Spontaneous Arousals And Sleep Apnea

You just got your brand new CPAP machine for your newly diagnosed severe sleep apnea diagnosis. You use it religiously for one month every night, but you don’t feel any better. If anything, you may feel worse. You take your CPAP data card to your sleep doctor that tells you that your numbers are perfect: It shows that your AHI went from 35 to .9, you had no leaks and you used it 8 hours every night.

Although I have many people who swear by CPAP, there will always be some others that just can’t either tolerate or benefit from it. The problem with CPAP is that during titration in a sleep lab, for the most part, it only addresses apneas and hypopneas. Some sleep labs treat the lesser forms of obstruction and arousals, but in general, most only titrate the pressure to treat apneas or hypopneas.

What this means is that everything else that can cause you to wake up doesn’t get treated, including snoring, flow limitations, and RERAs (respiratory event related arousals). Studies have shown that even if you’re about to stop breathing, pressure sensors in your throat pick up the fact that the airways are beginning to collapse, and it’ll send signals to your brain to wake you up to a lighter stage of sleep, to prevent your muscles from relaxing. Most of these signals stay in the deeper levels of the brain, so you won’t be able to detect any “cortical arousals” through your EEG scalp leads on a sleep study.

If you have an apnea, it’s also likely that you’ll suction up normal stomach juices into your throat. The presence of acid in your throat is enough to activate chemoreceptors which sends signals to your brain to wake you up to a lighter stage of sleep, so that you can swallow your stomach juices and prevent aspiration into your lungs. Many of the “spontaneous” arousals are probably reflux related.

Furthermore, not sleeping effectively can cause your entire nervous system to become en garde, edgy,hypersensitive, and over-reactive. Having any acid in the throat or impending obstruction is enough reason to keep waking you up often throughout the night. Sometimes, having a mask on your face is enough stimulation to keep waking you up, especially if you’re in a lighter stage of sleep.

Are you fully compliant with CPAP, but don’t feel any better? Please enter your responses in the text box below.

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13 thoughts on “Spontaneous Arousals And Sleep Apnea

  1. I am fully compliant, but I still yawn during the day, still feel a bit sleepy sometimes. This is a good explanation of what that might be. However, it would be very helpful if you had some explanation of how we might prevent the RERAs and the Clear Airway Apneas, and anything else that is continuing to disturb our sleep.

    It makes perfect sense to me if someone is not gaining benefit from a cpap they would stop using it. Why bother if it doesn’t bring the benefits that you hoped it would bring?

  2. I was also wondering the same as the other person who posted. What can be done to help prevent these problems? I have been on BiPap for almost 7 yrs(compliant) and I am still struggling with Excessive Daytime Sleepiness. I have gone through many different prescriptions the past 7 yrs and am still struggling.

    I wonder if this could be my problem and what could be done to help with it.

  3. Took me over a month to find the right combination. Initial pressure was 16. Only by changing masks and lowering pressure to 14 was I able to stop leaks and keep them from waking me at night. Once I got the leaks stopped I was able to work with the mask adjustments for most comfort. Now I am working back toward a higher pressure. I also found that the prescription that kept me semi awake during the day also had the same effect at night. Over course of 3 weeks weaned myself from Nuvigil. Now I wake up refreshed and still have energy at night. Not a life changing experience the first week but with these tweeks I am much more alert and focused all day. Couch potato has not been converted to a tri-athelete but definately getting up off my duff a lot more.

  4. I use a Cpap resmed machine (3 yrs now) with a lrg resmed full face mask my machine is on a high setting but I am still having trouble with lack of sleep and was wondering why, I do have other underlying health problems high blood pressure and Diabetes could this be a factor or am I doing something wrong, getting to sl…eep is not a problem go out like a light just cant stay asleep longer than a hour its so frustrating. Also if I doze in my kitchen chair as I often do of a day I wake with a jolt like some unknown force nudging me in my satate of semiconsciousness I have a joke to myself its my gardian angel stoping me from falling asleep please could you thow some light on my problem, Alby

  5. I am fully compliant, yet I still have frequent awakenings. I have a stuffy nose even during the day. My sleep mask is great. It’s a tiny nasal pillow that I scarcely feel. It’s so wonderful I wish I could wear it during the day. I love the feeling of being able to breathe which the CPAP gives me. I loved CPAP the first night even though I used a nasal mask and had it so tight it made marks that bled and I lost all feeling in the bridge of my nose for 2 days! Then I switched to the pillow.
    My problem is I have a neck whiplash injury and I’m in chronic pain which also wakes me up. The CPAP makes my pain worse because I can’t shift positions or sleep on my side because the mask pulls on my neck or blows air which wakes me up.
    I don’t feel terribly sleepy, but boy do I feel a lot of pain. But I love the open nostrils and feeling of air coming in. It’s so enlivening and peaceful. I’m a new user, (started in Aug) so we will see if I continue. But I got a lot of support from my doctors and Restoration, the company which rents me the equipment. They keep showing me how to get good equipment and how to adjust it for which I am grateful. Diana

  6. I feel better sleepwise. However, just about a year ago (well before I got diagnosed with sleep apnea as well as three heart blocks and an episode of atrial flutter) I developed panic attacks–never had them before or anything remotely like them–truly something from the bowels of hell at times.

    I guess I just want to note here that despite feeling rested and that I’m 100% on board with my sleep issues CPAP HAS NOT been a panacea. I think I might have had unrealistic expectations. Yes it minimized/eliminated the blocks/PACs/PVCs in the lab when I had the sleep study, but I haven’t been re-evaluated and don’t know if I should be. Also don’t know if the panic attacks can even be an offshoot of using CPAP therapy.

    Wonder if switching to an auto CPAP would help (grasping at straws).

    I became fully compliant from about day 10 after receiving my machine–straight CPAP at a pressure of 8 and it has a built-in humidifier. I no longer use a chinstrap and have gotten to the point that my air swallowing is non-existent to minimal. I feel lucky. I’m also 50 and thus, the dreaded perimenopausal and for myself I’m chalking up the panic attacks to that and certain stresses.

    Fool in CPAP Paradise???

    ps Oh well, nice to have this forum–Thank You!

  7. I have chronic fatigue Syndrome, dysotonomia, Pots, etc. so realisticlly what am I to expect from the Cpap? I am swallowing a lot of air. I am feeling panicky at bedtime. Today i fired my rental company that has consistently supplied me with terrible service and hope for a better relationship with the new company.
    I liked the old consistent air supply better than this autoset machine. I am still exhausted every day and getting worse. I do like my oxegen concentrator.

  8. My 7 yr old suffers from OSA and he is wears it every night has cold induced asthma and dust mite allergies so his nose is stuffed often. I am concerned that his cpap is enough for him. He was on a preset machine set at 6 and now a machine that adjust as needed. He does wear the cpap and still has issues. I have a monitor in his room and check on him frequently through the night that now over the last 2 years I have sleep issues.

    Thank you for the forum. Heartbroken mom in westchester,ny

  9. Yes. This describes me perfectly. I am very frustrated with this. I have a low BMI and no other medical conditions. I do not snore. I have been on my machine for over 6 months with a perfect score and a residual AHI of 1 (down from 15). Yet, I am exhausted. I still wake up a lot. Dr. Park, what can I do? Please help. Thank you.

  10. Marc,

    Sorry to hear. I can’t say what you need to do next without examining you. Many people do well with oral appliances when CPAP doesn’t work. It’s also important to make sure in general that you’re breathing optimally through your nose.

    Good luck.

  11. Dr. Park. I’m sure you are very busy but Is there any way to do a telephone consult with you? (Paid of course) I’m in health care as well and been dealing with this for sometime. Are there solutions I can read about in your books/blogs? Thanks in advance.

  12. 40 year old Male. Very healthy otherwise. Diagnosed mild to moderate sleep apnea. After recent septoplasty and turbinate reduction, titration pressure went from 10 to 4. Arousal index is still very high and none are related to apnea/hypopnea. Doc says I’m just hyperarousable. Very frustrated. All they do is prescribe sleep meds that don’t help. I wake up all night for no identifiable reason. Please help. Thanks for all you do. Will be happy to pay for consult. Just need to sleep.