Low AHI, High Flow Limit, Unrested

[robysue]

cby1,

Thanks for those screen shots.

The RERAs definitely appear to be real: Even at this scale you can see distortion of the inhalations that end with the large recovery breaths at the end of the RERAs (where the RERA flag is). But most of the rest of the breathing doesn't really look like it's that distorted even though your machine is scoring FL throughout the 4:30-4:45 screen shot. Most of those breaths just don't look substantially different than the ones in the 4:45-5:00 screen shot where there are little or no FL scored after 4:48.

My take is that the real FL seem to be closely correlated with RERAs being scored by your machine, and the FLs that are not closely tied to a RERA may not actually be "real" FL at all. Others may differ with my opinion however.

From your responses to my questions, I think you do need to start tackling the old "sleep hygiene" problems. It may help you sleep better even if it doesn't improve your data numbers. And overall quality of sleep is the real goal, not a super low AHI or RDI or perfect FL graph.

In particular:

Thank you Robysue - thorough as always. Answers below:

Any reason to believe that you are waking up a lot during the night? Any sense of spending a lot of time tossing and turning and semi-awake? How long does it take you to get to sleep at night?

Not really - although some nights I will wake up every few hours - not clear what the cause is. I usually drop off within 10-15 min.

On the night you posted the data, you apparently didn't go to bed until 3:15 and you got up at 9:50. That's only about 6 1/2 hours of machine time. Any chance you just need more sleep? Have you tried pushing bedtime back to 2:15 or 1:15? What happens when you go to bed earlier?

I do need more - generally get 7 1/2 - 8 - machine is always on - for 11 years . And yes, I need to get to bed earlier.

Do you have a regular sleep schedule? If so, what's it look like?

No - and that's an issue. Tends to be 1-9, but varies. That's my fault.

I know it's not easy, but trying to stabilize the sleep schedule would probably help. (She says as she knows that this is one of her own big, on-going bugaboo issues with sleep that is too fragile.)

I'd suggest picking a set wake up time that works for your overall lifestyle. And make sure that you get up at the same time every day regardless of how much (or how little) sleep you got the previous night.

Temporarily set bedtime approximately 7 hours before your desired wake up time. Try to NOT go to bed until your scheduled bedtime even if it means struggling to stay awake for the last 30-60 minutes or so. If you are NOT sleepy at bedtime, you may want to stay up until you are sleepy, but do try to keep it reasonable and try to make sure that you still have a chance to get 6 hours of sleep or so.

If there's no evidence of sleep fragmentation after a week or so of getting a "decent" 7 hours of sleep, then push bedtime back to 7.5 hours before your desired wake up time. Once you feel like you are actually sleeping for most of those 7.5 hours for a week or so, then push bedtime back to 8 hours before you want to get up.

How much caffeine are you consuming? What about alcohol?

No Caffiene (anxiety issue; not clear if OSA caused, or "primary" anxiety). Alcohol, 2-3 beers (*not* under-reported) with dinner most nights.

Not meaning to sound like a teetotaler, but that may be enough alcohol to be affecting your sleep cycles. Typically alcohol can make it easier to fall asleep, but alcohol can also reduce REM or delay REM. And if you're not getting enough REM, that could explain some of your ongoing problems with not feeling as well as you should. (http://www.webmd.com/sleep-disorders/ne ... ol-sleep#1)

If you're game, you might want to experiment and see if cutting back to 1 beer per night makes any difference in your sleep.

Do you spend a lot of time reading, watching tv, or web browsing in bed? Do you build in some "down time" before going to bed each night?

Nothing in bed - but I also don't schedule any down time.

A bedtime routine and some down time might help.

I'll write more later.

[palerider]

But most of the rest of the breathing doesn't really look like it's that distorted even though your machine is scoring FL throughout the 4:30-4:45 screen shot. Most of those breaths just don't look substantially different than the ones in the 4:45-5:00 screen shot where there are little or no FL scored after 4:48.

I don't believe the view isn't zoomed in far enough to tell. you have to see the inhalation curve to determine whether there is FL or not. on the other hand, maybe your eyesight is better than mine and you can tell whether the inhalation curves are flattened or rounded.

cby1, can you zoom in so that the individual breath shapes can be seen on the flow graph?

[cby1]

RobySue: Thanks, will wait to hear more - one question:

If there's no evidence of sleep fragmentation after a week or so of getting a "decent" 7 hours of sleep

< Not Hostile > What would qualify as evidence (or lack of) for sleep fragmentation? Do you mean my subjective perception of sleep quality? My ability to "sleep straight through", or ? Thanks.

PR: No problem to post more shots, but I need specific time intervals - not knowledgeable enough to intuit exactly which sub-periods you need for the zoomed images. I know how far in you need to zoom - just not which periods. Thanks.

[palerider]

PR: No problem to post more shots, but I need specific time intervals - not knowledgeable enough to intuit exactly which sub-periods you need for the zoomed images. I know how far in you need to zoom - just not which periods. Thanks.

wherever you're wondering about the flow limitations. alternatively, just do some looking yourself, zoom in to some spots where the FL chart is low, and look at the shape of the waveform, particularly on the inhalation (above the 0 line) phase, then move over to where the FL chart is higher, and compare the shape of the waveform.

I believe that the FL chart lags the flow chart by a few seconds, since it's a moving average.

[cby1]

Sorry for the delay PR; better late than never - let me know if this is what you wanted.

High FL:



Low FL:



Oh - this one has both:



And here's a bad night recently - 16-20, EPR = 3. Not sure I blame the EPR, just noting it. What else was different? NO IDEA.



Thanks.

[Pugsy]

What else was different? NO IDEA

2 most common causes when we see "different"....supine sleeping or REM stage sleep or maybe a little of both.
Normally REM doesn't last as long as your first "ugly different" time frame but this might be a situation where both are involved. The timing is just about right for REM...it just is lasting a little longer than what REM normally lasts.

For some reason you needed more than that 20 cm pressure and the machine couldn't go any further.
2 most common causes for such pressure changes...REM and sleeping on your back.

That's why I think it is "different"...

I will let PR talk about the FLs. I am not real good at that sort of stuff. It's fairly obvious there is a difference in the flow but whether it relates to your unwanted symptoms or not...that's the million dollar question.

Did they make you give up your bilevel machine? Or do you still have it?

[robysue]

RobySue: Thanks, will wait to hear more - one question:

If there's no evidence of sleep fragmentation after a week or so of getting a "decent" 7 hours of sleep

< Not Hostile > What would qualify as evidence (or lack of) for sleep fragmentation? Do you mean my subjective perception of sleep quality? My ability to "sleep straight through", or ? Thanks.

Back when I was fighting one of my early Wars on Insomnia, this was the definition given to me by Muffy/NotMuffy (later known as Sludge) and it's still the one I use when I actively engaged in reining my insomnia monster back under control when it escapes and starts playing havoc with my sleep:

There's no evidence of serious sleep fragmentation (from insomnia) once your perceived sleep efficiency >= 90%. And perceived sleep efficiency = (total estimate of sleep)/(total time in bed) where the total estimates of sleep is based on a combination of things including (for me): estimated time to get to sleep at the beginning of the night, estimated number of wakes I remember during the night, estimated length of time lying in bed awake after those wakes, estimated length of any "restlessness/tossing and turning" I remember. If I look at the biPAP data, I'll also through in any times I turn my machine off and back on even if I don't remember doing it. To estimate the total time I'm awake after sleep onset, I tend to do a pretty gross estimate: I'll multiply the number of wakes I actually remember by 5-10 minutes and any on/off cycles by about 3-5 minutes. I'll call any "short" restless period a "wake" of about 15 minutes and a longer one about 30 minutes. I'll add in my estimated latency to sleep to get a total estimate of WAKE and then subtract that off the total time in bed for my total estimate of sleep.

To put the perceived sleep efficiency >= 90% into context: If I'm in bed for 7 hours, then if my total wake time (including latency to sleep + all WASO) is about 40 minutes, then I was asleep for about 6 hours and 20 minutes, or about 6.33 hours. And so the perceived sleep efficiency = 6.33/7 = 0.904 = 90.4%.

[robysue]

There's clear evidence of flow limitations and they end with the RERAs in the data shown below. That's why I said the RERAs were real.

High FL:

This next graph shows pretty decent sleep breathing.

Low FL:

In this next graph, there's obvious flow limitations that end with the RERA. And then a normal sleep breathing breathing pattern resumes.

Oh - this one has both:

Now can you find a snippet of breathing that is flagged as moderate flow limited breathing (in the FL graph) but is NOT closely associated with a RERA flag in the flow rate graph? It's those "moderate flow limited breathing" sections of your first set of data that I think are not all that distorted and may be "false".

Finally you post this data with a question:

And here's a bad night recently - 16-20, EPR = 3. Not sure I blame the EPR, just noting it. What else was different? NO IDEA.

You've got lots of RERAs and Hs and FL at maximum pressure. And the FL graph gets worse after the pressure zooms all the way up to 20cm. Either you need more pressure OR your airway is adversely responding to the additional pressure because the pressure is high enough to trigger some instability in your airway.

It would be interesting to zoom in on the following periods:
4:07-4:15
6:30-6:45 and in particular around 6:35-6:40---i.e. right at that 4cm pressure increase that is not related to any events. It's the FL that's driving that increase.
7:30-7:40
The reason I'd like to see these time frames up close is that I'd like to know exactly what gets the pressure increase started. It's clear that the pressure increase around 6:35 is triggered by FL and nothing but FL (or snoring). It's less clear from the whole night scale about what's the trigger of the other two big pressure increases: Did the pressure increase come first and then the events start? Or do the events start first and thus drive the pressure up.

If you want to experiment for a night or two, you might want to lower your max pressure down to say 18cm and keep the min pressure at 16cm. If the problem is that your airway doesn't like the pressure being at 20cm, your data might just get a bit better. On the other hand if you really need more than 20cm of pressure to keep your airway open, the data should get worse.

[cby1]

Did they make you give up your bilevel machine? Or do you still have it?

Never got one - always had CPAP, no one will prescribe BiPAP for "insurance reasons". Gotta fail CPAP in the lab - what BS.

That said, I just completed my 5th sleep study in 11 years, and I'll find out on 12/7 what happened. This sleep doc might be more amenable to the BiPAP - he will actually look at the SH shots I bring in - and he sees some of the pinning at 20 cm. He actually seems to use logic sometimes . And I will complain of aerophagia. But whether I'll get one - your guess is as good as mine. BiPAP won't fix everything, I know that - but it might help.

If not, I may have to finally make good on my threat to buy my own - then I'd probably go ASV. But buying your own I think you go down a path where it may be hard to establish that coverage that Medicare will want to see - and you'll be out of pocket for life - or maybe not - who knows?

2 most common causes when we see "different"....supine sleeping or REM stage sleep or maybe a little of both.

For years now, I would have said supine sleeping was not an issue, as I get back and leg pain that prevents it - BUT - lately I have occasionally woken up on my back. That is a surprise. We'll see what the sleep study saw.

If there's no evidence of sleep fragmentation after a week or so of getting a "decent" 7 hours of sleep

By Robysue's definition, most nights would be >= 90% then - not bad - but I still wake up feeling worse than when I went to bed, and this persists until about 6 pm or so, and then I feel almost normal. Next day, same thing - for 2 1/2 years now. Tired and depressed in the morning, Anxiety/jittery in the afternoon, and a 1/2 decent night.

Ah, I see another response from Robysue - I will try to dig up the requested screenshots later tonight. Thank you both.

[robysue]

If there's no evidence of sleep fragmentation after a week or so of getting a "decent" 7 hours of sleep

By Robysue's definition, most nights would be >= 90% then - not bad - but I still wake up feeling worse than when I went to bed, and this persists until about 6 pm or so, and then I feel almost normal. Next day, same thing - for 2 1/2 years now. Tired and depressed in the morning, Anxiety/jittery in the afternoon, and a 1/2 decent night.

Ah, I see another response from Robysue - I will try to dig up the requested screenshots later tonight. Thank you both.

cby1,

I'd recommend trying to turn the machine off and back on anytime you wake up during the night. It's an easy way to see if there are more wakes than you remember.

Also do you have a fitbit or similar thing that can track movement in your sleep? Sometimes that can also help in tracking down whether fragmented sleep is the problem.

Also try to post those screen shots I'm interested in.

[Pugsy]

For some reason I thought you used to have a bilevel..oh, well, my memory is far from perfect.
I remember you and I talked about ASV but for some reason I was thinking you were already on a regular bilevel.

I don't know if you would feel better on bilevel or not. You might. I know that I discovered that I slept about 45 minutes longer on average when comparing APAP to bilevel auto...never could figure out why but I just did and 45 minutes more always makes a difference in how I feel during the day.

I have never had the FL issues you are showing though so I can't relate or draw from personal experience in that area. I suspect the "ugly different" sections are probably related to your being on your back sometimes and when you have a night where the "ugly different" doesn't happen then you most likely didn't spend much time on your back. It's a logical assumption since sometimes you get the really ugly time frames and others you don't.

Maybe this new doc will be willing to at least let you try regular bilevel. Your software pressure graphs support the need (at least on paper) and it would be worth investigating at some point to see if more pressure helped or hurt you in terms of how you feel.

Should you ever decide to get your own ASV...don't worry about Medicare for now as your OSA diagnosis now will cover everything but the machine just like it does now.
I have an ASV...Medicare knows nothing about it and I know if I wanted a new machine I couldn't get one through Medicare but I don't care. Medicare still covers all the other stuff (which isn't all that much but it's something).
What I like about ASV is that I can get by with a much lower EPAP/IPAP starting out the night and through the night...and it only increases (and it increases quickly) when it needs to for my OSA stuff.
It also decreases quickly...so I don't spend nearly as much time at higher pressures as I did when using regular bilevel. Centrals have never been an issue for me. I see the machine respond every now and then to a probable sleep onset central but for the most part all the changes I see in pressure are related to OSA and not central stuff.

I have no idea what ASV might do in response to your FLs. I suspect it would be rather aggressive.
Should you ever decide to bite the bullet and get your own ASV...try to get a ResMed if at all possible.
There's pros and cons to either and should you ever get in that frame of mind just send me a note and I will explain why I prefer ResMed ASV.

But hey....let's see what the new doc does next week and see if a regular bilevel machine might be a consideration to try. Your pressure needs alone support the need and the aerophagia issues offer secondary support for the need.

[palerider]

Sorry for the delay PR; better late than never - let me know if this is what you wanted.

High FL:

Low FL:

It takes a bit of looking, at that size, but you can see that the FL breaths are more flat on top, or even spiked at the start and the inhalation rate, instead of coming up, and then rounding and going back down slants off and then drops.

[cby1]

Thanks PR, and yes, even I saw the difference when I zoomed in.

Robysue's requested screen shots:

If you want to experiment for a night or two, you might want to lower your max pressure down to say 18cm and keep the min pressure at 16cm

I'll have a go. BTW, last night was 16-20, EPR = 2, not 3 (yeah, I'm wingin' I know it) - numbers were better, pressure stayed lower, FL somewhat lower (under 0.5 most of the night). Didn't feel any better though - but hey, only 1 night.

What EPR would you like to see with that 16-18 test? Thanks.

[robysue]

If you want to experiment for a night or two, you might want to lower your max pressure down to say 18cm and keep the min pressure at 16cm

I'll have a go. BTW, last night was 16-20, EPR = 2, not 3 (yeah, I'm wingin' I know it) - numbers were better, pressure stayed lower, FL somewhat lower (under 0.5 most of the night). Didn't feel any better though - but hey, only 1 night.

What EPR would you like to see with that 16-18 test? Thanks.

Whatever EPR you are most comfortable with.

I'll write more tomorrow about those wave flow snippets. They're interesting.

[ChicagoGranny]

Do you have a regular sleep schedule? If so, what's it look like?


No - and that's an issue. Tends to be 1-9, but varies. That's my fault.

So, are you committed to working on that?

Alcohol, 2-3 beers (*not* under-reported) with dinner most nights.

I would cut this back to one pint and allow at least three hours before bedtime.

I do cardio 6-7 days/week, resistance training 1x/week.

You don't say how long or intense the sessions are. But, there is a good chance you are overtraining. Three times a week training is sufficient for general health. The other four days you should try to do something light like a 30-minute stroll each day. If you work at a desk, try to stand frequently, walk to the water cooler, do some stretches, etc.

With training, less is often better. I believe you are in your mid-fifties. Things have changed. Overtraining can cause a general fatigue or worse.

Diet could use improvement;

Another item to work on. Don't try anything extreme. Just cut back the amount and eat what you enjoy - maybe a little less of the things that you know are bad and a little more of the things you know are good.

long-standing back problem

Any chance this is interfering with good sleep?