RERA and BiPAP

While I'm having a much better sleep using APAP I feel it could be better. Recently I've been waking up half way through the night feeling a little oxygen deprived. A break helps, I go back to sleep with my mask on and get up when the alarm goes off. While I don't feel like I used to before PAP therapy I know I could feel better.

Looking at my SH charts, the dominant factor is the RERA. Rarely does it go below 2.0 and it always fills up over 50% of the SH pie chart. If I can knock this down then I just know my sleep will be better. My AHI numbers are low, frequently in the minus ones but this is not everything if I've got an RERA issue.

Research has suggests that RERA and UARS could be linked. If this is the case and I do have UARS then would bilevel help?

Understand what the pie chart will show....if you have just one of anything the whole pie will be that anything and means nothing.
Half of the pie being RERA doesn't mean much..all it means is half your events were RERAs and that could be half of a total of 3 or 30.
Big difference between 3 and 30 in terms of how critical things are.

What is important is the overall total number and the average per hour number and maybe if there is any clustering going on.

The reason I'm asking the question is that my sleep is not as good as it was a few weeks ago. The RERAs do dominate the graph and a few nights ago there was indeed some clustering of events when I had an RERA count of over 5.

What is more puzzling is that my periodic breathing rate has definitely risen with quite a few nights of over 5%. Last night, for example my PB was 5.19% yet consisted of only nine events. One of those lasted for over 7 minutes. My AHI was 2.37. RERA was under 2 but I felt somewhat fatigued today. I'd download the SH graphs but now that I'm on a Mac I'm not sure how to do this. Maybe what I've posted below will work. I'd appreciate any feedback

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The image didn't work. Read these 3 pages. When you get to the bottom click on the next one. Posting is the same on a MAC as any PC. https://sleep.tnet.com/resources/sleepyhead/shorganize

To me the RERAs are more of a symptom of poor sleep and not necessarily the cause of poor sleep.
Now figuring out the cause of the poor sleep isn't always so easy to do.

Periodic Breathing can also be a symptom of poor sleep and awake/semi awake breathing irregularities could be flagged as PB. Do you have many events of any sort flagged during your time that is flagged as PB?
Any chance some of that PB time is awake time?

The usual remedy to try first for RERAs that are more numerous than we like to see and/or poor sleep quality in general when using apap mode is to try more minimum pressure in an effort to better hold the airway open and prevent the potential airway collapses that could be disturbing the sleep but maybe not growing up enough to earn some sort of apnea flag.

RERAs show that the breathing has been disturbed and the breathing pattern looks like breathing that is associated with arousals from some sort of respiratory event. It doesn't/can't tell us what caused the breathing disturbance. It's more of an alert that your respiratory pattern looks like it might have been changed somewhat and it looks like breathing patterns associated with some sort of respiratory event.
So we don't know with 100% certainty what happened but we do know that we don't feel so great...or that our sleep quality isn't so great....so we try to reduce the RERAs in hopes that whatever is causing the RERA flagging gets reduced and that we sleep better.
The only problem is that sometimes other things affect our sleep quality and our breathing pattern and if those things are unrelated to sleep apnea....changing the pressures and/or reducing RERAs may not give us the desired results.

As far as the PB...is it alarming?? Sort of depends on what it looks like when zoomed in up close and were there any apnea events happening at the same time and of course is it awake/semi awake breathing getting flagged.

Periodic Breathing ....check with your doctor if it bugs a person a lot. That's the best person to evaluate PB.

If it looks like this most of the time it's usually meaningless.



If it looks like this then bring it to your doctor's attention if you are seeing very much of it.

Holden4th wrote:While I'm having a much better sleep using APAP I feel it could be better. Recently I've been waking up half way through the night feeling a little oxygen deprived. A break helps, I go back to sleep with my mask on and get up when the alarm goes off. While I don't feel like I used to before PAP therapy I know I could feel better.

Looking at my SH charts, the dominant factor is the RERA. Rarely does it go below 2.0 and it always fills up over 50% of the SH pie chart. If I can knock this down then I just know my sleep will be better. My AHI numbers are low, frequently in the minus ones but this is not everything if I've got an RERA issue.

Research has suggests that RERA and UARS could be linked. If this is the case and I do have UARS then would bilevel help?

This is a rather complicated issue and I'd only comment because I feel my experience may be relevant and, thus, helpful. First, I will state what those abbreviations mean to me, because this is not an exact science and people could have different interpretations of what those mean. RERA: Respiratory Effort-Related Arousals, a disruption in the sleep process taking the person to a level of sleep closer to the awake state (doesn't have to be completely awake), caused by an abnormally elevated effort to inhale (usually, because of a throttling effect in the upper airways). UARS: Upper Airway Resistance Syndrome, a condition or disorder (not a disease) usually caused by an excessive incidence of RERA. Those are related but not the same thing.

I don't know what exactly SleepyHead reports but it cannot be very accurate because in order to be able to reliably detect RERA you need access to signals that are not available to a CPAP machine. Typically, that is a strain-gauge-equipped belt worn around the chest, which records the expansion of the rib cage, and then the software can correlate that to the airflow generated in response. To simplify, if the rib cage expansion exceeds an established baseline of airflow, then the person is making an effort to breathe that exceeds the effective result, i.e., the amount of air inhaled.

What SH may be reporting is probably derived from secondary factors, mostly by way of excluding other reasons for a decreased airflow. Probably the most relevant conclusion form that is that there are no other, standard, factors affecting the sleep, thus leading to a conclusion that either the sleep was good enough or that the reason for the bad sleep was not detected. In either way, consistently not getting enough air (as opposed to occasionally none at all, when the airway is completely blocked) is a situation that occurs often enough to be suspected and it definitely is a reason for poor sleep quality. During my last sleep study I did not have a single obstructional apnea or hypopnea event but I had a ton of RERAs recorded, along with many central apneas (I should note that the conditions for the study were unusual). The data from my machine consistently shows a negligible AHI, and I suspect most, if not all, of those are caused by me "resting". I do have a deviated septum and a bone spur that limit my airflow. While my CPAP machine seems to be taking care of my OSA (collapsing soft tissue) admirably well, my sleep is far from perfect. And I see an excellent correlation between the quality of my sleep and the condition of my airways (e.g., swelling of nose lining). But, although I only spent a week or so (the first week of my life on CPAP) on a constant CPAP, before I was given a bi-level CPAP machine, I have reason to believe that the bi-level is crucial to my ability to maintain a very decent overall quality of sleep. Contributing to that belief is not only that first week but also my experience when replacing that first bi-level machine in December of 2010 (multiple posts about it here, like this one: viewtopic/t115469/viewtopic.php?f=1&t=5 ... 91#p549991). In short, I was unable to make the Respironics System One work for me but then the replacement ResMed S8 worked perfectly. I explained that, too, in some posts of that time period. The difference was the settings that the latter had, and which the former lacked, that allowed me to customize the machine to assist with my breathing, mitigating the effects of my restricted airways. In short, I've configured it to respond to the lightest effort to breathe with an abrupt jolt of high pressure, to overcome the high resistance in my upper airways, to hold that pressure for a minimum amount of time, and then to drop the pressure to a much lower level to allow for the reverse process to occur (and to avoid aerophagia). In other words, in order for the airflow behind the "regulator valve" of my narrow airways to be as most people have it, the machine has to compensate by operating differently. A constant CPAP, obviously, cannot do that, and even some bi-level machines cannot.

In conclusion, I believe that upper-airway resistance can be - and is for me and many other people - a serious (and common) cause for sleep apnea, and that a CPAP machine with extensive capabilities for adjustment of its response and air delivery has the ability to help considerably a person with such issues, as long as it is configured accordingly.

McSleepy

SleepyHead (or Encore) can only report what the machine reports.
RERAs are flagged by the machine...not SH...SH doesn't do the flagging or analyzing.
The flagging is done by the machine according to the definition of RERA per Respironics

RERA

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.

McSleepy wrote:I don't know what exactly SleepyHead reports but it cannot be very accurate because in order to be able to reliably detect RERA you need access to signals that are not available to a CPAP machine. Typically, that is a strain-gauge-equipped belt worn around the chest, which records the expansion of the rib cage, and then the software can correlate that to the airflow generated in response. To simplify, if the rib cage expansion exceeds an established baseline of airflow, then the person is making an effort to breathe that exceeds the effective result, i.e., the amount of air inhaled.McSleepy

SleepyHead only reports data that the machine is recording. The ResMed 10 series states they are flow based events.

Respiratory Effort Related Arousals (RERA) reporting
RERAs are periods of increased respiratory effort leading to an arousal. These flow-based RERA events are logged and stored as summary and/or detailed data and can then be viewed in AirView™, ResMed’s cloud-based patient management system.

RERA reporting is available on the AirSense 10 AutoSet for Her in all modes.

McSleepy wrote: In conclusion, I believe that upper-airway resistance can be - and is for me and many other people - a serious (and common) cause for sleep apnea, and that a CPAP machine with extensive capabilities for adjustment of its response and air delivery has the ability to help considerably a person with such issues, as long as it is configured accordingly.

McSleepy

Typically, the airway of a person with UARS is already restricted or reduced in size, and this natural relaxation reduces the airway further. Therefore, breathing becomes labored. It can be likened to breathing through a straw.

As I mentioned in earlier in the thread, this is sometimes how I wake up feeling during the night, like I'm starved of air.

Based on Pugsy's suggestion I have upped my minimum pressure (to 12.5). I got this figure from my titration study and I also had a look at my 95% readings which are just a bit above this. I gone to 12.5 previously and going back to look at the graphs it may have been helpful. I have not seen the SH graphs for this yet.

I'll try this for a couple of weeks and see what happens.