Apnea events vs SP02(%); does this sound reasonable?

[lars4life]

.

[Pugsy]

Do you remember if during your sleep study if your OSA was particularly worse in REM?

I am. Don't do much of anything event wise except in REM where it gets ugly. Huge clusters and sometimes some really tough events needing so very substantial pressures and other night not much at all. My report would look like that if I were to try to use 4 cm of pressure for sure.

Whether it is position or REM they are unwanted and need to be dealt with more effectively. Will be interesting to see how they respond to APAP with a tight range.. Might give you a better idea where to set cpap at if that is what seems more comfortable for you. I got lucky, pressure changes even to max have never bothered me.

[jonnybee]

These graphs are from last night and the graphs are time synch'd. I decided to go with 9cm cpap since during previous auto ops my 95% pressure hung around 9cm. Plan to try auto with a tight range tonight. AHI last night: 7.7

[Pugsy]

Those look suspiciously like REM patterns. Could be positional also. Doesn't really matter, they are unwanted.

Leak is not a factor.

9 cm cpap isn't as effective as we would hope. If doing APAP, minimum should be at least the 9 cm. I will share that sometimes a 1 cm bump in minimum pressure can give remarkable change. At 9 cm minimum I have clusters in what is likely REM sleep and at 10 minimum I don't. Maximum needs to be close enough to your minimum choice to not disrupt your sleep (since pressure changes bug you) but still give the machine a little room for movement to see where it wants to go.
Straight cpap at higher pressure may suit you better. Hurts nothing to try either one though to see what suits you the best and gives you optimal therapy.

I forgot to ask. What is status of EPR during all this? Some people the reduction that comes with EPR does impact therapy negatively.

[Lizistired]

I forgot to ask. What is status of EPR during all this? Some people the reduction that comes with EPR does impact therapy negatively.

I wonder if labs use EPR during titration. It seems like all the DME's set it on 3. It was a big problem for me. That may explain that breathing pattern.

John, were they able to titrate you to REM at 5cm?
Has anything else changed recently? It seems odd that you went from a 3.3 AHI to this.
I think if the EPR is off, I would try the 8-12 auto that you mentioned earlier and see what happens.
You don't really need to worry about the SPO2. I don't think you are sleeping enough for it to drop, and it's one more thing that might interfere with your sleep.

[jonnybee]

I forgot to ask. What is status of EPR during all this? Some people the reduction that comes with EPR does impact therapy negatively.

I wonder if labs use EPR during titration. It seems like all the DME's set it on 3. It was a big problem for me. That may explain that breathing pattern.

John, were they able to titrate you to REM at 5cm?
Has anything else changed recently? It seems odd that you went from a 3.3 AHI to this.
I think if the EPR is off, I would try the 8-12 auto that you mentioned earlier and see what happens.
You don't really need to worry about the SPO2. I don't think you are sleeping enough for it to drop, and it's one more thing that might interfere with your sleep.

The report indicated I spent 40 minutes in REM. The conclusion stated that "successful control of sleep apnea (was obtained) with nasal CPAP at 5cm with 3 cm of C-flex added in". Control of REM specifically was not addressed.

I have always had EPR set on "3". I will try turning it off tonight (along with trying the auto 8-12) and see if it makes a difference.

Thanks.

[Pugsy]

I have always had EPR set on "3". I will try turning it off tonight (along with trying the auto 8-12) and see if it makes a difference.

Sounds like a good plan. If turning off is difficult, just a reduction to 2 or 1 may be significant. Won't know till you give it a try.

CFlex of 3 is really not the same as EPR of 3 since CFlex goes about their relief in a different manner. Maybe that factor is also contributing to the difference.

REM may or may not be a factor either. We can't tell for sure from what we can see. It just appears to be a little suspiciously to look like a REM pattern. I tend to look at that sort of possibility just because I have personal experience with it and from past history also know that sometimes my REM events are super tough and other nights just wimps and no extra pressure is needed. Again in the long run doesn't really matter because the events need to be prevented no matter what the cause. If positional, we can sometimes change sleeping positions but we can't control REM.

If you are bored or curious you can read about how the "Flexes" work on the Respironics machines. It's not a straight cm reduction in pressure. More of a small reduction and a rhythm change. ResMed of course just does the EPR cm reduction and it isn't an apples to apples comparison with C Flex.

http://cflex.respironics.com/

[AMUW]

jonnybee,
Take the suggestions above and below with a grain of salt for discussion with your professionals, not as medical advice; our cases could be different enough.
Having put out the disclaimer, here are some concepts to consider, in addition to Pugsy's:
- REM sleep with enhanced instability: I read that the first REM period starts 80-100 min after sleep onset; but you seem to struggle just during this first stretch, and for a rather long time
- one important curve you're not showing: flow limitations; in my case that would start the instability, cause the S9 Auto to increase the pressure, which when high enough would also cause mask leaks
- if you lower titration pressure is for one sleep position, but you're using another (like supine), the sleep lab should have tested you in those positions, and it should appear in their detailed report
- in my case cumulative nasal congestion built up with successive days on CPAP: the discomfort would build up during one night, and show very similar to your "periodic breathing" phenomena: from deep sleep breathing at 12-14 beats /min it would become the slower awake rate, superposed on which I could see a cyclic phenomenon of a long apnea followed by hyperventilation (repeating every 1-1.5 min), finally decaying into normal sleep
- if you should be having an acid reflux problem interacting with OSA, I am told that also peaks around 1-2 am (or a few hours after meal time)

A few factors that may have led to resolution in my case, alone or in combination (I don't know):
- antacid pills (PPI)
- treatment of nasal intolerance with anti-histamines
- switching my CPAP pressure from Constant to Autoset
- habituation of my nasal passages to the flow and pressure

Dynamic stability loss interpretation: to me the repeating apneas (mostly hypopneas) felt like a race car going over very rough repeating bumps and turns (like they show SFO hill chases in the movies), or a helicopter sustaining damage to a blade, or a skier not knowing how to negotiate the moguls... taking a long time to stabilize the compensation. And the cumulative arousals and sleep fragmentation led to daytime sleepiness.
Nowadays I still see a flow limitation trigger the process once in a while ... but for some reason my involuntary system is able to compensate much easier.

I hope this helps, or it brings somebody in with smarter interpretations.

[Slartybartfast]

Looks like you're generating a couple of "centrals" in your data now. That indicate your pressure might be getting close to where it needs to be. In my case, when my pressure is set too low, I end up with apneas and obstructive apneas. As the pressure rises, those disappear. Increasing the pressure still higher results in the appearance of what the S9 scores as "central apneas," but which are perhaps better described as non-obstructive apneas, since the cause of them is not known with certainty.

You don't ever want to draw any conclusions after only one night under any particular condition. I'd let it go for four nights at a minimum. Next thing I'd try would be to bump up the pressure to 10 and compare that with 9. That will let you know if you're going in the right direction.

It's odd that your lab said 5 cm worked. You're at about double that now, and still having those clusters of events.

BTW, I agree that the way they are clustering, they look an awful lot like REM clustered events. That first set of data you showed us didn't indicate any discernible clustering. If you're now getting REM sleep, even if it's disturbed by clusters of events, that indicates to me you're making progress.

Keep fiddling. A melody is beginning to emerge!

[jonnybee]

I really appreciate the comments. I am posting another screen shot of last night's graphs which includes flow limitations.

[Pugsy]

Boy if that last report doesn't look like a REM pattern I don't know what would.

You can get a general idea of normal REM patterns on the graph here. Of course always variables but you can get a close idea. Look for the little hypnogram box on the right side, part way down.
http://en.wikipedia.org/wiki/Sleep

I suppose it is possible that during titration sleep study REM may not have been present much. Especially if meds were involved or sleep itself wasn't good. I am worse in REM. At my titration study only had 150 minutes of very fragmented sleep. Tis no wonder they came up with less than optimal prescribed pressure because I had very little REM and outside of REM barely meet OSA diagnosis when just looking at AHI.

Again, whenever or whatever they relate to, those events are unwanted and need to be killed.

Edit for an off the wall thought. Wonder if it is those events that is disrupting sleep and not the just pressure increases? Just a thought. I know there is no way to know for sure but those bad boys are surely enough to really disturb sleep.

[AMUW]

jonnybee,
I apologize if I hadn't read your long struggle preceding the context of constant CPAP.
I joined into the discussion because 2 weeks into CPAP I was having very similar clusters of OAs and CAs, happening at very regular intervals ... as a matter of fact of higher severity. Which were also noticed during my titration study, and noted in the PSG report as probably temporary, mask-induced CAs.
I thought that comparing notes could be mutually beneficial.
Beyond the duration of the clusters, here is another possible reason which makes me vote against them representing REM sleep (although REM could have been the trigger): a nightly dreamer pre-CPAP, during these days I remember no dreaming whatsoever. Dreaming returned with the clusters abating. I can even say that my degree of upper airway resistance was being reflected in those dreams being about helpless struggle.
One thing you could do in your ResScan curves: increase the time scale resolution till you can count breathing cycles per minute. Much lower count than during comfortable sleep may indicate an arousal all the way into wake state. And you may observe flow cessations shorter than 10 sec, hence no bar got drawn on the apnea counter curve.
On those nights I was having frequent flow limitations and leaks; which your curves don't show as being a problem. Not even a single instance of changing position and bumping your nasal pillows? or during manual adjustment thereof before sleep onset?
P.S. Have you played at all with your air humidifier level and temperature?

[jonnybee]

Last night's ResScan graphs. Settings: Epr OFF; Auto mode w/pressures 8-12. AHI 2.9. Observation: Better control. Clusters less severe. Pressure bumping max in an apparent effort to curtail clusters but max pressure is apparently inadequate to do the job. Some interruption of sleep due to pressure increases causing slight leaks. Plan to try same setting for a couple more nights before increasing pressure to maybe 9-13. I'll report back after a few days. Thanks to everyone who has submitted suggestions/observations/comments. They have been greatly appreciated. I think we're on the right track now and with a little more trial and error I'll be able to get these things under control.

[Slartybartfast]

Great. Everything you said makes sense. With EPR off your average pressure is higher. If that results in fewer events, AND you're bumping against the upper pressure limit, that indicates you still need more pressure, though by the brief touching of the upper limit, it looks like you're just about there. Look at the progress you've made since you first brought this up! Now is the time for fine tuning and observation.

The minute variation trace is beginning to show ragged patterns at about the right times which coincide with REM sleep. I bet if you ran your oximeter you'd find your green line has fewer dips and peaks in it. Eventually you'll be able to see the same ragged pattern on your SPO2 trace that you see on the Minute Variation trace, both indicating REM sleep. Expect to see four or five periods of REM sleep. The first shortly after you drop off to sleep, and the last just before you awaken.

You're getting there. Just need to keep tweaking the numbers and watch what happens.

Eventually, though, you have to address the question about why your lab prescribed only 5 cm. Now you know that was totally inadequate. But why was that level prescribed?

[Pugsy]

I agree with Slartybartfast. Heading in the right direction. That minimum is not quite enough. Turning off EPR eliminated the 3 cm reduction during exhale which possibly also allowed events to sneak in.

Still looks like REM to me also but again whether REM related or not, they are unwanted and need to be stopped.

If APAP pressure ranges bug you, consider 2 to 3 cm range and even using straight cpap. Some people are just plain sensitive to that pressure change. APAP doesn't always suit everyone.