Reasons for so many RERAs?

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tlewis303
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Reasons for so many RERAs?

Post by tlewis303 » Fri Sep 05, 2014 6:38 am

Anyone know what can cause so many RERAs? See below:

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tlewis303
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Re: Reasons for so many RERAs?

Post by tlewis303 » Fri Sep 05, 2014 11:20 am

anyone? Pugsy? Wulfman?

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Re: Reasons for so many RERAs?

Post by Wulfman... » Fri Sep 05, 2014 11:34 am

I'm not sure how these new machines score "RERAs" (because it's all determined by "air flow"), but looking at the report, lots of the "RERAs" line up with the Snores (VS2 markers).

I wouldn't be concerned about one night's report. Sometimes I think some of this new machine technology can have a "downside".......TOO MUCH information. It's a double-edged sword.


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Re: Reasons for so many RERAs?

Post by Pugsy » Fri Sep 05, 2014 11:36 am

We don't know what causes RERAs for sure. We are never told. I have sort of thought of them as minor flow reductions from a minor obstructive airway tissue collapse that don't meet criteria for an apnea or hyponea. We assume flow reduced due to airway tissue collapse . If I saw a lot of them and my sleep quality was poor and I wasn't feeling so great. I would treat them like I would too many snores or flow limitations...a tiny bit more pressure. I don't know if it would fix things or not. I don't know if RERAs would be something that someone with UARS would see a lot of. I suppose it's possible but not guaranteed.

We do know the official definition. We are never told how to fix them or even if they need fixing or at how many of them means they need fixing...at least I have never found out at what point do they become a potential problem. I would suspect that clinical correlation would be needed...as in how is your sleep quality and how do you feel.

Respiratory Event Related Arousal... a sequence of breaths characterized by increasing respiratory effort leading to an arousal from sleep, but which does not meet criteria for an apnea or hypopnea.”

RERA Detection in the Respironics System One data..Respiratory effort-related arousal..defined as an arousal from sleep that follows a 10 second or longer sequence of breaths that are characterized by increasing respiratory effort, but which does not meet criteria for an apenea or hypopnea. Snoring, though usually associated with this condition need not be present. The RERA algorithm monitors for a sequence of breaths that exhibit both a subtle reduction in airflow and progressive flow limitation. If this breath sequence is terminated by a sudden increase in airflow along with the absence of flow limitation, and the event does not meet the conditions for an apnea or hypopnea, a RERA is indicated.

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Re: Reasons for so many RERAs?

Post by Wulfman... » Fri Sep 05, 2014 11:51 am

Sounds like more "hair splitting", or another variation of Flow Limitations.


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Re: Reasons for so many RERAs?

Post by Pugsy » Fri Sep 05, 2014 12:00 pm

Wulfman... wrote:Sounds like more "hair splitting", or another variation of Flow Limitations.
Yes...that's pretty much what it is but the addition is the possible arousal component.
Flow limitations don't always cause arousals but they say they can tell by the flow rate if that FL maybe caused an arousal (that we may or may not remember) and since it is the arousal that messes with sleep quality itself...might be good to know if there was a potential arousal going on that might impact sleep quality.

If you think about it ...not really all that different from the slight arousals that you get in APAP mode that you don't get in cpap mode.
They mess with your sleep quality so you don't want them and that's why you prefer cpap mode.

Arousals mess with sleep quality...no matter what the cause and RERAs are just another data point where maybe arousals get flagged and thus another data point to show something that on paper might could be improved upon.
If an otherwise very minor flow reduction or limitation looks like it might be causing an arousal from sleep (RERA) doesn't meet the criteria to be a full grown up apnea or hyponea...it still could mess with a person's overall sleep quality and we always want to limit that from happening.

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Re: Reasons for so many RERAs?

Post by Wulfman... » Fri Sep 05, 2014 12:10 pm

I would say.......if you felt good when you woke up (and before you looked at the report), don't worry about em.
And, if it was only one night (or a minimal number)......then you REALLY don't worry about them.


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Re: Reasons for so many RERAs?

Post by Pugsy » Fri Sep 05, 2014 12:33 pm

Wulfman... wrote:I would say.......if you felt good when you woke up (and before you looked at the report), don't worry about em.
And, if it was only one night (or a minimal number)......then you REALLY don't worry about them.
Yep, I agree. This is where the clinical correlation part comes into play.
On paper there's not enough of them for an alarm but if someone is feeling crappy...the RERAs and the snores MIGHT (stress the might part) be something that COULD (stress the could) be a factor in minor arousals that might be impacting sleep quality.

IF I saw this night after night and felt crappy I might want to see if I could reduce them a bit on the off chance it might help how I felt because it sure wouldn't hurt to try.

IF I saw this only occasionally I wouldn't do anything. I never worry about anything unless I see it consistently. Fluke nights I shrug off.

If I was sleeping great and feeling great I don't go worrying about little stuff like this on the reports. One of my best days (early in my therapy) in terms of how I felt was after one of my worst night's reports. On paper I should have felt like crap but I felt really good that day. That was back when I never looked at my reports until evening so wouldn't create a self fulfilling prophecy and give myself a crappy day because the numbers were crappy.

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Re: Reasons for so many RERAs?

Post by tlewis303 » Fri Sep 05, 2014 12:52 pm

Well I didn't feel good today versus the last couple of days and that was before I looked at the data.
I'm going to set my pressure to 8 per dr advice and set ramp back to 4. Stick with this for a bit.
Making too many changes at a time can be bad for sure. I have felt better running at 8 now for the last 2 weeks for the most part.
I've been on 6 for a year prior. Thats the problem with this data is its hard to see patterns, I go by how I feel on a constant level first.

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Re: Reasons for so many RERAs?

Post by Machinehead » Wed Mar 18, 2015 7:07 pm

I believe that RERAS are MORE disruptive than OSA. The problem with OSA people is that they usually maintain sleep. The defining characteristic of a RERA, is that there is always an arousal at the end of it. The majority of pts I see are Medicare, COPD. Its very Common to have an AHI of 5 and an RDI of 20-40. Its not a simple fix either. OSA, even at AHI's of 100+, pop the airway open, pt is fine. RERAS are much more difficult. You have to stabilize the airway, then open it a little. They usually require a much higher pressure. Just my opinion.

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Re: Reasons for so many RERAs?

Post by tan » Wed Mar 18, 2015 9:37 pm

Machinehead wrote:I believe that RERAS are MORE disruptive than OSA. The problem with OSA people is that they usually maintain sleep. The defining characteristic of a RERA, is that there is always an arousal at the end of it. The majority of pts I see are Medicare, COPD. Its very Common to have an AHI of 5 and an RDI of 20-40. Its not a simple fix either. OSA, even at AHI's of 100+, pop the airway open, pt is fine. RERAS are much more difficult. You have to stabilize the airway, then open it a little. They usually require a much higher pressure. Just my opinion.
Is there any correlation between Flow limitation chart and RERA for such patients?

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Re: Reasons for so many RERAs?

Post by Morbius » Thu Mar 19, 2015 4:15 am

Machinehead wrote:I believe that RERAS are MORE disruptive than OSA. The problem with OSA people is that they usually maintain sleep. The defining characteristic of a RERA, is that there is always an arousal at the end of it. The majority of pts I see are Medicare, COPD. Its very Common to have an AHI of 5 and an RDI of 20-40. Its not a simple fix either. OSA, even at AHI's of 100+, pop the airway open, pt is fine. RERAS are much more difficult. You have to stabilize the airway, then open it a little. They usually require a much higher pressure. Just my opinion.
Well, I'm going to disagree with just about everything there. My generalizations are:
  • OSA is more disruptive than UARS (low AHI/high RDI);
  • OSA people do not maintain their sleep;
  • COPD (moderate to severe anyway) have hypoventilation episodes and not UARS characteristics ("Overlappers");
  • The fix for RERAs is not aggressive pressure attack ("The Krakow Kool-Aid"); and most importantly
  • While the defining characteristic of a RERA is that there is always an arousal at the end of it, one wonders if scorers and reviewers are really checking to see if that is the case.
See http://jap.physiology.org/content/116/3/302 discussing the role of the arousal.

In the case of FL, are you seeing some benign flow limitation, an arousal somewhere near there, and going "AHA! There's a RERA!", try to hammer it to death with pressure, and then conclude that when the patient finally gets to consistent sleep (passes out, really) at 57 cmH2O that high pressure is the key?

Or have you found a poor sleeper with a little nose, and now made sleep even harder?

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Re: Reasons for so many RERAs?

Post by Morbius » Thu Mar 19, 2015 4:23 am

tlewis303 wrote:Anyone know what can cause so many RERAs? See below:
Yeah I do, but 17 is not a lot of RERAs.

Besides, "by definition" they need to be > 10 seconds, so that gets rid of 5 of them, and in the case of those long "RERAs", one wonders if that is simply benign FL interrupted by spontaneous arousal.

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Re: Reasons for so many RERAs?

Post by Morbius » Thu Mar 19, 2015 4:28 am

Morbius wrote:Well, I'm going to disagree with just about everything there. My generalizations are:
So if my generalizations are correct, what you really want to do is control arousal threshold, and not try to engineer breathing waveforms.

And the easiest way to do that, of course, is DRUGS!!

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Re: Reasons for so many RERAs?

Post by Morbius » Thu Mar 19, 2015 4:30 am