Sleep Wake Junk with CA's - Waveforms

[Jay Aitchsee]

People often ask, "what about all these CAs?" And the reply is often that it looks like Sleep Wake Junk (SWJ). Sleep Wake Junk is characterized by irregular Flow Rate waveforms followed by a CA's or sometimes OA's. It is most often seen in the early morning hours.
Some examples below. These are NORMAL waveform segments. The the OA's and CA's would not count toward AHI in a lab sleep study.




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Below is an example of a disturbance or arousal of unknown origin.
The machine scored a 16 second Obstructive Apnea (OA); however, we can see that there is sharp increase and irregularity in the Flow Rate Waveform immediately preceding the event, indicating a likely arousal. Additionally, we can see that the pulse rate and the oxygen level actually increase during the event. With an actual OA, it would be typical to see the O2 fall during the event and then rise with an increase in pulse after.
Likely, I changed positions or rolled over and held my breath for 16 seconds while doing so. The small break in the Pulse Oximeter trace reinforces the supposition that this was movement related.
This event would not be scored as an OA in a lab sleep study





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CA Examples:




Edited to consolidate images

[Arlene1963]

Jay I really do want to thank you for posting this.

When I started CPAP I was having many clear airway events and they scared me silly.

The info you sent me back then showing me how to look at flow rate in my SH data transformed anxiety into understanding.

AHA - just SWJ!!

I'll always be grateful for this forum and this sort of info!

[chunkyfrog]

Thank you for posting this, and for always sharing your knowledge so generously here.

[Jay Aitchsee]

Jay I really do want to thank you for posting this.

Thank you for posting this, and for always sharing your knowledge so generously here.

Aww shucks, you're welcome

[Pugsy]

We had a thunderstorm a couple of nights ago and it woke me up but didn't lose power and I just lay there for a few minutes listening to the thunder.

I grabbed the waveform graphs (this is from Encore) so that people could see what normal asleep breathing looks like compared to SWJ. The bigger picture makes it a little easier for me to spot normal asleep vs SWJ.
Doesn't look like I had any "false" events flagged during this time but you can still see the definite change in air flow. Sometimes I get SWJ events flagged and sometimes I don't.
I did 2 images..one a little closer up.
I like the interactive ability that SH offers but I also like the big picture that Encore offers. Sometimes it's hard to get the "big picture" when using the SleepyHead zooming in feature.

This is from a PR S1 560 machine I was trialing.
You will probably need to click on the image and then enlarge to see it larger.





SleepyHead..same time despite time stamp...Encore messes up when DST is in use.

[PEF]

This is just so interesting! Many thanks to Jay and Pugsy for helping us new people learn something about the whole CPAP process!

[Jay Aitchsee]

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[Jay Aitchsee]

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[Omne]

Thanks Jay, it's really valuable to see the graphs. It answers some questions I've had and it will help me sort out what's important.

[Omne]

OK, question. I looked at the waveforms for a couple of nights. As an example In one 50 minute period I had what appear to be 11 post arousal events, Hs and CAs. Irregular breathing before and lasting a after.

Now that I know that, what do I do about it? There doesn't seem to be any correlation with pressure or flow and they seem to happen randomly and throughout the night. They're still causing my SpO2 to drop into dangerous levels. Does this mean that the CPAP isn't going to be able to prevent them or are they treated exactly the same as any other event just from a different cause?

[Sir NoddinOff]

Thanks Jay. Good stuff every newbie and all others should look into.

[Pugsy]

They're still causing my SpO2 to drop into dangerous levels.

How low are we talking about?
If you are awake or semi awake there shouldn't be any drop in O2 levels unless some other problem is going on. When awake breathing is taking place, even if it is irregular, the airway tissues shouldn't be collapsing to prevent air flow...it may be irregular and get a flag but the flag is from the irregularity and not physical collapse of the airway (either partial or full).

Is it possible you were sleeping on your back during this time frame in question?
If you were for sure asleep and the arousals are partial and related directly to the apnea event then the usual fix is more pressure...and if using auto adjusting pressures that means more minimum pressure.
Something that will better prevent the airway from collapsing in the first place.

[Omne]

They're still causing my SpO2 to drop into dangerous levels.

How low are we talking about?
If you are awake or semi awake there shouldn't be any drop in O2 levels unless some other problem is going on. When awake breathing is taking place, even if it is irregular, the airway tissues shouldn't be collapsing to prevent air flow...it may be irregular and get a flag but the flag is from the irregularity and not physical collapse of the airway (either partial or full).

Is it possible you were sleeping on your back during this time frame in question?
If you were for sure asleep and the arousals are partial and related directly to the apnea event then the usual fix is more pressure...and if using auto adjusting pressures that means more minimum pressure.
Something that will better prevent the airway from collapsing in the first place.

When I ran the oximeter the other night it dropped into the 70s a few times and the 80s several times. I was definitely asleep, or at least fading in and out without knowing it during the posted period. From what Jay posted I wasn't sure about the pre-apnea arousals and what they signified. Is it possible to regularly arouse prior to the apnea?

Or if the majority of my night is choppy like that, not a lot of nice regular breathing, does that mean something else is going on besides apnea?

The other problem I'm running into is that I've run the minimum up to 13, 14 and 15 but exhaling becomes so difficult at 14 and 15 that I'm constantly aware of it and I can't sleep even with EPR/Flex on.

[Pugsy]

When I ran the oximeter the other night it dropped into the 70s a few times and the 80s several times. I was definitely asleep, or at least fading in and out without knowing it during the posted period.

Were these drops brief or prolonged?
Quick drops usually are related to loss of contact and aren't real drops/desaturations.
Oxygen in the blood doesn't go down fast nor does it go up fast.
If it goes from 95 down to 80 in the blink of an eye...it's a loss of contact artifact which is to be ignored.

Or if the majority of my night is choppy like that, not a lot of nice regular breathing, does that mean something else is going on besides apnea?

Looks like crappy sleep (poor sleep quality) night but as to what causes it I don't know. If most of your night looks like that I would imagine that you don't feel those nice low AHI numbers.

With the difficulty exhaling at your pressures despite what exhale relief is offered...I am thinking a bilevel machine might be more to your liking. I don't know how difficult it might be for you to try one to see if it helps with both the exhaling relief along with maybe helping with overall sleep quality.

If you really are having real desats that go down slowly and up slowly...you need to be getting with your doctor.

[Omne]

The 70s were without a mask. With a mask it usually drops into the 80s over several minutes if I have a couple of events relatively close together. Half my time is spent in the low 90s, below my basal rate.

As far as the choppy sleep. Some nights it's all like that. It looks like the best nights are about 40% like that with regular sleep patterns mixed in. Since it's been that way a lot I'm not sure how much is apnea and how much is something else.

The CPAP is helping with the SpO2 and it's helping with the sleep quality but not a lot. A few nights have been great but the last one was a few weeks ago.

I can shoot a note over to my doctor about the bi-pap and see what he says. I'd like to avoid going out and buying one outright simply due to cost. If I have to I will but it's worth a shot to get insurance on it.

Thanks for the info.