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[Treatment] Low AHI but erratic flowrates, often still fatigued
Low AHI but erratic flowrates, often still fatigued
Hello all!

I started on the PAP about two months ago, but the treatment hasn't been completely effective. A bit exhausted of pouring through this forum looking for new things to try -- I've tried tape, a loose collar, and a v-com. Of all three of these, the v-com has I think helped most, at least at reducing AHI (which was already low without the v-com using various pressures: went from 1.5 AHI avg to maybe half that). Still, I have what I think are abnormally erratic flowrates with lots of arousals in comparison with what I've seen here and online (v-com helped with this too but not that much?). I also still wake up at night, albeit much less often than pre-PAP (from say 5 times a night pre-PAP to ~2 times a night with PAP). It's also still that about half the days I feel what I think is unreasonably fatigued, in spite of the low AHI -- possibly due to the erratic flow rate and awakenings? I did some nights with a friend's apple watch that only takes O2 readings at irregular intervals and saw a few times that I was around 90% as well as occasionally briefly elevated heart rate at night at times in the 90+ range (possibly due to dreams?). In my diagnostic sleep study, I also saw elevated heart rate (as well as low O2 at times but perhaps that is more normal pre-PAP treatment). I wonder if the heart rate stuff is causing problems or is the result of ineffective apnea treatment -- any thoughts on that would be appreciated too. My primary concern, however, is the erratic flowrates full of arousals even if there are few apnea events -- what should I do?

Other information: I'm a fit male in my early 20s, sleep hygiene is relatively good I'd say. I use a nasal pillow mask, it works for me, mouth breathing isn't issue -- I did one night on nasal mask and it was bad so sticking with the P10. I'm thinking about biting the bullet and buy a MAD or Nasal Stent to see if those help make my sleep more restful.

From my sleep study

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RE: Low AHI but erratic flowrates, often still fatigued
Attached the images correctly here. Two nights on 10 with vcom, zoom section is from latter night where the first part of the zoom is from REM and second from deepsleep, there are arousals in both. Will include sleep study screen caps in another reply.

Sleep study night one

sleep study night two

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RE: Low AHI but erratic flowrates, often still fatigued
More sample nights, with and without vcom

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RE: Low AHI but erratic flowrates, often still fatigued
@sancardinal15, Your leak rate looks great, looks like you have a handle on that. Those flow limits are certainly degrading your sleep quality. Around here folks recommend EPR and autopap to manage flow limits (from my personal experience it works as suggested). Someone more knowledgeable than I will probably come along and analyze your charts and give you some advice. In the meantime search some of Sleepriders threads concerning flow limit and EPR you will find a wealth of knowledge in those pages. There is lots of conflicting advice about machine configurations and best practices out there, I spent a good bit of time down that rabbit hole, making small gains and spending too much time twirling knobs. For me personally the best advice I found was here, on these pages, just searched the posts for my specific issues, dug in, read, read, and read some more. Implemented what was suggested to people who had charts and issues that looked similar to mine and things are looking up.

One more thing, I try to respond to people who are still fatigued after they get their pap therapy somewhat ironed out (there's always improvement to be had), but are still experiencing serious fatigue. The one question I have is - Did you also show signs of PLMs (periodic limb movement) in your sleep study? The pages you attached only concern the OSA portion of the study, generally PLM is a little further down in the notes, even if the medical folks didn't mention anything about it, its still worth your time to look at the details and confirm that you were in fact negative. If you showed any signs of PLM it is very much worth pursuing remedies for that also. It can be a major factor in degrading sleep quality once your OSA is managed.

Good Luck! Keep keepin on, you're getting there.
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RE: Low AHI but erratic flowrates, often still fatigued
@sleepy quixote, thanks, I've attached some screen caps from nights I did with EPR as well as a detail from the second of those. Those nights weren't so great as I awoke many times, but perhaps it was due to bad sleep hygiene those particular nights, I am not certain. I might not have trialed EPR enough and can give it another go (without vcom, as it seems you aren't supposed to use a vcom with EPR). As for PLM, I don't think my very basic at-home sleep study tested for that. I used a "sleep owl" device which I just taped to my index finger -- its just a sensor about the size of a coin. My sleep study report doesn't seem to mention anything about that -- it does make a note about this, however, which maybe I should pursue: "High heart rate variability noted which may be suggestive of a cardiac arrhythmia. Note that heart rate measurement on home sleep apnea tests can be subject to artifact and is not confirmed by EKG" -- this might also just be generic comment from the lab not super-specific to my case, so I'm weary about taking it too seriously? I did have heartrate spikes but these were brief, and might be unrelated to the apnea? could be from dreams I wonder?

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RE: Low AHI but erratic flowrates, often still fatigued
@sancardinal15, That zoomed in chart looks a lot like mine when those flow rate disruptions correspond to my PLM bouts. Your best flow limit management shown there is on the 21st, and that's the best of the lot even of those you posted earlier, and the settings are pretty much what folks around here recommend. Frankly I'd ditch the ramp, set the mode to autoset, set a minimum of 7, max of 10 - EPR3 and give it a week (I run min 7 max 9.6 EPR3). The reason you set a minimum of 7, is EPR doesn't kick in until after 7 and you are starting out with a relief on expiration of 4 right away. Ramp just delays your reaching therapeutic pressures and lets the flow limits get a head start which frequently can cause the machine to start auto adjusting sooner in your sleep cycle than it might otherwise. For me any time the machine starts making adjustments above 8 I wake up, my strategy has been to manage the flow limits reducing the frequency of machine adjustments and it seems to be working for me. I'm a super light sleeper so pretty anything that happens along the lines of therapy disturb my sleep, leaks, hisses, pressure above 8, rapid in succession pressure adjustments, etc... 

More on the line of PLM questioning, its a bummer the home tests don't detect it... You really need it diagnosed to get it treated if you have it. Does either of your shins feel like you've been climbing stairs in your sleep? One or both calves feel tired in the AM? One indicator is RLS (Restless Leg Syndrome), many folks who have RLS also have PLMs, if you don't know what RLS is, look it up, I had it for years and thought it was just normal leg stuff. If you have it then go to a neurologist and when you're discussing meds mention you think you might have PLMD too, several of the meds treat both.

Not sure about the cardiac stuff, I wear a go2sleep ring and it shows my heart rate all over the place, elevates a lot when I'm doing Stairmaster in my sleep.

I'm going to go find the link to the OSCAR wiki that will explain how to configure your charts better for the more advanced users here who can give you more precise advise.

P.S. I did a trial with the V-Com too, was a mixed bag, I think the effect was mostly placebo. The first night was great, then down hill from there. Still don't know what I think about it...
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RE: Low AHI but erratic flowrates, often still fatigued

Here's the link to instructions of configuring OSCAR charts for discussion on the board -

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RE: Low AHI but erratic flowrates, often still fatigued
@Sleepy_Quixote, thank you for your thoughtful posts. I'll go ahead and try the settings you suggested and post my results tomorrow.

I wonder if my experience with the vcom may also be false -- the first few nights certainly seemed better but looking at flow rates it seems it hasn't been the most helpful. See the amount of flow limit/snore from last night w/ vcom at pressure of 8 -- on the other hand, this was also the first time in probably more than a year that I slept through the entire night without getting out of bed (though I'm sure there were unconscious awakenings). That said, I started yawning around noon today having gotten up just before 8, so some unacceptable fatigue I figure.

I've gone ahead and attached a screencap of my Overview page from OSCAR. I started using vcom on June 2nd and have used it every day since (but won't tonight). It clearly helped reduce avg AHI I think (see what you think?). Flow limits also seem a little better with vcom overall but then the last three nights for instance have been quite bad as I've lowered the pressure. Not really sure what to make of it all at this point. Probably need to experiment more.

As for RLS, at first glance, I can't say I recognize any of the symptoms listed prominently online ("The sensations in your legs may feel like aching, throbbing, pulling, itching, crawling, or creeping). I am, I hate to admit, a rather neurotic person and do fidget a lot (lot lot, including my legs), but have never experienced the symptoms listed for RLS. I am also completely capable of sitting still if I put my mind to it and this is not painful for me. Still, I wonder if there is someway for me to check for PLM without going through the excruciating system (maybe I can ask my partner when I'm with them again or try to film myself in my sleep meanwhile?). I have asked my partner about movements during sleep in the past and she said she hadn't noticed anything, but perhaps I can be more deliberate about this and check more carefully.

I've adjusted the OSCAR view per the wiki instructions, thank you for the tip.
It's incredible to me that people are so generous with their time on forums like these. I mean it when I say I really appreciate the help.

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RE: Low AHI but erratic flowrates, often still fatigued
Your flow limits are very high.
I'd try bringing in EPR. If me I'd set it at 3, fu)time for now
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RE: Low AHI but erratic flowrates, often still fatigued

Any time Gideon chimes in on your thread that is golden, pay attention.

I see a brief window of about 5 days reduced AHI early in your V-COM trial then a gradual daily increase. The chart in the Overview to focus on is the Flow limitations chart. In that one, when the trial started you showed 5 or 6 days steady then gradual increase till yesterday, I'm not seeing the benefit in the charts. That said, sometimes how we feel during the day is more important than the charts. We would like to see Flow Limitations around .03 - .06, that's not a type-o, it's totally doable. 

Its possible you slept through the night just because you were running a static pressure and weren't being disturbed by the machine constantly making flow adjustments, that's the whole idea of managing Flow Limits with EPR, lower/fewer flow limits means fewer machine flow adjustments to manage your airway, fewer Flow Limits = better sleep quality. You slept through the night with the static pressure but looking at the flow rate and flow limit graph looks like a pretty crappy nights sleep to me.

Your Session Times overview chart looks a lot like mine did, lots of breaks, but you go right back to it. Good on you, many people just give up and set the mask aside. Not us. Thanks to advice given on this board I've registered 9 nights straight through in June best month yet, the cool thing is even the shorter sleeps are better than some of the long fragmented sleeps of the old days.

You won't be able to rely on a partner for detecting PLM, mine drops off to sleep in about 5 minutes and sleeps like a rock. The only time she ever got woken up by the PLM was when it was at its worst. It cycles up and down, sometimes even wakes me up, lol. Not sure filming yourself sleeping would show unless you slept with your legs out from under the covers. The PLMs are a more like a tremor at the ankle, with the foot waving up and down, probably wouldn't be noticed on camera under covers. To see how the meds are working I put the go2sleep ring on my toe and check the toss and turn graph. Efficacy is fairly evident.

For now lets focus on getting those flow limits down and concentrate on reducing the fragmented sleep.

Were all in the same boat here, just looking for help and looking to pay it forward by helping. 

See you tomorrow.
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