RERAs -- OSA, central, unknown? Weird new breathing issue.

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Sibbs
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RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sat Jul 04, 2015 6:23 am

Hi all -- Happy 4th!

Help me to troubleshoot some new sleep events?

Background-- started CPAP therapy about 9 months ago after sleep study demonstrated OSA. Use everynight and my average AHI is in the 4-5 range with an occasional mid 6. Down from 15. Has helped immensely.

Have recently had a new phenomenon pop up. During the first hour of going to sleep have the feeling that I can't breathe; wake up suddenly with the feeling like I'd forgotten to breathe. Repeats several times during this first hour and wakes me up repeatedly. Scary feeling. After the first hour, I sleep fine for the rest of the night. Sleepyhead sometimes shows a higher than usual AHI (6-7) sometimes not. Last night, a particularly bad night, I noticed that I had 16 RERAs and 7 clear airway events over about an 1:15 period at the beginning of the night. Few elsewhere in the night.

Can someone explain RERA's in this context? I've done some looking here and on Google and can't quite tease out whether they're central events, OSA, or unknown. I'll try to get some sleepyhead graphs up later, but I don't see anything odd... other than that they're there.

I suspect there's a link to a new pain medication my doctor had me start at roughly the same time, but want to understand what the data themselves represent before thinking that through.

thanks as always!
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Julie
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Julie » Sat Jul 04, 2015 6:44 am

What's the name of the new med?

Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sat Jul 04, 2015 7:48 am

It's nucynta. I have a genetic connective tissue disease and this is our latest effort to deal with the nerve pain it produces. I know there's a link between these types of meds and OSA.

Just trying to figure out if my machine is signaling OSA or central events via the RERAs.

If OSA I'm less concerned, just more tinkering with settings. Central concerns me more.
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Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sat Jul 04, 2015 7:56 am

And here's my machine's definition:

"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."

Sounds to me like obstruction related, not central, but open to thoughts on what might be going on. It's the sensation of OMG, I forgot to breathe that is disturbing me, but maybe I'm being woken and just can't sense the obstruction that cleared.
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ChicagoGranny
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by ChicagoGranny » Sat Jul 04, 2015 8:25 am

Sibbs wrote:I suspect there's a link to a new pain medication (Nucynta) my doctor had me start at roughly the same time ...
You may have hit the nail on the head:
Nucynta (tapentadol) is an opioid pain medication ... can slow or stop your breathing, especially when you start using this medicine or whenever your dose is changed.
Sibbs wrote:I'll try to get some sleepyhead graphs up
Yes, do that and let's talk about your pressure settings. They may need to be increased while you are taking the drug. As you may know, there are some experts here who can interpret and advise.

For help taking appropriate screen shots of SH, see - viewtopic.php?f=1&t=88983&start=0

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Julie
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Julie » Sat Jul 04, 2015 8:43 am

It's a little strange that the list of side FX for Nucynta are grouped by 'less common' and 'rare', but only 3 (gastric) by 'more common'. And there are of course so many in all, but I wonder if you're not having silent GERD that arouses, but doesn't awaken you - it's common in OSA in any case, and a strong medication with gastric effects could be making it worse. Could you sleep if the head of your bed was up on 5" blocks - it often helps with GERD. Or possibly your MD could prescribe something to counteract the effects of the drug. I can't comment on RERA's as I'm not very familiar with them.

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Sheffey
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sheffey » Sat Jul 04, 2015 8:55 am

I doubt that GERD is the problem, but just in case, here are the symptoms:
A burning sensation in your chest (heartburn), sometimes spreading to your throat, along with a sour taste in your mouth
Chest pain
Difficulty swallowing (dysphagia)
Dry cough
Hoarseness or sore throat
Regurgitation of food or sour liquid (acid reflux)
Sensation of a lump in your throat
Dry throat
For me the only symptom was dry throat. When doing public speaking, I always made sure water was at hand and I had to take a sip every 10 minutes or so.

I would bet this is the problem:
ChicagoGranny wrote:Sibbs wrote:
I suspect there's a link to a new pain medication (Nucynta) my doctor had me start at roughly the same time ...


You may have hit the nail on the head:

Nucynta (tapentadol) is an opioid pain medication ... can slow or stop your breathing, especially when you start using this medicine or whenever your dose is changed.
Opiods are known to cause muscle relaxation and when the muscles in your airway relax more, you are more likely to have breathing events while sleeping.
Sheffey

Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sat Jul 04, 2015 9:25 am

Yes, many possible side effects and a relationship between various opioids and sleep apnea-- well established in the research literature.

Which is why I'm first trying to figure out what exactly the data on RERAs I'm getting means. I think it's important to do that before trying to figure out the causal connection. So, who can help w info on whether RERAs can signal central apnea at work vs obstructional.

Sleepyhead pic with early section of night selected below: Image
Last edited by Sibbs on Sun Jul 05, 2015 7:50 am, edited 1 time in total.
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DeepFriedDuck
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by DeepFriedDuck » Sat Jul 04, 2015 10:36 am

Sibbs wrote:Sleepyhead pic with early section of night selected here:
Too difficult to read.

Here are instructions on format charts for posting - https://sleep.tnet.com/resources/sleepyhead/shorganize

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Pugsy
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Pugsy » Sat Jul 04, 2015 10:53 am

Sibbs wrote: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,
Given the definition and what the machine looks for in flagging RERA I would lean towards the obstructive side of things because with centrals there isn't much of an effort (if any effort at all).
I think I would still treat them like obstructive wannabes which means a little more baseline pressure if I was seeing them every night. Random short lived clustering.....I don't know I would do much of anything unless I was seeing it every night and a strong pattern seemed to be developing.
If they are central in nature then they shouldn't respond to more baseline pressure.

While opioid meds can suppress the respiratory drive, they can also simply make the airway tissues a little more floppy and thus needing a little more pressure to get the job done.

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Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sat Jul 04, 2015 11:05 am

Thanks Pugsy, that's how I was reading it as well. Will up the baseline pressure a little and experiment.

What had me a little freaked out was this feeling of shallow / stopped breathing when half-awake and not feeling any obstruction. But maybe I just wasn't fully aware.

DeepFried: I've done the usual screenshot-- did the image zoom features not work for you or were there other issues? I thought this would be a better option than the giant in-thread images, but maybe something looks different on your end than mine.
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DeepFriedDuck
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by DeepFriedDuck » Sat Jul 04, 2015 12:21 pm

Sibbs wrote:did the image zoom features
The image did not display properly in Chrome or Firefox.

Oh well, sounds like you are progressing anyway. I agree to raise the pressure and see what happens.

Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Sun Jul 05, 2015 7:49 am

After last night I'm a little less sure about it being a mechanical issue with my tissues (ha, pun!) vs. central. Raised my baseline from 8.0 to 9.5.

See my info below-- used a big direct thumbnail pic this time. If you'd like to see other data let me know. thanks folks, this isn't a pleasant experience, for sure.

Image
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musculus
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by musculus » Sun Jul 05, 2015 5:41 pm

Sibbs wrote:After last night I'm a little less sure about it being a mechanical issue with my tissues (ha, pun!) vs. central. Raised my baseline from 8.0 to 9.5.

See my info below-- used a big direct thumbnail pic this time. If you'd like to see other data let me know. thanks folks, this isn't a pleasant experience, for sure.

Image
Maybe put the data in a shared folder or zoom in to show a typical RERA event in detail.

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Sibbs
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Re: RERAs -- OSA, central, unknown? Weird new breathing issue.

Post by Sibbs » Mon Jul 06, 2015 6:42 am

musculus wrote:Maybe put the data in a shared folder or zoom in to show a typical RERA event in detail.
Great idea. I've put the 2nd night's data in my public shared dropbox folder here: https://dl.dropboxusercontent.com/u/177 ... 000345.zip.

Thanks to you and others for taking a look. Happy to add more data if it would be helpful.
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