BiPAP titration and no REM

Hi,

I previously posted about struggling to stay awake during work after using my CPAP despite my numbers looking good. After follow up with my provider, he finally agreed to have me do a BiPAP in lab titration on the hopes that I would respond better to that than I did to the CPAP. I just got the results back and am confused by them saying that the "titration" (they never changed the values) was successful when I had very little sleep and never got to REM. I also have the complicating factor of being autistic and having sensory issues. Couple other factors that may impact things: I have long covid which consists of tachycardia and disordered breathing pattern (on cardio/ pulm stress test) in addition to the brain fog and fatigue. I'll include some of my initial study and titration below.

Original baseline study (no mask):
5mg ambien needed to fall asleep after 2 hrs of being unable to sleep
TST 5 hr 7 min
Sleep latency of 2 h 27 min Eff. 87.73%
Stage %: Awake 8.6, N1 8.1, N2 91.9, N3 0, REM 0
AHI 62.24 (2.72 apnea, 59.51 hypopnea) all obstructive
# awakenings 31
Wake after sleep onset 43 min
Arousal indexes: Apnea 2, hypopnea 30.8, spontaneous 10.3, total 43.1
No leg movements
Recommendation for cpap. I think the pressures were 4-14 usually around 10 when I tried to use it at home.

BiPAP titration study (8/4 with an EPR 0, N30 mask same as I had used with CPAP - did not change at all over the night)
5mg ambien needed to fall asleep for test - do not take at home
TST 3 h 55 min
Sleep latency onset of 25 m Eff 65.33
Stage %: Awake 31.8, N1 14.4, N2 83.7, N3 1.9, REM 0
AHI 11.72 (2.8 apnea, 8.92 hypopnea) 0.76 central apnea this time
# awakenings 42
Wake after sleep onset 125 min
Arousal indexes: Apnea 2, hypopnea 8.2, spontaneous 25.2, total 35.4
Minimal leg movements
Impression: BiPAP is successful at 4/8 cm with mild residual obstructive events noted
Recommendations: AutoBiPAP therapy is recommended with the following settings: Min epap 04 max ipap: 14 cm ps4 with heated humidification

So my questions are:
Has anyone ever seen instances where you never get to REM despite the OSA being treated with BiPAP?
Does this rule out their original theory of REM rebound being the reason why I couldn't stay awake after using the CPAP?
Is it possible that my sensory sensitivities as a result of my autism prevent me from sleeping with the OSA treated to the point where it would override the sleep medication?
I know I sometimes dream when I'm at home, but that can't be seen in any of my studies. Is it possible that at home I'm getting REM despite the OSA, but unable to get it while wearing a PAP mask?
If I can't stay asleep with the PAP machine and sleep medication, what else is left for me to try? (CBT - I has been mentioned, but I currently don't have the mental capacity to do that on top of my normal therapy for depression)

Please feel free to share your thoughts. I have not yet seen my provider following the second study (they are scheduled further out), but would like to have further questions and thoughts when I get to that point. Previously he's been very reluctant to acknowledge that I felt worse on the CPAP despite the breathing being treated and I'm not encouraged by the lack of REM being dismissed in the impression and recommendations.

Thank you

LaASD wrote: ↑

Mon Sep 16, 2024 9:19 am

my normal therapy for depression

What is that therapy composed of? Meds by chance? If so, what name.

Are you aware that we can dream in any sleep stage and it isn't limited to REM stage sleep?'
Also, just because you don't remember dreaming (in whatever stage) doesn't mean you didn't dream.

LaASD wrote: ↑

Mon Sep 16, 2024 9:19 am

spontaneous 25.2,

Something is causing an awful lot of spontaneous arousals. That alone will make you feel like crap....that many arousals on a per hour average. Any idea what might be going on?

Pugsy wrote: ↑

Mon Sep 16, 2024 9:39 am

LaASD wrote: ↑

Mon Sep 16, 2024 9:19 am

my normal therapy for depression

What is that therapy composed of? Meds by chance? If so, what name.

I have treatment resistant depression currently on cymbalta 120mg and wellbutrin 300mg plus talk therapy twice a week. Super hesitant to consider switching meds as I have been on many in the past (others tried include: zoloft, prozac, lexapro, and abilify in combo with the wellbutrin) with no effective relief or dangerous side effects. I've even tried TMS therapy with only partial success. Where I'm at now is about as good as it gets for me in terms of my depression treatment. I've recently, post second sleep study, been trialed on modafinil 100mg by my psychiatrist, but haven't seen much of an impact. Sleep meds didn't keep me asleep when I tried them on the CPAP the first time so they're trying the stimulant route instead.

Pugsy wrote: ↑

Mon Sep 16, 2024 9:39 am

Are you aware that we can dream in any sleep stage and it isn't limited to REM stage sleep?'
Also, just because you don't remember dreaming (in whatever stage) doesn't mean you didn't dream.

I am aware that you can dream in other sleep stages. Now that I'm thinking of it though, I'm not sure if they didn't mention anything about dreaming on the study reports because they can't tell (or don't note) instead of because it didn't happen.

Pugsy wrote: ↑

Mon Sep 16, 2024 9:39 am

LaASD wrote: ↑

Mon Sep 16, 2024 9:19 am

spontaneous 25.2,

Something is causing an awful lot of spontaneous arousals. That alone will make you feel like crap....that many arousals on a per hour average. Any idea what might be going on?

Honestly, my gut tells me that it's sensory intolerance to the mask. It's almost like I'm unable to turn off the sensory hyper awareness even while asleep and it eventually gets to a point where it wakes me up. When I was trying the CPAP at home, I became highly irritable and any sensory input would quickly put me into overload the day after I wore the mask. (If you're not familiar with the concept of sensory overload and autistic meltdowns, think fabric on skin or background refrigerator noise being so intense that it prevents me from functioning.) That said, the long standing depression history also would impact my sleep on its own. I've had insomnia my entire life (as far back as age 3 or 4) which is why I pushed for a study with the mask because I knew I wasn't staying asleep despite the OSA being fully treated according to my CPAP.

I've also been undergoing workups for unknown health things the last couple years along with the long covid symptoms and frustratingly have not gotten anywhere in terms of a diagnosis. Since there's the question of the OSA, cardiology won't give me an actual diagnosis of inappropriate sinus tachycardia despite there being no physiologic cause for the tachycardia. On the second sleep study the only heart rate data included was min 77, max 103, average 90 during the sleep and that's while on metoprolol 100mg at night and the BiPAP. My inflammatory markers are all mildly elevated along with chronic pain, but with a normal ANA rheumatology won't do much. I've also been worked up by endocrinology with both thyroid issues and Cushing's ruled out. There's a lot of circular logic in terms of some providers thinking it's all psychological, but my psych and therapist both say it's not. So any or all of that could be having an impact. Of course it could be the other way too and no sleep lead to all the other issues.

I won't be telling you to change meds or reduce meds or stop meds. That's not my job nor why I asked.
I asked because almost all of those mood meds come with some side effects that are a potential problem.
Main thing is that they tend to make someone feel fatigued or sleepy (not necessarily the same thing) or they mess with the sleep stages because they can suppress REM.

You might dig deep for the side effects and look at multiple sources. SSRIs and SNRIs are well known to mess with sleep.
Most mood meds (anti depressant or anti anxiety) are going to be in either the SSRI category or the SNRI category.

And yes I do understand the autism and sensory thing. I just don't have a fix for that issue. Sorry.
About all I can offer is keep trying so the brain gets used to the sensations and doesn't want to fight it anymore.

Pugsy wrote: ↑

Mon Sep 16, 2024 1:26 pm

I won't be telling you to change meds or reduce meds or stop meds. That's not my job nor why I asked.
I asked because almost all of those mood meds come with some side effects that are a potential problem.
Main thing is that they tend to make someone feel fatigued or sleepy (not necessarily the same thing) or they mess with the sleep stages because they can suppress REM.

You might dig deep for the side effects and look at multiple sources. SSRIs and SNRIs are well known to mess with sleep.
Most mood meds (anti depressant or anti anxiety) are going to be in either the SSRI category or the SNRI category.

It makes sense that it could be a side effect of the medication. Unfortunately I'm not sure there's a way to address it as a side effect while remaining on the medication. I'll ask my psychiatrist, but what I'm finding online is that a sleep aid is often recommended and the study was that bad with one.

Feeling out of options at this point I guess. Are there any other things I need to ask my provider to consider? He seems so focused on the fact that the BiPAP fixes my breathing that he's ignoring that I'm not actually getting any sleep while using it. Seeing the second study with the bipap it makes sense that when I first was on the CPAP at home I became non-functional to the point of not being able to work or drive. I was probably awake more of the night than I was asleep.

Sending you a wet cyber-hug, because it can't hurt--I hope.

LaASD wrote: ↑

Mon Sep 16, 2024 9:19 am

5mg ambien needed to fall asleep for test - do not take at home
TST 3 h 55 min

Pugsy wrote: ↑

Mon Sep 16, 2024 9:39 am

Sleep latency onset of 25 m Eff 65.33
Stage %: Awake 31.8, N1 14.4, N2 83.7, N3 1.9, REM 0

Wake after sleep onset 125 min

Look at those numbers.
Let's round up the first to a test time of 4 hours.
It took you 25 minutes to fall asleep. You were awake for125 minutes after you fell asleep. That's 150 minute, 2.5 hours of wakefulness in a 4 hour test.
No wonder you had no REM sleep in those conditions.