Help - daytime sleepiness, frequent deep sighs

[CrazyDreamer]

I've been absent from the forum for about four years, had been diagnosed and treated.  Doctor prescribed fixed pressure of 7.0 and told me to avoid using auto with higher setting as it could cause central apnea (I believe that is what he said).  I have tried numerous masks and tried to make the P10 work but a deviated septum makes that unbearable after a few days so I stick with a N20 which is pretty comfortable.  I may need to tighten it up after recent haircut.

I thought my treatment was good since I always have fairly low AHI readings.  However, I have seemed to become more and more tired during daytime.  When my wife and I would go on trips I used to do nearly all of the driving but during recent long trip she did most of driving because I can't stay awake.  I often need to take naps.  After lunch I often get extremely sleep, sometimes feeling like I could fall asleep standing up.  When I take a nap in my recliner I sometimes awake with a headache and have thought about buying another machine to keep next to my recliner but figure I should first focus on making sure getting the best treatment at nighttime.

I considered getting another sleep study but am not sure my doctor is up to the task of getting me treated well.  When I last visited in 2018 I took my laptop and showed him some of the events I was having and he seemed to only be interested in my AHI and said I was doing great.

I recently purchased an oximeter that can send data to my phone and have worn that during some naps.  Late last night I wore it for an hour while sitting at my desk to get an idea of what is going on while I'm awake and taking deep sighs.  When driving, I will take these deep breaths maybe every 5 minutes or so and my wife will sometimes look to see what is going on with my loud breath.  As can be seen below, last night at my desk my oxygen saturation quickly dropped to 89 but afterwards got better.  I often would take deep breaths even with I had readings of 93 or 94 so I did not see a strong connection there.

Last night I read some posts of 2SleepBetta http://www.apneaboard.com/forums/Thread-...hile+awake and SevereApena - http://www.apneaboard.com/forums/Thread-...ly-stopped posted in late 2020 who seemed to have similar symptoms.  Based on what I read there, I decided to change my machine settings last night.  So, I am presenting two nights of readings, July 26/27 with fixed 7.0 and EPR 2 and July 27/28 7.0/11.0 and EPR 3.

I'd appreciate any helpful suggestions.  I am having a hard time focusing my attention and lengthy posts or articles are something that I prefer avoiding for now.  I'm seeing a psychiatrist tomorrow for possible ADD/ADHD symptoms that seem to be getting worse at age 64.

   

   

   

[sheepless]

did you have central apnea in your sleep test? did the doc tell you to use fixed pressure because you actually had increased central apnea using the machine or because s/he thought it might be a possibility? if you had increased central apnea, was it before or after the initial 3 months of using your machine?

personally, I'd try raising epr to 3 to combat your flow limitations and rera. see if ca goes up. then I'd experiment with a range of pressure, using apap mode and setting a min of 7 and max of 20 for starters, probably reducing max depending on what happens.

I was dxed with ADD in long before I started cpap but long after I was first dxed with apnea (central at the time, no treatment available). sleep deprivation will cause symptoms similar to ADD (and depression) or exacerbate existing ADD (and depression). I used adderall and modafinil for years but find much less need as my pap therapy improves my sleep. doctors will prescribe these to help you get through the day but keep in mind they're antithetical to good sleep. imo, best to stay away from them unless you really need help to function, like at work, at least until you determine you're getting the very best therapy you can from your pap machine.

[CrazyDreamer]

Thanks.

Here is my sleep study that I posted back in 2017: https://imgur.com/mJdV8hj

I don't know how to read all of this but I don't believe I ever was diagnosed as having central apnea but my doctor made some comment that if I used pressures higher than needed that it would cause central apnea.

Last night's sleep was with an EPR seeing of 3. In my OP I wrote that I went from fixed 7.0 to 7.0/11.0 and EPR of 2 changed to 3. I believe back in 2017 someone had suggested trying 7/11 and that's why I went with those numbers last night.

I can see differences in my charts but don't understand them well enough to know if it was better, though I maybe seem less tired today. I do see I had 5 RERA events Monday night but none last night after making the changes, but AHI was slightly higher.

[sheepless]

both screenshots posted show fixed pressure at 7cmw and epr 2 although I see now that the pressure graph goes up to 10 on the 27th so you must have made the change from fixed 7 sometime after running the machine at 7 that day/night. higher pressure may trigger ca in some people, particularly in the first 3 months of use. you did have 3 or 4 ca after switching to apap mode but they occurred at about 7cmw rather than the higher pressures. no ca noted in your sleep study but that may be a summary only. try contacting your doc to get the complete results. they often neglect to include important info in the summaries. meanwhile, it's not clear yet whether you are prone to pressure induced ca. I'd stick with these settings for a bit to see what shakes out. we can tolerate a few events (the system says up to ahi of 5 although we can do better). if ca increases substantially, dial back epr to 2 again.

let's see what others suggest.

[staceyburke]

Only suggestion I would have is to record your oxygen all night and see if it stays above 88%. If it drops lower than that for more than a few minutes it needs to be discussed with your Dr.

[CrazyDreamer]

Thanks.

I am reluctant to go back to same doctor. Some things I just didn't like about him: 1. Seemed goofy. 2. told me that not to worry about any of the chart stuff as long as AHI was good. 3. He had apnea himself but said he had quit using his CPAP! He had his assistant give me two diazepam before sleep study, so don't know how much that may have influenced things. 5. He really tried to push me on overpriced equipment, very reluctant to give me a prescription and I ended up going to places that didn't require a prescription. I can afford to go to another doctor, but have high deductible and it would be all out of pocket. I figure next July I can go under Medicare coverage, if needed.

The oximeter I used for a bit late last night was a fingertip one and I must have my phone on nearby and all of that is a bit difficult but I may just buy a different type.

[CrazyDreamer]

I am pretty sure this is not a factor, but just thought I would mention that I did have COVID-19 in June 2020. During my illness, my oxygen saturation did not decline during my frequent checks and a chest x-ray done a couple of weeks later showed my lungs were clear. I think my tiredness has been getting worse and started well before COVID-19 disease.

[2SleepBetta]

If you care to pursue my approach here, CD, it is what comes to my mind. However, there are others here who are far more knowledgeable and astute in diagnosis of problems than I, including StaceyBurk and sheepless. I hope those who see more and better will chime in. (sheepless, by the way, has an excellent disclaimer in the fine print of his signature line, which would be apt for me as well, both here and everywhere. I'd  like his permission to quote it in my line.)

In your FR curve I do not recognize many of the so-called "Norwegian sighs" which I always see, almost at fixed intervals, in my FR curve--not to suggest you do not have them. The largest spikes along your leak curve often coincide with your FR spikes and all those larger spikes may be caused by big sighs for all I know. My accelerometer shows that my sighs cause very small and brief bodily motions and frequently, though occurring amid well shaped peaks, sighs will have a small trailing FL late in the exhale half cycle. 

I mention a shade of skepticism about the FL flags, but don't doubt you likely have a lot of flow limitations that may overwork you in sleep, cause awakenings and cause unrested sleep. As members multicast, TBMx, cathyf and I have posted there are questions about what the FL flags mean to us because they represent a mixed bag of real inspiratory volume loss for each breath, but also two separate wave shape effects (counting peak flattening) and respiratory rate effects. A sample of my breathing indicated, if analyzed and interpreted correctly, that only about half the (higher level) flagging arises from/at tidal volume drops in the FL-dense sample period. Personally, I lean to "seeing" the FL flag as a byproduct of the Resmed blower control system, which must respond fast and nimbly to threats and make pressure adjustments, especially upward ones, to be awaiting results of complex computation/analysis of the past: hence the use of the most recent shapes and their indices.
                                                                                             *****************
Noted in your  earlier OSCAR presentation (times are mostly shown below  as" hhmm" in hour and minute digits of OSCAR clock time):

Both your presentations are showing Fixed 7 cm and EPR2 pressures.

0104 Negligible leak, but low level, brief FL flare, otherwise, status quo,  not much change until leak and FL burst at 0243

0246 Change of position and/or head tuck?; change of sleep stage? L and FL drop 0250

0306 Snore, FL and moderate leak flare until mask and/or body shift (?) triggers  continuous familiar leak level; another RERA  and large snore 0310. FR signal attenuated by leak. FL, some, probably unjustified, skepticism about FL levels, but think that the session history suggests positional effects in view of quiet FR and FL curve after 0432 , noting especially no FL along with resumption of familiar 8L leak. 

I recommend good trial of a cervical collar to benefit from or eliminate  that "do" item where positional effects are present.

I don't comment on the later presentation, because it does not change my first impression of your earlier one with the big run of FL and leak in the middle.
                                                                                        ******************
In that earlier presentation I'd like to look at transitions extending 034600-034900 and  052500-052900 as expanded views, omitting the Pressure, Snore, and Event Flags views, but including Tidal Volume, Inhale and Exhale time views. (Note one of OSCAR's many improvements: If you click and drag a graph area while holding down the shift key, the duration of the view no longer changes when you release the click). My goal is to see the "before" through "after" for each of the time spans indicated, but do want to see the shapes of the inspiratory waves and their peaks so too pointed of peaks from using a too lengthy view duration needs to be avoided. The views can be widened by clicking "View" and eliminating the whole left sidebar.

Desirably, you would, (1), fill your screen and individual graph frames by hovering over one of each single graph's lower ruled lines to see, click on and drag down, drag to size the frame vertically and , (2), right click just outside the left  frame member of the graph to see a tool for changing (reducing now) the value-reaches of the y-axis. In the fly-out box  click the first control to set "Override" and then set the values in the "reach-value" boxes farther right so as to very nearly fill but not overflow the graph frame. For the FR curve, set its upper and lower bounds to, + , and,  -, values to 60L/min size.
                                                                                      ******************
Am pleased my thread may have had a role in your posting here on this topic. Thanks for the reference  and good luck. 

2SB.

[CrazyDreamer]

2SB: Can you please explain to me what you mean when you write "034600-034900"? Does that mean 3:45-03:49?

The second presentation is with my machine at an automatic setting of 7/11 and EPR was set at 3. I don't know why it displays the way it does. I turned on my machine last night and changed the settings and then started therapy. Maybe I should have let the machine shut off before starting therapy. The pressure chart shows that pressures were within the 7/10 ranges. I will probably post another chart tomorrow. Tomorrow I am also receiving another oximeter that I plan to wear all night.

[CrazyDreamer]

2SB, I hope these are the views you were asking for.  I'm working with the old SleepyHead software on an old laptop but can install Oscar on my newer desktop if it makes much difference.