Confused! No good CPAP pressure for RERA's!

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gobears
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Confused! No good CPAP pressure for RERA's!

Post by gobears » Wed Jul 23, 2014 1:07 pm

Hi All,

I am really confused and need help about how to treat RERA's.

First, some useful facts:
  • I have been battling sleep apnea for several years now.
    My AHI is always very low, but my RDI is very high (like 20-40). So, my arousals are caused by RERA's.
    My sleep studies have been done at Stanford sleep clinic
    I have had 2 nose/turbinate surgeries, and tongue suspension surgery, and one soft palate surgery. The surgeries reduced my RDI from 40's to 20's.
    At my last titration study at Stanford, pressures between 4 and 9 had high RDI, 10 was pretty low, and 11-15 had high RDI.
    The doctor felt the pressure at 10 was not a reliable result given the other numbers, and feels we need to keep titrating up. Another doctor at another clinic said put it on APAP and set the pressure at 4.
    I have nevertheless stayed at 10 and feel reasonably ok there, but I also feel it is far from optimal.
    I chose 10 based on the results, and some formulas that predict your pressure based on weight, neck size, etc...
Does anybody else have this bizarre set of circumstances (super low AHI, high RDI, and no good pressure during titration)?

Lately, I have been playing with various pressures and looking at sleepy head.
Regardless of pressure, I show almost no apneas or hypopneas.
Snore, leak, etc... are all very low.
So, what could I be looking for in the sleepy head reports to improve my condition?

Would a zeo help? I think zeo will only catch arousals that result in being awake for more than 3 minutes, which I feel would be useless.

Sorry for the long post, you never know what info is useful. Hope somebody can help!

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archangle
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Re: Confused! No good CPAP pressure for RERA's!

Post by archangle » Wed Jul 23, 2014 2:16 pm

Do you think your airflow problem is in the nose? Maybe an oral mask or a full face mask would help if you can breathe better through your mouth.

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Re: Confused! No good CPAP pressure for RERA's!

Post by Guest » Wed Jul 23, 2014 2:51 pm

My nose does not have great airflow, that is true.
But I am not a good mouth breather, I don't like the feel.

I once tried a full face mask but I had so many leaks.
I change position, and sleep on my side, and so far, only the Activa mask has worked for me.

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gobears
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Re: Confused! No good CPAP pressure for RERA's!

Post by gobears » Mon Jul 28, 2014 6:03 pm

Anybody else have suggestions / comments?
I am surprised nobody has experienced this problem before.

ITs basically a battle between smoother breathing by higher pressure versus creating higher numbers of arousals due to a nervous system that is a little more sensitive and easily stimulated by higher pressures.

Without an EEG, I simply cannot know which pressure is best, right?
Or, is there a strong correlation with "events" in sleepyhead?

I have been experimenting with different pressures, and have tried changing the criteria for an event.
I shortened the time & thresholds down to <3sec and then there are many more "events".
These events are user defined and are not same as a hypopnea, but I have noticed 7-8 is optimal (about 35 events per night) versus 4 & 10 which are in the range of 70-90.

However, I have heard that a 3 second pause of breathing may not be a good measure of a rera?
Maybe it should be a non-rounded shape of the breathing?

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Re: Confused! No good CPAP pressure for RERA's!

Post by Guest » Wed Aug 20, 2014 4:23 pm

I am kind of surprised nobody is interested in this topic.
Have I violated the board's principles or need to ask in a different way?

My situation is simply:
(1) I have many arousals but almost not apnea / hypopneas.
(2) Then, what do I look for in sleepyhead to identify patterns of breathing that are likely arousals?

Hope somebody can please help.

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justinjustin
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Re: Confused! No good CPAP pressure for RERA's!

Post by justinjustin » Wed Aug 20, 2014 7:20 pm

Guest wrote:I am kind of surprised nobody is interested in this topic.
Have I violated the board's principles or need to ask in a different way?

My situation is simply:
(1) I have many arousals but almost not apnea / hypopneas.
(2) Then, what do I look for in sleepyhead to identify patterns of breathing that are likely arousals?

Hope somebody can please help.

Non-rounded breathing. It looks like little sawtooth or jagged cutoffs at the peak of the flow curve. This is UARS.

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archangle
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Re: Confused! No good CPAP pressure for RERA's!

Post by archangle » Thu Aug 21, 2014 12:14 am

Unfortunately, I'm not sure even the professionals have a good handle on RERA's, other than trial and error of CPAP pressures.

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Re: Confused! No good CPAP pressure for RERA's!

Post by zoocrewphoto » Thu Aug 21, 2014 2:46 am

I am not familiar with RERAs as I only had a few compared to tons of obstructive events.

One thing I noticed is that the doctor who suggested using the auto mode on teh machine set it to start at 4. That is probably too low considering that they felt you needed a pressure of 10 before. . If you are going to try auto for awhile, try it closer to your straight pressure. So, maybe a minimum of 8 or 9 and then see if it wants to go higher than 10 on its own.

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Re: Confused! No good CPAP pressure for RERA's!

Post by Paralel » Thu Aug 21, 2014 11:37 am

How do you know you are having RERAs? If you are getting this data from a Respironics machine, I'd be suspicious. I'm not convinced of the accuracy of their RERA algorithm.

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Re: Confused! No good CPAP pressure for RERA's!

Post by Pugsy » Thu Aug 21, 2014 11:58 am

Paralel wrote:'m not convinced of the accuracy of their RERA algorithm.
It's probably fairly accurate in terms of what it sensing in the breathing. The latest AirSense Resmed machines just released now say they can flag RERAs also. So I would imagine it's fairly accurate. Now as to just how important they are in the grand scheme of things...I suppose that is up for debate as is what do we need to do about them....and if we need to do something about them at what point are they problematic?

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Re: Confused! No good CPAP pressure for RERA's!

Post by Jay Aitchsee » Thu Aug 21, 2014 2:28 pm

Guest wrote:I am kind of surprised nobody is interested in this topic.
Have I violated the board's principles or need to ask in a different way?
Would a zeo help? I think zeo will only catch arousals that result in being awake for more than 3 minutes, which I feel would be useless.
Part of the problem probably is that ResMed machines (until the latest release) don't score RERA's, so many members would have no experience in resolving them. On the other hand, I have followed several conversations on this forum about RERA's and, in my opinion, non have been definitive as to treatment. Some, I think, believe successful treatment requires a more advanced machine such as a bipap or vpap, but I can't say that this has been proven.

Additionally, fragmented sleep could have other causes, environmental or physiological, such as noise or pain. Once apneas have been corrected, if one is still not sleeping well, it becomes much more difficult to determine the cause and requires ruling a number of things out one at a time starting with good sleep hygiene, meds, etc.

A search for RERA brings up over 1600 matches and 110 pages, so there has been quite a bit of discussion in the past. viewtopic/p931749/search.php?keywords=rera Maybe something from these posts could be helpful to you.

Zeo will score awakenings with a resolution as short as 30 sec and can be displayed with the appropriate model and software. See viewtopic/p931749/viewtopic.php?f=1&t=9 ... 47#p915640 but Zeo has some difficulty distinguishing between wake and REM so it may not help.

Here's a fairly recent discussion about RERA with some interesting comments. viewtopic/t100075/viewtopic.php?f=1&t=9 ... rt+arousal

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gobears
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Re: Confused! No good CPAP pressure for RERA's!

Post by gobears » Wed Sep 03, 2014 3:25 pm

Thanks for the responses!

How do I know that I have RERA's?
All of my sleep studies (several of them) show very low AHI (< 5), yet very high RDI (as high as 35).
My last titration at Stanford tried pressures from 6 to 15, and only 10 was good (which seems like an anomaly).
At all other pressures, despite essentially no apenas/hyponeas all night, I still had RDI > 10.

To my understanding, there are 2 types of arousals that are not apnea/hyponea, both of which are "clear airway" events:
(1) Flow Limitation = Non-rounded shape of breathe.
(2) Increasing/decreasing amplitude showing increased or changing effort.

However, it is very hard to distinguish from sleepy head data.
I did notice one thing: I have many events every night where I stop breathing for about 3 seconds. Its usually preceded by some changes in breathing pattern.
I defined my own events in sleepy head to flag these, and sure enough, I get between 30 and 100 per night.
Maybe that is what I should target?

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Re: Confused! No good CPAP pressure for RERA's!

Post by Nick Danger » Wed Sep 03, 2014 3:29 pm

Paralel wrote:How do you know you are having RERAs? If you are getting this data from a Respironics machine, I'd be suspicious. I'm not convinced of the accuracy of their RERA algorithm.
His titration study at the sleep clinic showed significant RERAs. I suspect the Respironics is accurately sensing the same thing they found at the sleep study.

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Re: Confused! No good CPAP pressure for RERA's!

Post by palerider » Wed Sep 03, 2014 3:30 pm

gobears wrote:To my understanding, there are 2 types of arousals that are not apnea/hyponea, both of which are "clear airway" events:
(1) Flow Limitation = Non-rounded shape of breathe.
flow limitations aren't clear airway, they're caused by a partial collapse of the airway and resultant difficulty inhaling.

if the airway were actually clear, then there's be no limitation... they're not completely blocked, but they're not clear either

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Re: Confused! No good CPAP pressure for RERA's!

Post by tiredintenn » Wed Sep 03, 2014 3:50 pm

I'm in the same boat as you. Multiple titrations. No pressure that alleviated reras. pap causes more arousals. I have tried cpap, apap and now ASV. also, mouthpieces made by dentists. None have worked. Sorry, not much help. I do not think sleep medicine has caught up to treating uars, maybe they dont care since there isnt money in it (ie no insurance coverage for treating uars / reras). sleep doctors think we are a one size fits all and if you dont fit in that category well good luck. most on here will just tell you to check your data and keep trying pap. maybe they are right. maybe it takes years for it to be effective. i personally think pap is a waste of time if it is more disruptive to your sleep than the reras. since with uars you have no desats it is no more dangerous to your health that waking up all the time. so if pap is creating arousals, what's the difference. Also, based on the research i have done, surgery is probably a waste of time and money and will likely create more problems than solutions. lose weight, exercise, eat healthy and hope they find a better treatment option for uars.

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