Respiratory rate

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Fenelon
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Respiratory rate

Post by Fenelon » Sat Jul 22, 2017 11:57 am

Hello again everyone,

I posted a question about SPO2 the other day (thanks for the replies) but while trying to educate myself on this topic, I seem to have reassured myself about SPO2 at expense of becoming concerned at respiratory rate! Given what I have read this seems to be high for me. The following image is fairly usual for me regarding respiratory rate, ranges normally being Min:0, Med. 12 (+4), 95% 22(+8), Max 50. Are these numbers too high? I can't find any reliable data on 'normal' respiratory rate fluctuation.

Thanks again in advance for any help given.


http://imgur.com/a/kWnro

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robysue
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Re: Respiratory rate

Post by robysue » Sat Jul 22, 2017 8:24 pm

Fenelon,

The first thing that I want to say is that there are two obvious things that need a lot more of your attention than the RR data does.

1) Your treated AHI on this night is 7.36, and most of the events are OAs. Your pressure settings may not yet be optimized.

2) Your leaks could use some work. You spent 7.59% of the night in Large Leak territory. While that's not really horrible, it is a bit of a concern that one of your official Large Leaks looks like it lasted for at least 30 or 40 minutes. Moreover, during several of the shorter Large Leaks, there are a fair number of unclassified apneas scored. On your machine, the algorithm used to determine whether an apnea is an obstructive apnea (OA) or a central (clear airway) apnea (CA) becomes unreliable in the presence of Large Leaks.

So in my opinion, these are the data you need to be working on right now.


Next I want to express my opinion about your RR data. You write:
The following image is fairly usual for me regarding respiratory rate, ranges normally being Min:0, Med. 12 (+4), 95% 22(+8), Max 50. Are these numbers too high? I can't find any reliable data on 'normal' respiratory rate fluctuation.
"Normal" respiratory rate data is hard to come by because it varies pretty significantly over the course of a 24 hour period. Most sources will cite a "normal (wake) resting RR rate" as something like 12-20, some will cite a smaller subrange of that. Most people's RR while sleeping is a bit slower than their resting wake RR, but some people's sleep RR is not slower than their resting wake RR. But as far as I know, unless there's something clearly out of whack at night, a slightly higher sleep RR is not considered clinically significant in any way.

The normal sleep RR does show some pretty significant variation over the course of the night: In many people with normal sleep, the RR goes up in REM and the breathing becomes more irregular---it can look more like wake breathing than non-REM sleep breathing. Turning over in bed and doing a lot of tossing and turning can also affect the RR rate.

And, significantly, sleep disordered breathing events can effect the RR over short periods of the night: After an apnea or hypopnea occurs, it is common for a person with sleep apnea to take several deep, quick recovery breaths, both to get the breathing restarted and the body reoxygenated if your apneas are accompanied by O2 desats. These often show up in SleepyHead data as spikes in both the RR and VT graphs. If enough apnea events happen over the course of the night, the short periods of high RR and high VT can distort the 95% RR and VT numbers and make them higher than they would be if the sleep apnea was properly controlled by the CPAP.

The min RR = 0.0 is most likely that at some point you had an apnea that lasted just long enough to cause SleepyHead to take the Flow Rate data and compute a short-term RR = 0. Note that when SH says the RR=0, that does NOT mean you didn't breath at all for a full minute. The RR at time t is typically calculated by multiplying the number of breaths in the last 15 seconds or so by 4. If you have an apnea that lasts 15 or more seconds, that gives a RR = 0 for that period.

Finally it's worth noting that in your particular data, the highest RRs seem to be associated with some pretty significant flow limitations. It could be that the machine was having a bit of trouble telling exactly where you quit exhaling and start inhaling, and that can cause a PAP machine to "double count" breaths. When this happens, it's also not uncommon for the machine to also have weird data in the VT graph as well. Some people have more trouble with machines double counting their breaths than others.

The thing is: To figure out whether the machine is "double counting" your breaths when the RR is very high requires you to zoom in on the Flow Rate curve as well as the RR curve.

It would be interesting to see what a five-minute snippet and a two-minute snippet of your breathing looks like during one of the high RR periods. Could you show us the zoomed in Flow Rate, Pressure at Mask, Flow Limitation, and RR curves for a 5-minute period like 3:10-3:15. The do a 2-minute zoom for the part of 3:10-3:15 that has the highest RR. You've got to zoom in far enough where it's easy to see the individual breaths for us to tell whether the machine is double counting some of your breaths.

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ajack
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Re: Respiratory rate

Post by ajack » Sat Jul 22, 2017 8:50 pm

If the data is right and the machines can mess yp and not take variables into account.
your minute vent is 7.2l.m and 15bpm that's ok, I think it will improve as you fix your therapy. the rapid breathing is with high flow limit and probably low tidal volume.
you need to get rid of the pie chart in preferences

without any more data available and by the charts, I'd raise the min to 12 and leave the max on 20. turn the epr to 2, it won't help the CA but it will make getting use to cpap easier.

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Re: Respiratory rate

Post by robysue » Sat Jul 22, 2017 9:51 pm

xxyzx wrote: you have flow limits during some of those indicating hypops are lowering oxygen so your RR goes up to compensate
The places where the RR is the highest correspond to parts of the events chart with NO events being scored. There is, however, flow limitation being scored. Flow limitations are NOT the same as hypopneas. If there were hypopneas during the periods with greatest RRs, they'd show up in the event table.
when your RR is zero you could be having centrals
The RR will also drop to 0 if you are having a lot of OAs. Indeed, if you look at the places where the RR drops to 0, it is strongly correlated to some dense clusters of OAs and UAs. And since the UAs are associated with Large Leaks, there's a really good chance that some, possibly all, of those UAs are OAs that the machine could not classify because of the Large Leaks.

i would like to see your spo2 and heart rates alongside the data too
Most likely this data does not exist. Most of us do NOT sleep with a recording oxymeter.

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Fenelon
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Re: Respiratory rate

Post by Fenelon » Sat Jul 22, 2017 11:12 pm

Firstly, thank you to everyone for your replies and Robysue for the very detailed answer - all of your time is greatly appreciated.

Here are the graphs from Sleepyhead zoomed in for 5 and 2 minute periods and the pie chart removed.

I don't have SPO2 or pulse rate for that night but I did strap the pulse oximeter to my finger last night and all looks well, SPO2 mainly in high 90s, one brief dip to 92 and a couple dips to 94/95, again fairly brief. Average pulse 59, mainly in 60s with one very brief spike to 80.

Again, thank you for your help, if you require anything else please let me know.

Best wishes
Fenelon

http://imgur.com/a/C8tUl
http://imgur.com/a/AngLd

ajack
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Re: Respiratory rate

Post by ajack » Sun Jul 23, 2017 2:13 am

there is a thread over on apnea board with a similar flow pattern, The end of the story is It needs more min pressure, the machine is double counting the irregularities as breaths. add the 3cm to the minimum pressure and go to 12cm as suggested, then see how it is..

your events happen in 3 clusters, I would try positional therapy to see what can be sorted, the first is to buy a $10 soft foam cervical collar to keep your neck straight.

you also have some leaks to sort out.

As you would know. If your o2 is above 90, it's fine. A few bumps here are there are ok.

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Fenelon
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Re: Respiratory rate

Post by Fenelon » Mon Jul 24, 2017 7:24 am

Thank you Ajack.

Last night I upped the minimum pressure to 10, I'll put it to 11 tonight and 12 tomorrow. I have one question regarding centrals. I've posted last night's SleepyHead as I've read about the sleep/wake/junk stuff and centrals. Do you (or anyone) think I can safely ignore the centrals here, insomuch as the clusters at 22.00 and 01.15, well, I think I am awake, if not I am certainly only beginning to fall alseep. Can these then be discounted? And if so, are the few other centrals insignificant? i.e is it safe to continue an increase to minimum pressure?

As always thank you everyone for your help and time.

http://imgur.com/a/W8gyL

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Pugsy
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Re: Respiratory rate

Post by Pugsy » Mon Jul 24, 2017 7:31 am

Fenelon wrote:Do you (or anyone) think I can safely ignore the centrals here, insomuch as the clusters at 22.00 and 01.15, well, I think I am awake, if not I am certainly only beginning to fall alseep. Can these then be discounted?
Awake/semi awake stuff can be discounted and it really looks like these Centrals are SWJ...too close to known awake time.
Fenelon wrote: And if so, are the few other centrals insignificant?
No not significant. It's normal to have a central here and there randomly through the night. Might be a real central as in sleep onset central or might be a turn over in bed hold your breath central which isn't real. Either way not enough of them to worry about.
Fenelon wrote:i.e is it safe to continue an increase to minimum pressure?
I would think so. If you look at your pressure graph you don't seem to have an increase at all in centrals with the higher pressures that your machine already is going to. If pressures were causing your centrals I would think you would see a lot more clustering when the pressures went higher.

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Fenelon
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Re: Respiratory rate

Post by Fenelon » Mon Jul 24, 2017 7:35 am

Thank you very much Pugsy!

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robysue
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Re: Respiratory rate

Post by robysue » Mon Jul 24, 2017 8:14 am

Fenelon wrote:I have one question regarding centrals. I've posted last night's SleepyHead as I've read about the sleep/wake/junk stuff and centrals. Do you (or anyone) think I can safely ignore the centrals here, insomuch as the clusters at 22.00 and 01.15, well, I think I am awake, if not I am certainly only beginning to fall alseep. Can these then be discounted?
Centrals are always an interesting question because our machines simply cannot tell when we are awake, when we are asleep, and when we're transitioning to/from sleep.

Because you think you were awake for those clusters around 22:00 and 1:15, I'd be inclined to ignore them, at least for now. But I'd also keep an eye on them: If clusters of sleep transition CAs become so long and pronounced as to prevent you from completing the transition to sleep in a timely fashion, that can be a real issue. In other words, seeing 1 or 2 CAs as you drift off to sleep is one thing; having a string of 10 or 20 CAs as you drift off to sleep is something else. Your clusters of CAs are not yet long enough to be a huge concern, but I think they are worth keeping an eye on---particularly if you wind up noticing a positive correlation between times when the clusters show up and times when you struggled to get back to sleep.
And if so, are the few other centrals insignificant?
I'd say that they're insignificant as long as they don't increase significantly.

The CAs around 23:20, 2:05, and 4:30 come at the end of what looks like a dense OA cluster. They may be post arousal CAs, and the arousal would have been caused by the OA cluster. But the ones at 23:20 and 2:05 also come when the pressure is very high, and so there's a chance that once your pressures hit the 15+ range, the extra pressure may be causing some problems. Prudent watching is all I'd do for now since you're not getting strings of 10 or more CAs on top of each other.

The two CAs at 3:15ish and 3:30ish are not enough to worry about in my opinion. There is a change in the Flow Rate curve just before the 3:15ish CA, so this may be a normal post-arousal CA, and the arousal is most likely a spontaneous arousal, not a respiratory-related arousal.
Last night I upped the minimum pressure to 10, I'll put it to 11 tonight and 12 tomorrow.
<lots deleted> i.e is it safe to continue an increase to minimum pressure?
That of course is the main question, isn't it?

On the one hand, the one cm increase in minimum pressure didn't really do much to break up the clusters of OAs, but on the other hand, it seems to have increased the number of CAs, although most of the CAs are at times when a few CAs are common. But some of the CAs get mixed in when your pressures are at their highest as well. (We don't know if this is new problem because you didn't post the pressure curve for the data from 7/21) So it's worth considering whether too much pressure might trigger too many CAs in your case.

Also worth considering in your case: Your data for 7/21 showed a lot of flow limitation going on and the question is: Did the Flow Limitation graph settle down any with the one-cm bump in min pressure?

I'm a rather cautious person when it comes to dial-wingin' Before I make a pressure change on my own machine, I want to know exactly what it is that I'm trying to fix and I want to have an idea of how I will know if the pressure change made things better, worse, or about the same---both in terms of what I'm trying to fix AND in terms of everything else. And I also don't do well with changing things every day.

If I were you, I'd leave the min pressure at 10cm for about 3 or 4 days. At the end of that period I would consider an additional 1 cm increase in the min pressure If the AHI is still too high, the OAs still outnumbered the CAs and most of the CAs appear to be normal sleep transitional CAs. I'd also monitor the Flow Limitation curve: It should get better as you increase the min pressure, but in some people, the Flow Limitations don't respond to increased pressure because whatever is driving them, it ain't obstructive sleep disordered breathing: In other words, not all flow limited breathing is directly caused by an airway in danger of collapsing. In a few (unlucky) people, too much air pressure can wind up triggering breathing patterns that look flow limited, which can cause the machine to increase the pressure and aggravate the problem.

In other words, I would recommend leaving the min pressure at 10cm for a few days. Then, if the clusters of OAs are still around and the CAs have not gotten any worse, I'd bump the min pressure up to 11 and leave it there for a few days to see if things improve. If not, continue the process of a 1cm bump in min pressure every few days until either the clusters of OAs disappear OR the number of CAs becomes significant OR you have trouble tolerating the pressure during the times you are awake and trying to get to sleep.

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Fenelon
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Re: Respiratory rate

Post by Fenelon » Mon Jul 24, 2017 9:07 am

Thank you for the detailed reply Robysue, it's greatly appreciated. Although I've learned a lot the past few weeks, I'm afraid the flow limitation graph is beyond me at this point. I've posted a link (and also one that includes the pressure graph for 7/21) - but I am not exactly sure what I should be looking for in terms of an improvement with the flow limitation. Simply smaller numbers? Again - thank you for your time.

http://imgur.com/a/a3TYF
http://imgur.com/a/zlu59

(7/23 zoomed in)

http://imgur.com/a/VQlH6

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robysue
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Re: Respiratory rate

Post by robysue » Mon Jul 24, 2017 9:40 am

Fenelon wrote:but I am not exactly sure what I should be looking for in terms of an improvement with the flow limitation. Simply smaller numbers?
I'll try to write more later.

But yes, what you should be looking for are smaller numbers on the spikes on the Flow Limitation graph. And fewer spikes. A perfect Flow Limitation graph would be a horizontal line at 0. You aren't going to have a perfect Flow Limitation graph night after night, but ideally you'd like to see a lot fewer really high points on that graph.

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Fenelon
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Re: Respiratory rate

Post by Fenelon » Mon Jul 24, 2017 11:41 am

Thanks again Robysue!

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Re: Respiratory rate

Post by Fenelon » Tue Jul 25, 2017 12:04 am

So, last night I kept the pressure the same but I had a really bad night, image below. A couple of questions, mainly concerning the centrals as was discussed earlier in this thread. The first cluster of centrals prior to 22.30 I was definitely awake still. The second cluster around 23.00-23.30 there's a possibility I was still awake but also that I had just fallen asleep. If it is the latter can they still be disregarded or are they now 'real'? Again the cluster at roughly 04.15, I was either awake or I've just fallen asleep, you can see there was a break in treatment as I got up to go to the bathroom. My clear airway index stats are: Last 30 days, 4.21 and Last week 3.22 and the last four days since I upped the pressure runs as 1.96/6.33/2.89/4.86. Given that some of these might be able to be disregarded, do these figures look worrisome? Any opinions would be gratefully appreciated.

My final question regards the UA. Can I also disregard these from last night or at least view them with the possibility that they are not real - simply a result of the the large leakage, since they correspond exactly together?

As always thank you for your time!

http://imgur.com/a/Ol9DF

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Pugsy
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Re: Respiratory rate

Post by Pugsy » Tue Jul 25, 2017 6:45 am

Ouch...indeed an ugly night.

About the UAs...I don't think we can throw all of them out the window. Something happened in terms of airway and/or air flow movement.
In view of of the large large leak the machine knew something was going on but it couldn't quite figure out what to call it.
They could very well be obstructive apneas or hyponeas too. Since you had a cluster of OAs right immediately preceding the time in large leak and the OAs sort of reduced during the large leaks...but UAs increased...I am betting the leaks got so bad that effective therapy pressure couldn't be maintained and more OAs joined the leak party.

So you did have an ugly night last night. No way around it but it was because of the leaks. We all have them from time to time for any number of reasons. I have bad leak nights too. See my report below.

As for the central clusters...We know the first one was an awake cluster and there's a good chance the second cluster and the little past 4 AM was awake/semi awake cluster. Those I think you can safely toss out the window.

The UAs...sorry, but I wouldn't be tossing them out the window...they are something but the machine couldn't identify what due to leakage affecting its ability to sense stuff. If it was just 5 minutes of big leak would be a different story but you have essentially a little over an hour spent in prolonged large leak. Unless you were awake for that time frame...those UAs are most likely OAs....IMHO.

Quit worrying about the centrals and work on preventing leaks.

Just to show you that you aren't alone in fighting leaks.
Image

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