn't appear to be any noticeable flattening around times that I woke up.  So I don't know what the hell is going on.

I'm looking into doing a WatchPAT test, and maybe a home sleep study with AXG Diagnostics because I really don't know what I'm chasing right now - all I know is I have all the symptoms and characteristics of UARS, and there doesn't seem to be anything else that can so consistently cause these awakenings every REM cycle (that I know of).

[Dormeo]

"It feels very mechanical as though it's happening as certain bodily functions like sleep cycles and breathing changes occur. Even if I take Ativan or Trazodone, which could theoretically overcome mental issues, I still experience the same disturbances, they are just dulled a bit and happen slightly less frequently. Which makes me think all that the drugs are doing is dulling my arousal threshold a bit and improving insomnia when I try to get back to sleep, but the breathing issues still exist so it doesn't solve the problem completely."

I know you have the feeling there is some breathing disorder implicated in your wake-ups, but I'm not seeing the evidence to back this up. It is normal to wake up off and on during the night, and waking up at the end of a REM period is pretty common (though, again, if all you know is that you were dreaming when you woke up, you don't know whether it was REM or not).

I would urge you to continue using the Trazadone for a while. Improving your arousal threshold and helping you get back to sleep more easily are good things! Plus it takes about 4 to 6 weeks for people to feel the full benefits of using Trazadone. What do you have to lose by persevering? That's not a rhetorical question.

[deebob]

I mainly just don't want to take an anti-depressant. I don't like the feeling of chemicals changing my mood and all that.  And the few days I used Trazodone didn't make that big of a difference....it helped me sleep one or two nights when my anxiety was high, but I was still sleeping poorly and waking up frequently.  My mood seemed a bit better but it was kind of a strange artificial feeling.  And I also felt some side effects that werent good, particularly I felt extremely lethargic and tired in the afternoon. Like I needed to lay down on the couch and didn't feel like doing anything.  And then I gradually started taking less of it to taper off of it quickly, like half a pill one day, quarter pill the next day, and I felt really crappy and extremely lethargic for a few days after. Like I couldn't get out of bed until noon and felt like doing nothing all day.  I just couldn't really tell if it was doing enough to make it worth it, and I'd prefer to not take something like that.

I just can't think of what the heck is going on if it's not breathing related. I've never heard of anything like this happening to anyone else without it being breathing related.  The other thing is, there is evidence of me sleeping poorly over a year ago, when I wasn't even conscious of my sleep problems and wasn't dealing with depression and anxiety related to all of this, and I was mouth breathing and snoring back then. My physical characteristics of narrow jaw and recessed mandible commonly cause snoring and breathing issues, and would explain why my energy and sleep has been noticeably and gradually getting worse the past 5 years or so, until it reached a breaking point last year. I also think my sleep has gotten worse the past month when my nose became more congested - which is another clue that breathing is an issue. I may experiment without PAP for a couple days to see if my sleep is worse as well. I have gone a few nights without it in the past few months and it's been hard to notice if my sleep was much worse, it may have been similar.  

I also wonder if higher pressure might make a difference. The Autoset is currently trying to go up to the max of 10 that I set it to, so why would it do that if it didn't feel the need to raise the pressure to 10? What if I didn't set it to 10? Would it try to go higher ?

[sheepless]

"If it's not SDB I really don't know what else could be causing this."

sorry, I'll quit bugging you after this, but by golly you could be a poster child for denial. as I recall your psg documented something like 6.8 plm AROUSALS per hour. that's more than 54 plm arousals in 8 hours. so far you've come up with nothing with more evidence than that.

I apologize if this offends; that's not my intent.

[deebob]

I really just don't think that PSG data is a reliable indication of what goes on during a normal night.

I was the most anxious I've ever been in my entire life. I was physically shaking when I was laying in that bed. I had to take Trazodone out of desperation because I was so damn anxious that I wouldn't have slept. Any kind of PLM that occurred that night is probably not happening on a regular night at home when I'm calm.

Also, do PLM awakenings cause you to wake up with your heart racing and shortness of breath?  What I experienced in bed last night, every hour or less, felt very much like the descriptions I've read for UARS patients experiencing norepinephrine release resulting in increased heart rate.  In other oximeter tests I've done, as well as with my Oura ring data, I frequently experience elevated heart rates associated with these frequent awakenings. Does that occur with PLM?

[Sleeprider]

I’m just going to put out there that arousal can become habitual, and may not be related to anything you are or are not doing. https://www.atsjournals.org/doi/full/10....1610-816OC

[Dormeo]

I may already have posted this link in this long thread, but here is a nuanced discussion of relationships between depression and sleep:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548844/

I also thought you might be interested in a patient's report on doing Cognitive Behavioral Therapy for Insomnia, here on another forum:

http://www. a DME-owned forum .com/viewtopic/t175067/CBTi--Therapy-for-Insomnia.html?sid=2aa326c89ce196f8b766c5596b1401df