weeks worth of data, no consistency-what next?

[College3girls]

I apologize in advance if this is too much data at once. I'm posting for my mom, theresmp. She just started BIPAP. Am I not waiting long enough for her to settle in, or should I be adjusting settings? She had a couple of great nights when first starting, but now her AHI runs about 11, and sometimes more. I don't want to wait too long to make changes since it has taken a year to convince the sleep Dr her therapy hasn't been effective. The Sleep doc and insurance just look at compliance. Her DME is more responsive to helping, but he won't change anything without going through the sleep Dr. first.

Once again, I'm counting on the expert help I've received in the past. Mom is not bothered by high pressure, but is sensitive to mask leaks. Although her simplus mask leaves a permanent red mark on the bridge of her nose, she says it doesn't hurt unless she touches it with a finger. She sleeps through the night with the mask. She falls asleep rapidly, within 10 minutes. She states she finds the"'air" comforting, and would not be able to sleep without it.

[Pugsy]

What is the EPAP and IPAP after ramp? I know max IPAP is 25 but what is it after ramp and before events start driving it?
Pressure support is 4, I see that.
She is all over the place with her results....hmmm....sleeping position change a factor????
It's hard to evaluate the graphs when the scale is so tiny...like seeing what the pressures are.

[College3girls]

Pugsy, I don't know if sleep position could be a a factor, but I do know Mom tends to start out on her back, and then go to her side. She probably can't remember what position she is in on a "bad" night, but I'm going to suggest to her to concentrate on sleeping on her side. I know she snores, mask and all, when on her back especially.

I'm re-posting one good day, and then the next day, a "bad" day, with hopefully a better scale for you to see.

IMG]http://i1357.photobucket.com/albums/q74 ... 520142.jpg[/IMG]

[Pugsy]

There may be some REM stage sleep involved in the bad night as the ugliness starts approx around the time the first REM stage would start but REM doesn't normally last for 2 hours...so I suspect supine sleeping is at least the primary culprit with maybe a little dose of REM thrown in.

Whatever the cause...the minimum EPAP isn't able to do a good job preventing the ugliness when it happens.
With a diagnosis of "mixed" apnea I assume some centrals were showing up at some time but for right now they don't seem to be a problem.

When we can have really good nights on some nights and really ugly nights on other nights (and we can't blame leaks) then we have to assume that one of the usual culprits has jumped to the top of the list...supine sleeping pressure needs are greater or REM stage sleep or a little of both.
That's really the only variables left that I can think of to explain the obvious drastically different reports and most likely a need for greater pressures at some point in the night and not others.

Either try staying off the back (easy to say but very hard to do for some people) or more EPAP starting point from where it is now to cover the times where higher pressures are obviously needed.
General rule of thumb is EPAP for OAs and that's primarily what seems to be shown here.
That's assuming more EPAP and its then higher IPAP (keeping PS of 4) doesn't create centrals. Can't be swapping OAs for centrals.

Some people don't have a huge difference in pressure needs when comparing side sleeping to supine sleeping but others can see a huge difference in pressure needs. Your mom may be one of those. I know someone who needs a cpap pressure of 19 when supine sleeping and only 9 when on their side...so yeah, guess who worked hard to learn to stay off their side? Me? I have tested it both ways and my pressures don't vary all that much with supine sleeping vs side sleeping but do with REM stage sleep. Meaning I see high pressures even with a wall built to keep me on my side in what is likely REM stage sleep. So I gave up trying to stay totally on my side since I was going to need the higher pressures anyway due to REM sleep.

I suspect your mom's probably primarily supine sleeping event driven....if she can stay off her back there's a good chance the really ugly reports won't happen nearly as often and not nearly as ugly. If not, then she likely needs a bit higher EPAP/IPAP baseline to cover the higher pressure needs times. It's hard to control sleeping position though.
Those wedges and foam things slide out...and tennis balls...well, just what we need...something else to disturb sleep while the body figures out that if it stays off its back the tennis balls won't hurt. Not my idea of a good solution to use something that wakes us up in pain.

[robysue]

College3girls,

First thing I noticed about the "good" data is that its from a session that's only 1 1/2 hours long. Since it starts at 19:30 = 7:30 pm, was this just an early evening nap? Or did your mom go to bed for the night at 7:30 and then take the mask off at 9:08 and return to sleep without the mask on for the rest of the night?

Regardless of what happened, the fact that the "good data" is from a session that's only 1 1/2 hours long, it could be that your mom really didn't hit any REM during this session. Or maybe only a very little bit of REM right before she woke up---notice that there's a distinct rise in pressure (with a couple of OAs) in the last 5 minutes of this session. Maybe she woke up right after a very short REM cycle?

On the "bad data" night, the first 90-95 minutes of the night looks very much like the "good data" night: Mom turns the machine on at 19:48 = 7:48 pm and sleeps pretty soundly until 21:30 = 9:30. The beginning of that first cluster is about 100 minutes after she turned the machine on, and assuming a latency to sleep of about 10 minutes or so, the timing of that first cluster of events makes it reasonable to ask: Is the start of this cluster REM related?

Any mention on your mom's sleep test(s) about whether her sleep apnea is much worse in REM than in non-REM?

Once the cluster starts, it keeps on going for two whole hours. That's longer than a REM-cluster should last, so even if the initial trigger for the cluster is REM, there's this question: Why does the cluster last far beyond the end of the first presumed REM cycle? Maybe the answer is back sleeping. May the answer is that her breathing never fully stabilized after the rapid increase in pressure at the start of this cluster for some reason, and your mom got caught in a vicious feedback loop of events trigger pressure increases which trigger unstable breathing which leads to more events being scored which triggers more pressure increases which trigger more unstable breathing which leads to more events being scored which triggers more pressure increases .....

At any rate: Something POSITIVE happens between 23:30 (11:30 pm) and midnight, and after midnight your mom's breathing settles back down and remains excellent until she turns the machine off at 3:01 am. Things to note about that second GOOD stretch of data in the "bad night" include:

• The pressure steadily decreases down from its peak around 23:40 until it reaches her min pressure settings around 1:00. And after 1:00 am, there are no more dramatic pressure increases all the way up towards her very high maximum pressure settings.
• The super stable breathing pattern lasts about 3 hours (from midnight to about 3:00 AM). Mom likely had one or two additional REM periods during this time that did NOT trigger any huge clustering of events. Sleep varies, and that may be why. Or perhaps the original trigger of the two hour nasty cluster was supine sleep instead of REM sleep. Or perhaps the fact that there were no more sudden, huge pressure spikes during these 3 hours allowed your mom's breathing to stay stabilized.
• The total machine run time is about 7.25 hours, but it ends at 3:01 AM. Which again leads to the question of what happened after 3:00AM? Did your mom get up for the day?? Did she take the mask off and return to sleep without it?

Things that I'd consider asking about if I were you:

• What does Mom's sleep schedule actually look like? When does she go to bed each evening? When does she wake up for the day? How well do these times (reported by Mom) match up with the data recorded by the machine?
• Are the time stamps on the data accurate? If not, is the problem that the BiPAP's internal clock is way, way off? In which case you need to figure out how far the clock is off and use SleepyHead to correct the time problem?
• What do Mom's sleep studies say about the AHI in REM sleep? What about in supine sleep? And was there any REM supine sleep on any of her titration studies?

If it's not too much of a burden on Mom, you might ask her to keep a note pad by the bed so that she can jot down the following things when she first wakes up for the day:

• Position she thinks she fell asleep in
• Position she was in when she woke up
• Does she remember sleeping on her back (or waking up on her back) at any point during the night?

I'd also have some questions for Mom's sleep doc (if she has one):

• If Mom's breathing seems to become unstable once the pressures are above 21/17 and they're relatively stable below 21/17, would it be reasonable to see what the data looks like if we capped her pressures at 21/17? Would it be worth trying that for a week or two just to see how bad the clusters are if the pressures were capped at 21/17?

[robysue]

Whatever the cause...the minimum EPAP isn't able to do a good job preventing the ugliness when it happens.
With a diagnosis of "mixed" apnea I assume some centrals were showing up at some time but for right now they don't seem to be a problem.

If there's a diagnosis of "mixed" apnea, then there's a bit of a central component to the situation, isn't there?

And in that case, it's possible that the problem might be the EPAP has gotten high enough to start triggering the "central" part of the mixed apneas: Mixed apneas do start out as centrals, but end up looking like obstructives when they're scored on an in lab test.

At any rate: It's worth trying to see the breathing is always unstable when the pressure is super high. And if so, it's worth seeing what might happen if the max IPAP pressure were capped at something like 21 or 22 cm.

When we can have really good nights on some nights and really ugly nights on other nights (and we can't blame leaks) then we have to assume that one of the usual culprits has jumped to the top of the list...supine sleeping pressure needs are greater or REM stage sleep or a little of both.

Well there's also another obvious factor to consider on these two nights: On both nights the first 90 minutes or so is clean good breathing.

On the good night, there's no more PAPing after the first 90 minutes. On the bad night, there is.

What if the good night is only good because Mom turned the machine off before the REM cluster had a chance to really develop and trigger a massive pressure increase? If Mom had kept the machine on past 21:08 on the good night, would the time between 21:08 and (say) 23:00 look as ugly as that 2 hour mess on the bad night?

Either try staying off the back (easy to say but very hard to do for some people) or more EPAP starting point from where it is now to cover the times where higher pressures are obviously needed.

What if the pressure increase is triggering mixed apneas?

General rule of thumb is EPAP for OAs and that's primarily what seems to be shown here.
That's assuming more EPAP and its then higher IPAP (keeping PS of 4) doesn't create centrals. Can't be swapping OAs for centrals.

Thing is: A mixed apnea is scorable on an in lab sleep test as a mixed apnea: You pick up both the central component AND the obstructive component. But on a PAP machine, it's either going to be classified as a CA or an OA, and I'd bet that it would be classified as an OA. And here's why:

My understanding of a mixed apnea when scored on a sleep test is that it starts out looking like a central---there is no airflow and there is no effort to breath according to the data gathered by the belts around the chest and the abdomen, so the apnea starts off looking like a central. But after several seconds into the apnea, the belts start picking up an effort to breath, but there's still no airflow into the lungs. So at this point the airway is clearly blocked, and the apnea is now looking like an OA. One hypothesis is that the airway collapses after the central apnea started.

Now think about how the PR BiPAP distinguishes between CAs and OAs: It waits 5-6 seconds after there is no airflow into the lungs before it sends out that PP for determining the patency of the airway. If the apnea is a real mixed apnea (as scored on an in lab sleep test), then the (original) problem is that the brain forgot to send the signal to breathe. But within a few seconds of NO breathing, the airway collapses. But because the PR waits for about 5 seconds into an apnea to send out that first PP, by the time the PP is sent, the airway is collapsed and the machine labels the event as an OA instead of a CA.

Add to this: As I recall it's more likely that a real CA will be misclassified as a PAP-scored OA than it is for a real OA to be misclassified as a machine scored CA. (After all, a real in-lab CA is scored when there's no effort to breathe regardless of the patency of the airway. But a real OA is scored when the combination of breathing effort and no airflow strongly indicates the airway is obstructed.)

[Pugsy]

If there's a diagnosis of "mixed" apnea, then there's a bit of a central component to the situation, isn't there?

I would assume so but we don't know how much "mixed" it was but from what these reports show...I have to assume centrals have not reared their ugly head yet in enough numbers to be a problem.
As for the machine maybe mistaking the classification..that's always a possibility but I have to assume that...at least for now..it has them correctly flagged because we can what if all we want to but we have to go on what we see.
That's all I know to do. We both know this software stuff from the machines comes with its own limitations.

REM could very well be a factor. I just don't see it lasting 2 hours but maybe it did act as a trigger.

All I know to do is address what is known and shown and see what happens. Capping the IPAP max would be a good idea. Increasing EPAP base seems a logical step based on what is shown right now...but that's why I also mentioned keeping one eye out on centrals ....just in case. We don't want to go swapping OAs for same number of CAs.

What if the pressure increase is triggering mixed apneas?

What if is isn't? What if it is plain old supine sleeping with a bit of REM sleep tossed in to monkey up things that we are seeing here?

Actually if it were me..I would try the simple approach first. Try to see if staying on her side made any difference at all before I started what iffing all the other stuff.
I was just tossing out the EPAP increase as something to mainly talk over with the doctor about. I wasn't really suggesting that be the first go to thing to try tonight. Just something to consider down the road and discuss with the doctor should it be found that the ugly reports persist despite staying on one's side.

[College3girls]

Robysue, here are two consecutive good days of a least 7 hrs time for each. Again, for whatever reason, the times for start and end are way off- they should be around 11pm to 7 or 8 am. Hope this helps you help Mom. I'll be visiting her on Thursday and will look at her data since 5/30. She called me all excited a bit ago- last night was another good night at a 3.
She is going to concentrate on sleeping on her side, and try to jot things down.

[robysue]

College3girls,

What I notice on these two good days is:

Except for the two peaks where IPAP goes to 25 on the first of these two good nights, the IPAP stays below 21 cm.

Let's look at the two nights in some detail.

First this night:



Clusters of events are still showing up, but they're not lasting as long as on that bad night you posted earlier. On this night, the time stamps are:

19:41. Machine is turned on
a bit before 20:00. Machine is turned off
about 20:15. Machine is turned back on
about 20:20. Ramp period ends

about 20:40. First cluster of events starts: This first cluster of events lasts about 5-10 minutes and drives the pressure WAY up to IPAP = 24 or 25. There's also a very LARGE leak spike at the end of this cluster (about 20:55). At the same time the large leak is detected, the machine starts lowering the pressures. Whether the machine is lowering the pressure because of the large leak or because the breathing has managed to stabilize is not clear at this "full night scale". (I'll be honest, I don't know how the Resmed machines handle large leaks; but PR Auto machines do start lowering the pressure in response to large leaks in an attempt to reseal the mask.)

That first cluster is way too soon for it to be REM related. It might be sleep transitional related if your mom was a bit restless at the beginning of the night, which is a reasonable hypothesis since she turned the machine off about 20 minutes after going to bed and back on about 15 minutes later. That first cluster kicks in about 20 minutes after the ramp goes off, so maybe she wasn't fully asleep until 20:20?

It's also possible that she flipped onto her back for a few minutes and then back onto her side.

At any rate: It's comforting to see that this first cluster of events did NOT result in a 2 hour period of unstable breathing with the machine constantly increasing the pressure back up to the IPAP > 21 cm range for extended periods of time.

about 21:10. An isolated OA or two occurs and drives the pressure back up to IPAP = 25ish. At around the same time, there's another spike in the leak graph and the machine immediately starts lowering the pressure. Again, it's not clear if the machine is lowering the pressure because the breathing has stabilized or it its lowering the pressure in an attempt to reseal the mask. I just don't know that part of the Resmed Auto algorithm all that well.

But as the pressure decreases from that second spike with IPAP = 25, Mom's breathing starts to settle down and become more stable. The respiratory rate also starts to decrease towards a more typical sleeping respiratory rate as the pressure decreases after 21:00, with the RR finally settling down in the low to mid-teens by around 22:00, which is just about when the pressure has finally returned to what looks like your mom's minimum pressure settings.

And the breathing remains good until the second cluster of events starts about 23:40.

23:40ish. The second cluster of events starts around now. This is about three hours after the last cluster started and about 3.5 hours after your mom turned the machine back on at the beginning of the night. The timing is close enough where it could well be another REM cycle. Or again, Mom might have flipped on her back. Or both. Notably the pressure increase for this cluster is NOT as sharp as the pressure increase for the first cluster. And IPAP tops out at around 21 or 22 cm rather than zooming all the way to 25 cm. This cluster seems to last from about 23:40 to about 00:10, and a 30 minute REM cycle this far into the night is actually pretty common. So this could be REM related. Or REM+supine sleep related. But, again, it could just be supine sleep related. Snoring also increases during this time frame as does the respiratory rate.

Again, it looks to me like your mom was lucky that the situation didn't degrade into another 2 hour long stretch of lots of events with the pressure staying at its maximum setting. The OAs end and higher than normal respiratory rate returns to baseline by around 00:10 or so; the snoring persists for a few minutes longer. The pressure starts to decrease by 00:15 or 00:20.

So again, it's an open question about why this cluster ended in 30 minutes of lasting for 2 solid hours. Maybe it was just REM and your mom wasn't on her back. Maybe she flipped back onto her side at the end of 30 minutes.

Mom's breathing remains pretty stable from the end of this cluster for the rest of the night if we're just looking at apneas and hypopneas. There's some variation in pressure related to flow limitations later in the night (between 1:30 and 3:30), but the IPAP pressure never gets much above 17 cm until 2:30 and between 2:30 and 3:30, the IPAP pressure never gets much above 20cm, and it's above 20 cm for only a few minutes.

1:30-2:30 There's a decided uptick in the respiratory rate during this time. Since this starts about 90 minutes after that second cluster of probable REM-related events, it's possible that there's another REM cycle somewhere in this hour. (The respiratory rate is typically less regular in REM than in non-REM and the respiratory rate often goes up---sometimes by quite a bit---in REM sleep.) But things never get particularly bad apnea-wise during this possible REM cycle. Why? Maybe mom's not on her back. Or maybe the machine is simply doing a better job of helping keep the breathing stable.

I'll post a detailed report on the second night in a separate post.

[robysue]

Now let's look at that second night you posted:



You posted this image twice, so we don't have the graph that shows the respiratory rate or the flow limitations.

Nonetheless, here's what we can see in this night:

The pressure never gets above 21 or 22 cm. And it's above 20 cm only briefly for three different times during the night. The first little cluster of events is about 75 minutes after your mom turned on the machine. A bit early for REM, but not so early that we can conclude that it's not REM-related. And the times between the peaks in the pressure graphs are about 90-120 minutes apart. That's a bit longer than what we'd expect for REM related stuff, but it's not ridiculously long between REM cycles.

So it's possible that this is what a night looks like when the REM sleep is not REM-supine sleep. Or it's possible that this was simply a good night where the first set of REM-events did not lead to a deteriorating cycle of too much pressure leading to unstable breathing leading to more events and so on and so forth.

So the big questions remain: Are the worst clusters on the bad nights just a combination of REM and supine sleep that might be fixed by increasing the min EPAP so that the pressures don't have to go up quite so high? Or are the worst clusters REM-related at the start, but the breathing never stabilizes after the sudden increase in pressure and increasing the min EPAP might not make things better and could make things worse?

I'm wondering: Would your mom be willing to sleep with some kind of low-light video camera on so that you could actually see if she's doing substantial supine sleeping only during the worst parts of the bad nights? Or whether she's supine sleeping for brief periods on all nights? The data from a few nights of video taping her sleep might just go a long way in figuring out what to do to improve her PAP therapy.

[Pugsy]

The clock being off???
Confirm that the clock on the S9 is correct and that you have the correct time zone selected in SleepyHead user profile...you will have to edit the profile to see time zone in SleepyHead.
Sounds like one of them is not set correctly.

[College3girls]

I'd checked earlier today, and found sleepyhead was not at the correct time.

I think I've set it correctly now. I'll know on Thursday when I again visit Mom, specifically to download her data and she where she is at. She will be practicing sleeping on her side. Keeping my fingers crosses.