Hello Guest, Welcome to Apnea Board !
As a guest, you are limited to certain areas of the board and there are some features you can't use.
To post a message, you must create a free account using a valid email address.

or Create an Account


New Posts   Today's Posts

Persistent CA events and fatigue with low-ish AHI
#1
Persistent CA events and fatigue with low-ish AHI
Hello all.


I am new here and, while I am enormously grateful for all that I have learned in reading through the posts here over the last couple of months, I have yet to find a solution that helps with my current difficulties, so I am starting my own thread. Any thoughts or advice would be very much appreciated.

Because this is a rather long post, I will summarize it here at the start - more information can be found below and I am of course happy to answer any questions. Thank you all so much for reading.

Short version:

I have a "mild" sleep apnea diagnosis. After more than four months on APAP, my AHI is hovering around 1.5-1.7 and my daytime fatigue and brain fog is actually getting much worse. Almost all recorded events are CA events, often (but not always) occurring more frequently during the second half of my sleep period. Because AHI is low, my doctor does not believe that my fatigue and cognitive problems are related to sleep apnea - I am not sure, but would welcome any advice from those here. Thank you.


Long version:

I received an obstructive sleep apnea diagnosis just over five months ago. The diagnosis itself was "mild" obstructive sleep apnea (9.5 AHI), with "Positional component noted with an increased AHI while in the supine position, REI-26.3" - I was subsequently told that if I had not rolled onto my back for the last hour or two of my sleep, I would not have been diagnosed as my AHI remained around 2 while on my side (my usual manner of sleeping). I was only given the report summary, but no centrals were noted.

I am fairly fit and my current BMI is ~21.  I get at least an hour of cardio in most days, often more.

For many years, I have struggled with insomnia and anxiety, which often inhibits both sleep onset and my ability to remain asleep - this often makes it difficult to discern the cause of sleep disturbance unless there is an obvious feature.

Possibly related to my apnea and certainly related to my sleep issues more generally, I have chronic sinus congestion and swelling. A series of ENTs have been little help in this regard. I am still a nose breather, but maintaining this often requires a lot of rolling back and forth at night, nasal sprays, nose strips, etc.


I was fortunate to get a ResMed Airsense 11 very quickly and have been using it every night since, with the exception of a 12-day thru hike when I used an AirMini.

For the first month or so, I had a lot of difficulty getting used to being on the machine, set to APAP 5-15, but eventually got to a place where I am able to sleep through the night, even if seep onset is still somewhat delayed.

Once things settled in to a routine around the second month, my AHI averaged around 0.3-0.7, with almost all events (95-99%) being CA events, with only a few exceptions outside of that. The problem came with the fact that I was not feeling less tired: spaciness, brain fog and a feeling of general fatigue not only persisted, it was worse than ever. This lasted most of month three, until, over the course of month four and into month five, my AHI began to creep up again (current average is around 1.5-1.7) and the already disruptive brain fog and fatigue became still worse, reaching a level where not only my personal life, but my employment is hanging by a thread and I may soon not be able to continue.

Because the AHI, even on my worst nights, remains well under 5, my doctor has told me that he is "not concerned" and does not believe my fatigue is related to sleep apnea and that the (often clustered) CA events are simply "normal." This may be the case - I honestly do not know. Some nights the CA events are spaced more or less evenly throughout the night, but more often than not, almost all of them occur during the second half of the sleep period. Sometimes this follows my waking up to use the bathroom, while at others I find myself waking up briefly every hour or so - I have not noticed that the subjective experience of fatigue and brain fog corresponds directly to having had a better or worse sleep the night prior.

I am currently using a ResMed n30i nasal cushion. Some nights I find that a fair number of large leaks get recorded, while on others, there are no large leaks at all - I am not sure why this occurs, but the leak frequency does not (to my eyes) appear to correspond with recorded events.

Thank you so much for reading - I would be very, very grateful for any advice. I have attached screenshots from the last two nights, which I feel are fairly typical. Fatigue felt especially bad yesterday (i.e. following the night of 2. Aug).

Thanks again.


Attached Files Thumbnail(s)
           
Post Reply Post Reply
#2
RE: Persistent CA events and fatigue with low-ish AHI
Welcome

Your flow rate looks very good to me, breathing seems pretty stable and overall it looks pretty good. the doctor's reaction is unfortunately pretty standard, most don't care to look past basic AHI.

However i think we can do better with the settings. if you want to stick with APAP i would use 6-10cm. Or even better (in my eyes) try CPAP @7cm. Hopefully a more stable pressure will reduce CAs. You could try to reduce EPR to 1 but i think you should try to limit leaks first, as they seem to cause flow limits.

Your leaks were above the max threshold quite a bit, it's probably disturbing your therapy and sleep. It looks like mouth breathing to me so have you considered a chin strap, soft cervical collar or tape?

Good luck and keep posting charts with the new settings  Sleep-well

ps: please hide the calendar next time.
Post Reply Post Reply
#3
RE: Persistent CA events and fatigue with low-ish AHI
Thanks so much for the welcome and for the quick response - my sincere apologies about the calendar, shall be certain to hide it in future.

I realize now that I failed to attach one of the images I referenced (a night with a more even distribution of events and fewer large leaks). I don't know if it makes much of a difference, but I am attaching it here just in case.

I think I will try staying in APAP for the moment - when I briefly switched to the ResMed AirMini it was set for CPAP at 7cm and I had a lot of issues with aerophagia. That said, it was only for a little over a week and maybe I just needed more time. 

Unless I am mistaken, EPR is already set to 1cm, as you suggest potentially trying in the future - or am I misunderstanding?

I had not looked into mouth taping, a chin strap or a cervical collar - I had been worried that, given my somewhat unpredictable sinus congestion, it might be dangerous for me. If this is not the case and if mouth breathing is a likely culprit, I am certainly willing to investigate and to learn more! May I ask, would a full face mask potentially serve the same function, or is this a different issue altogether?

Thanks again!


Attached Files Thumbnail(s)
   
Post Reply Post Reply
#4
RE: Persistent CA events and fatigue with low-ish AHI
reducing epr can help with CAs. somehow missed it was already at 1 so you could try to turn it off, but it would probably increase FLs. so i would first try to reduce FLs.

no same thing. with a ffm opening your mouth would maintain pressure, so no leaks and your airway remains stented (thus keeping FLs down). w/e works for you!

and apap is just fine too if cpap isn't working out.
Post Reply Post Reply
#5
RE: Persistent CA events and fatigue with low-ish AHI
Thank you again for your help - am now checking back in after a few weeks.

I was unfortunately informed by my insurance company that they will stop paying for my machine if I make any modifications to the pressure settings on my own, so I am waiting for my next appointment with the sleep doc to hopefully make a few changes here.

In the meantime, I switched to a full mask - the AirFit F30i nad have seen some changes in my charts, though I am not sure if they are positive or not and they have certainly not resulted in any decrease in fatigue or brain fog during my waking hours.

AHI most nights has dropped back down to around 1.0 or below, but I am now getting OA events once again, where these seemed to have disappeared when using the N30i cushion. These events seem to consistently occur after around 3-4 hours of sleep, at which point I wake up. I do not actually know if it is the apnea or the increased air pressure that awakens me, but it is always that air pressure that I am aware of and which prevents me from going right back to sleep. These events appear to occur in clusters, accompanied by CA events - I even had my worst AHI night since starting CPAP last week, with 13 events in about 10 minutes.

This has all been accompanied by a fair bit of insomnia, which makes the situation feel particularly desperate, and my daytime fatigue and inpaired cognition seems to be worsening.

Any idea what might be going on here? Grateful for any suggestions. Thank you!

Images from a slightly "better" night attached.


Attached Files Thumbnail(s)
               
Post Reply Post Reply
#6
RE: Persistent CA events and fatigue with low-ish AHI
Was it insurance or the DME supplier that said you cannot edit settings? Almost everyone here on Apnea Board has to control their own settings themselves. Yep I know, I'm not you, but I'd probably call that "don't touch the settings or we won't pay" bogus. Insurance really only cares about "are you using CPAP?" and" is this patient benefiting from therapy?"

Think about it, who at the insurance would know who edited your CPAP? Conversely someone monitoring settings at your DME supplier might know, because they didn't set pressure x-y or added EPR x, so on. So yeah this is probably packed with more bologna than Oscar Mayer sells at the grocery.

Another subject, as you're concerned about CA (Central Apnea or clear airway on the machine)... Did you get your detailed sleep study report yet? Did you request it? If negative, you need to get it ASAP. Post it here redacted of your personal info and we can tell more about your CA.
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.
Post Reply Post Reply
#7
RE: Persistent CA events and fatigue with low-ish AHI
Thank you for the quick response. The "do not touch the machine" message came directly from my insurance - I do not know how or if they are actually monitoring and I recognize that what you are saying makes sense. On the other hand, I am very hesitant to risk losing the machine, however miserable it seems to be making my life. I will see if I can get additional information from my doctor.

I have an appointment with the sleep doc in two weeks and have just left another message with his office explaining my situation and requesting the detailed report - hopefully I shall hear back from someone soon.

Thanks again.
Post Reply Post Reply
#8
RE: Persistent CA events and fatigue with low-ish AHI
Copy. For what it's worth, since you're here in the US, the doctor will be legally obligated to supply the report once you request it. HIPAA law gives you the right to request and receive it. If they do refuse, report them to the local or regional medical board.
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.
Post Reply Post Reply
#9
RE: Persistent CA events and fatigue with low-ish AHI
To coin a phrase "my body, my choice".
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
Post Reply Post Reply
#10
RE: Persistent CA events and fatigue with low-ish AHI
I did hear back from my sleep doctor this morning regrading the initial sleep study. He stated that while there were a few "transient" centrals, these were "well below threshold for clinical significance" and "most likely during periods of transitional sleep". This said, I have not yet received the study itself.
Post Reply Post Reply


Possibly Related Threads...
Thread Author Replies Views Last Post
  OSCAR Data - Low AHI but still not feeling great, and are these real OA events? Santino 27 873 23 minutes ago
Last Post: Santino
  Apnea Events less then 10 Seconds r4robin 5 148 24 minutes ago
Last Post: Crimson Nape
  [Diagnosis] Clear Airway, CSR events frolic 17 840 7 hours ago
Last Post: G. Szabo
  Need help. Fatigue/Daytime sleepiness even with low AHI FindingCourage 21 625 10-08-2024, 08:45 PM
Last Post: staceyburke
  Need help with increased Clear Airway events zood 7 451 09-30-2024, 09:08 PM
Last Post: zood
  CA events - Advice lukewpc 5 260 09-30-2024, 04:27 PM
Last Post: lukewpc
  24 CA events, I am practically worried. Ddobson85 4 226 09-30-2024, 09:37 AM
Last Post: G. Szabo


New Posts   Today's Posts


About Apnea Board

Apnea Board is an educational web site designed to empower Sleep Apnea patients.