Topics: UARS obstructions, 420e, etc.

[jrgood27]

well it seems after trying 8 masks, the search is still on. RG - i liked the breeze a lot. but i have a very strange reaction to nasal pillow masks - i wake up frequently in the midst of giant inhalations - almost like a startle response.

regular nasal and full face masks don't do that though. i guess something about the direct airstream of the pillows is freaking my brain out.

i never did have a cpap titration. i barely slept during my initial study and my sleep doc thought it would be better to titrate using the APAP at home.

which i think was a smart decision, but now i think i see a titration study in my future - though i think i'll need to be heavily sedated for it. i just wonder if i'm having arousals even with the CPAP. thanks for the suggestions. i have to get back on the horse and the encouragement helps. jenny

[-SWS]

Actually, sleepydave there is deltadave here. SAG is actually

LOL!!! SAG is not the lovely lab rat we have pictured above.

For those newcomers who are trying to figure out Dave's various screen names: On this message board he posts as StillAnotherGuest. We have fondly shortened that handle to "SAG" (but you really need to use his long screen name to correctly search for his posts). On yet other message boards he has posted as both sleepydave and deltadave (think he may even have some old posts here under either handle as well). Those various screen names on the various patient message boards are all Dave, who is the "RPSGT manager of an accredited sleep lab" as Rested Gal cited earlier in this thread. Dave has patient advocacy in his blood in no small way.

Above you see Rested Gal in one of Dave's sleep lab locations. I'll let her try to explain that one... or just stay silent about the intriguing mystery of just why she's running sleep studies on rottweilers in Dave's lab! Hmmmm.... .

[-SWS]

...i never did have a cpap titration. i barely slept during my initial study and my sleep doc thought it would be better to titrate using the APAP at home.

which i think was a smart decision, but now i think i see a titration study in my future - though i think i'll need to be heavily sedated for it. i just wonder if i'm having arousals even with the CPAP.

Jenny, to the best of my knowledge there is absolutely no established sleep-science epidemiology that essentially says: "Yet in a small percentage of patients the sensory-based input that was introduced by CPAP therapy was never completely normalized by neural plasticity. For that small percentage of patients CPAP-related sensory input continued to source sleep disturbances throughout the night that adversely affected sleep architecture."

Genetically the human species is amazingly diverse, Jenny. And that genetic diversity is part and parcel of what allows any species to survive when environmental conditions change (including potential dangers presented during sleep). You can probably guess that I personally suspect some of us are "light sleepers" thanks to a species survival imperative driven by no other than evolution's genetic diversity itself. Most people (including the venerable Dr. Dement himself- as described in The Promise of Sleep) can move by the railroad tracks, then eventually and naturally acclimate to sensory input that was initially disruptive to sleep. However, I think some people will never be able to live and sleep by the railroad tracks no matter how long they allow for plasticity-based neurological acclimation to finally normalize their sleep. Similarly, I think there are a few people who will never sleep comfortably with CPAP-related sensory input.

Perhaps these few "sensory sensitive" CPAP patients, if they even exist that is, must rely on pharmaceutical supplements (sleep aids, sensory mitigating pharmaceuticals, etc.) or even alternative therapies for SDB. I sure hope no one misconstrues my own far-flung postulations as if they were even close to being medical fact. They most definitely are not.

[StillAnotherGuest]

I think a fairly definitive assessment of UARS can and should be made through physical exam and PSG, and in the end, there shouldn't be too many questions left on the table for any given UARS patient. BTW, "upper airway" refers to anything north of the vocal cords, so all the structures involved in apnea and hypopnea also participate in UARS. If there is a fixed "upper" upper airway obstruction, this should easily be identified by any good ENT guy, and then the surgical approach opens up (or maybe FF alternatives).

UARS is not that hard to identify in even the most basic of sleep labs. Increasing effort seen in the thoraco-abdominal belts, flattening in the sum channel, concomitant snoring, flow limitation in the pressure transducer (even if the sleep laboratory is not using pressure transducers in the diagnostic, they're definitely using them in intervention), and the use of suprasternal notch pressure transducers are all diagnostic aids in identifying UARS. As an aside, if the PB IFL1 is seeing a flow limitation, then you can rest assured that the sleep lab is seeing it as well.

Is there really such a thing as an unresponsive flow limitation? If such a "fixed" obstruction exists (and in re: prevalence, we're talking about a subset of a subset), we have to consider what it is actually unresponsive to. Saying it's exclusively pressure ignores the equally dynamic force in "pressure" therapy, which is flow. Pressure gradient seen because of fixed obstruction can be largely, if not completely, overcome by flow. Just because an obstruction is not affected mechanically by pressure does not mean it is not affected whatsoever.

If you meet diagnostic criteria for UARS (like AHI <5, RERAI >10), then we would expect some sort of improvement during titration. Or alternatively, UARS that is unresponsive to pressure therapy probably isn't UARS, or at the very least, there are significant other issues underfoot. If during titration, the underlying sleep architecture continues to be a train wreck (delayed sleep latency, increased WASO, WAFA, Stage 1, arousals and awakenings) then there is more searching to do.

...i think i see a titration study in my future - though i think i'll need to be heavily sedated for it.

Let's say, for arguments sake, you then get a normal sleep architecture during the titration. How would you account for that? Was it the pressure or the medication? Unless you plan on duplicating that medication regime every night, you've added a whole new variable. What if the OSA/UARS is minimal to non-existent? You know, CPAP titration unto itself can be a good diagnostic tool for UARS (i.e., it disappears with pressure therapy). I believe in your case, PSG is going to provide a lot more insight that just a titration number.

So OK, let's say there is truly a fixed resistance component in a specific case of UARS. A different strategy may be considered, for instance, utilizing a somewhat more aggressive flow-based approach (basically a pressure-support methodology) to overcome the work of breathing associated with the resistive forces. Ideally, this would take the form of some form of Proportional Assist Ventilation, but might also be accomplished through the use of bilevel support (and consider tailoring inspiratory waveforms by adjusting rise time when available), or in a rudimentary form, through the use of EPR.

One must view this strategy in the light of a very important concept. When looking at UARS under ambient conditions, the body is breathing in a "negative pressure" mode. Diaphragm drops down, negative force in the airway is generated and breath is drawn in. Unfortunately, this negative force can serve to collapse unstable airways. As positive pressure is applied, particularly bilevel, increasing positive pressure is applied during inspiration, and breathing is done in a "positive pressure" fashion. While distendable structures may be mechanically dilated, another effect is the relief of some of the Work of Breathing that would have normally be needed to overcome the forces of resistance. And relief from the negative pressure swings.
SAG

[rested gal]

sleepydave below is this message board's very favorite StillAnotherGuest, also known as "SAG"!

Actually, sleepydave there is deltadave here. SAG is actually

Why does this remind me of the name changes the Aura/Headrest/TwilightNP has gone through?

[kyethra]

after my autopap trial where there was no difference in level of sleepiness of ambigious data from the autopap (I would always take it off at some point during the night or it might leak due to position) I've concluded it doesn't really matter what I have- UARS or Catathrenia, but it does seem more likely to me that I have catathrenia based on that.

However I recently started on xyrem and that has been a breath of fresh air. I can now get up in the mornings! And I sleep well at night-- good restful sleep and not just hours of dreams and movements. No more torturing the husband or waking up with my hair all in knots Its really quite amazing. I hear that normal people sleep this way. And its easier to stay awake during the day too, thats improving as we increase the dose.

Interestingly my neurologist wanted me to use my autopap when she prescribed xyrem since it can sometimes cause decreased breathing. Wow, was she right. Before the xyrem the stats on the machine were pretty low-- my AHI was always less than 2, and pressure was less than six (it was set to start at five). Now its really quite different. My AI is usually pretty low, zero one or two, but HI is up there. It ranges from about 7-20 a night. My pressure is also getting up there. It ranges usually from about 7-10. But I now keep the mask on all night and I don't have leaks since I'm not sleeping like I'm posessed.

I find this rather fascinating. I'm very glad that I have the autopap and that allows me to use the xyrem because the xyrem sure gives me hope that I can do more and be awake more and so forth (I'm keeping my fingers crossed that it keeps working).

[kolayrufig]

Прикольный форум, побольше-бы таких тем.

[galinakiraevas]

Интересный у Вас сайт! Мне все очень нравится!

[alenasteregina]

Отличный у Вас сайт! Есть пару предложений по поводу дизайна.

С Уважение Алена Стригина.

[M.D.Hosehead]

air-pressure-unresponsive UARS events

I don't fully understand this.

It would seem that, even with upper airway restriction, if air intake is under positive pressure from xpap, the negative pressure in the chest/abdomen must decrease. If xpap does not, in fact, decrease UARS arousals, I would suspect that something is wrong with the theory that UARS arousals are due to negative pressure.

Can someone enlighten me here?

[anutachkabelova]

Здравствуйте. Вчера читала тут тему про "пневматическое оружие без лицензии" а сегодня уже её нет. Как её найти?