I'm trying to figure out what my problem is and would greatly appreciate any help.  The short story is that I have moderate/severe sleep apnea (AHI 39).  I've been on CPAP for 4.5 months now and still feel just as tired as I did before I started CPAP.  I've had 3 sleep studies now, one diagnostic, one for titration and the most recent to assess why I haven't seen any improvement in how I feel when awake.  This last was done in conjunction with a sleep latency test.  The sleep specialists concluded that there was nothing wrong with my sleep or objective sleepiness, but I've been looking at my sleep study (which I ended up having to get from my primary care physician a week after my appointment with the specialist), and some things strike me as odd.  Below I've listed out some of the relevant statistics from my first and third sleep studies:

                                      Study 1 (w/o CPAP)                 Study 3 (w/CPAP)
AHI                                          39                                            0
Respiratory Arousals/hr             34.3                                          0.2
Non-resp Arousals/hr                   8                                            16.6
Tot. Arous + Awakening/hr         53                                            23
Sleep Efficiency (%)                   73                                            78

Stage 1 (% of sleep time)           51.6                                         16.2
Stage 2                                     37.9                                         60.2
Stage 3                                     0                                              4.4
Stage 4                                     0                                              0
REM                                          10.5                                         19.2

Latencies
Stage 1                                     10                                             17
Stage 2                                     9.5                                              1
Stage 3                                      --                                            143
REM                                          150                                           66

No central apneas, minimal limb movements, great O2 w/CPAP.

It seems pretty clear that OSA is well-treated, but several things concern me:
(1) 144 spontaneous awakenings or arousals in 6.4 hours of sleep seems pretty bad to me.  Could this be why I feel so poorly rested in the morning.
(2) Very little "deep" (Stage 3 or 4) sleep, even with CPAP.  I'm a 37 year old male.  Shouldn't a much larger proportion of my sleep time be spent in these stages?
(3) Somewhat low amounts of REM sleep.  The report actually comments on this, otherwise I probably wouldn't even have mentioned it.
(4) Pretty short REM latency.

I don't use caffeine or any medications except Ibuprofen for occasional headaches and soreness.  While some of the oddities here could probably be put down to lab effects, in the last lab visit I felt relatively comfortable and had a much easier time with all the wires attached to me, etc. (probably the result of being acclimated to CPAP).  Still was "aroused" 144 times.

I took too long to fall asleep in the sleep latency tests for them to classify me as havingexcessive daytime sleepiness, but I was pretty tense and wired for that part of the test, so I'm not really sure how to interpret it.  And I feel plenty tired during the day, so I think there's something funny going on.

Thanks for any input.

sanctacaris wrote:

                                      Study 1 (w/o CPAP)                 Study 3 (w/CPAP)
Non-resp Arousals/hr                   8                                            16.6
Tot. Arous + Awakening/hr         53                                            23
Sleep Efficiency (%)                   73                                            78

Stage 1 (% of sleep time)           51.6                                         16.2
Stage 2                                     37.9                                         60.2
Stage 3/4                                   0                                              4.4
REM                                          10.5                                         19.2

Latencies
REM                                          150                                           66

(1) 144 spontaneous awakenings or arousals in 6.4 hours of sleep.
(2) Very little "deep" (Stage 3 or 4) sleep, even with CPAP.
(3) Somewhat low amounts of REM sleep.
(4) Pretty short REM latency.

I took too long to fall asleep in the sleep latency tests for them to classify me as having excessive daytime sleepiness

Hi Sancataris:
You're probably tired because you lack quantity as well as quality.

What was the MSLT score, just curious.  Can you get the sleep architecture graph?
Was the sleep specialist a, well, sleep specialist?  Board-certified and/or PhD in sleep?

REM latency's a little short (normal 90 minutes), but it was prolonged in the first, and if they didn't mention it in the MSLT then it's not narcolepsy-grade, if that's where you were going.  You can have a short REM latency period if you're simply tired, so I'd hold on that for now.  Normal REM amount is 20%, so that's OK, relatively speaking.

SWS is supposed to be 20% at your age, so yeah, that's pretty low.

Awakenings are like arousals of 15 seconds or more, so if your arousal/awakening index is 23, yeah, that's wicked.

Minimum sleep efficiency should be 85%.  So 78%'s not too hot, especially if you think that was a pretty "good" night.

That the first night was an extraordinary wreck is odd.  Even lab effect wouldn't destroy it that much.

That sleep architecture graph will be very helpful.  All 3 nights if you got 'em.  And the results of the second night.
sleepydave

Thanks a lot for your insight, sleepydave.  All my follow-up appointments have been with a PA at the Swedish Sleep Medicine Institute here in Seattle, although he said he'd talked with a doctor there about my study.  The doctor is board-certified in sleep, and her signature is on the letter to my primary care physician stating that I appear to be getting enough sleep and am not, in fact, sleepy.  

MSLT scores for naps 2, 4, 6, and 8 hours after I woke up were 12, 17, 15, and 20 (i.e., they stopped the test and I still hadn't fallen asleep).  You can see why they concluded that I'm not sleepy.  Total sleep time for each of those naps (in minutes) was 1.5, 2, 7, and (of course) 0.

That was after sleeping 6.4 hours the previous night.  I was pretty tense at that point and spent a lot of time lying in bed wondering what was going on with the study, when I was going to fall asleep, etc.

I wouldn't say my third night in the lab represented a particularly good night, but nor was it notably bad (unlike the first two nights).  The main difference from a normal night at home was that I didn't spend as long in bed as I usually do, and there was a period when I just lay awake in bed for a while, which doesn't happen to me that often (and could be responsible in part for the low sleep efficiency).  Why do you describe the first night as a complete wreck?  I assumed it was pretty typical of someone with a fairly serious case of untreated OSA.

I'll see if I can get electronic copies of my sleep architecture graphs from the sleep docs' office and also the results of my second test, which they haven't ever given me.

Thank you so so much for taking the time to look at these results.  You're such a help to all of us.

Yo Sanctacaris:
With probably 25 variables to look at to help diagnose the 84-odd sleep disorders, "typical" isn't a word you can use too often.  And even though the information you posted is excellent, there are still a bunch of missing pieces before we can get to deciding anything.

But while we're waiting for the other stuff, there's info in that first study that makes it NOT typical, and looking at the other info you presented, certainly makes us want to look in a different direction.  How about somebody else mosey up and take a stab?  If not, I'm going to call on people!

Also, while you're at it, get the respiratory event details re: apneas, hypopneas, position and stage dependency and desaturations during the diagnostic.  And the CPAP level and titration.  I'll bet they're almost all hypopneas with marginal desaturations, 50-50 shot of REM dependency.

If not, have I got a story about CSDB.
sleepydave

Thanks, sleepydave.  It's nice to know I'm not typical.  That means I'm special, right?

Colorado School for the Deaf and Blind?  Controlled Substances Database?  What is this CSDB of which you speak?

Here's additional info from the first study:

                                               Total                 Index
Apneas                                     96                     18.1
Hypopneas                               114                    21.5
Mean SaO2                               94%                
Min SaO2                                  84%
Time below 90%                       12.5 min              3.0
NREM Apnea + Hypop                205                   43.2
REM Apnea + Hypop                     5                     9.0
NREM "Respiratory Events"         235                  49.6
REM "Respiratory Events"             12                   21.5
Sleep time on Back  (min)          137
Sleep time on Side (min)            182
Apneas on Back                          87
Apneas on Side                            9
Hypopneas on Back                    94
Hypopneas on Side                     20
AHI on Back                                                     79.6
AHI on side                                                        9.7

My CPAP pressure is 7.  I was actually titrated at 5 (the study I don't have), which is the pressure they started out at, but the sleep specialists pumped it up to 7 when I didn't report any improvement in how I felt during the day after the first month.  I tolerate both pressures well.

I mostly sleep on my side (and did so before I was diagnosed with OSA), so the positionality is very relevant.  I only slept on my back so much at the sleep lab because they asked me to.

Thanks again for all the help.

Hey sleepy dave, I'm impressed to say the least with your knowledge of sleep apnea. I'm newly diagnosed but long suffering. I didn't get my results from the sleep center. Is that something I can just request? Also when i get the results can you refer me to a site or book or something where I can compare my stats to what they should be and how to interpret them? I don't want to bother anyone here. And besides i like reading up on stuff. Thanks, Mike.. nah, mega thanks, mike


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Thanks to all, Michael

Hi Mike:
You know, I haven't really seen anything out there (not that I've really looked, either) that I think would have all or at least most of the answers to the questions re: sleep studies of the people who are coming to these forums.  What's really needed is an intermediate level text that goes beyond the very basic explanations, yet doesn't get into the scientific jargon.
But I do think we've been building up a pretty good knowledge base here, try using the search function and the parameter you're interested in.
Yeah, one of these days we should try to get a guide together, maybe when the bad weather sets in.
sleepydave

Overlooked the search thing. I never realized it was there. Man will I be be doing some heavy research right here at this site.  Thank god I found you all.


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Thanks to all, Michael

Well, it looks like it's going to take a few more days to get my sleep study results from the sleep specialist's office.  By the time I get the sleep architecture stuff scanned and posted it could be after the holidays.  I'll be back in touch when that's all done.  In the meantime I've been reading some articles on GERD and sleep--seems like that could explain all the non-respiratory arousals and my sleepiness not showing up in the sleep latency tests.

Hi SC:
OK, but be a little careful with that GERD stuff.  Sometimes the theoretical arguments that GERD=OSA sound attractive, but that relationship is still not slam dunk.

Here's a little blurb in one of last months trade magazines.  Also a shameless plug for the boards and hurricane relief (hey, if you can get two birds stoned with.. with... how's that go again?)

GERD OSA

But GERD that bad would probably give you a very positive MSLT.

While you're looking for stuff to read, I'll give you another piece.  While no one should fall into the trap of looking at a couple of pieces of information and coming to the conclusion "oh, yeah, I got that", there's a lot of good stuff in here.

It's a state of the art summary on insomnia.  Yeah, I know, everybody tosses that term around like nobody's business.  But the study of insomnia is quite scientific.  The International Classification of Sleep Disorders lists 10 different forms of insomnia.  And anybody can (and often does) have several sleep disorders simultaneoously.

Persistent low sleep efficiency, and that negative MSLT, kinda raises suspicion of insomnia.  Course, a sleep specialist woulda picked up on that right away, hence my original question.

But it makes for good and informative reading, and I hope that at least some people will benefit from it.

Insomnia
sleepydave

Thanks once again, sleepydave.  That insomnia article is great.  I'd recommend it highly to any other possible insomniacs cruising this thread.  And yes, I wouldn't be at all surprised if insomnia is an issue for me.

As to GERD, the articles I've been reading have been about the link between GERD and sleep disturbance, not the GERD-OSA connection.  They are, taken as a group, pretty interesting.  They seem to suggest that GERD can cause microarousals and that treating GERD can improve sleep quality and daytime performance, even in patients who don't experience many of the common GERD symptoms (e.g., heartburn).  One consistent finding is that MSLT scores don't seem to measure GERD-related sleep disturbance very well.  This is all interesting to me because I was told I had reflux problems many years ago by a couple different doctors, but I never really worried about it because I didn't get bad symptoms.

Thanks for all your help.  I'll get those architecture graphs up as soon as I can.

At long last I have all my sleep study results and have scanned the sleep architecture graphs.  Sleepydave, I just PMed you asking how to get those sleep architecture graphs to you (or post them here), but I'm not sure the message actually got sent.

Here are some results from my second (titration) sleep study:
AHI                                             1.6
Respiratory Arousals/hr                3.4
Tot. Arous + Awakening/hr           12.5
Sleep Efficiency (%)                     59 (I was having trouble sleeping with the mask, especially the el cheapo one they started me on)

Stage 1 (% of sleep time)             16.4
Stage 2                                       54.3
Stage 3                                       8.6
Stage 4                                       0
REM                                            20.7

Latencies
Stage 1                                       5.5
Stage 2                                       11
Stage 3                                       117
REM                                            154

What other info would be useful?

Ok, let's try to get these things up:

OK, as far as respiratory events go, it looks like 5 cmH2O in Study 2 took care of everything.  Including all the arousals.

At 7 cmH2O there's the bunch of arousals.  I'm a little surprised that the pressure during that night remained at 7, they didn't kick it up a little to try to address the arousals.  They must have been real confident that the arousals did not have a respiratory cause.  Given the good response at 5 tho, I guess that's possible.

So on the diagnostic, you had numerous awakenings and only light sleep.  On CPAP, you now have big chunks of wake during the night.

The easy out would be to say machine intolerance, and you "just have to get used to it", but at this point I don't think that's it.  My vote is get back to the sleep specialist to work on what was (and probably still is) a low arousal threshold and now appears to be sleep maintenance insomnia.  The OSA looks to be quite well controlled at 5 cmH2O.
sleepydave

Thanks yet again, sleepydave.  Your analysis sounds right on to me.  I'm pretty fed up with my current sleep professionals, so I think I'll take my results to a different doctor and talk with them about insomnia.  Anyone know a good sleep doc in Seattle?