UARS and Spontaneous Arousals - Can BiPap or SV help?

I have been on CPAP (APAP) for a little over a year, still with multiple awakings each night. I am an engineer and have Encore Analyzer plots for this entire year with 100% compliance, BUT I am not sure they tell the entire story. CPAP eliminates snoring and reduces apneas to a low level but does not seem to produce deep restful sleep. (No pills please). Have some COPD and even after 8 to 9 hours average sleep, I still yawn and could go take a nap!

Sleep Architecture last February had zero Stage 3 or Stage 4 sleep.
At Titrated Pressure of 7 AHI was reduced from 70 REM AHI and 10 NREM AHI to 2.6 and 0.9 respectively. (34 total apneas reduced to 0)
Spontaneous Arousal Index INCREASED from 45/hr to 52/hr

Using an apap I get decent AHI numbers that seem to have a periodical sine wave distribution to them, but still do not get good sleep. If I go back for another sleep test, is it possible that a BiPap or SV will help control these multiple awakings and allow sounder sleep?

ww

Well, have you started a controversial topic ? (yup) -- IMHO there are two answers - yes and no
Firstly I am going to deal with the topic of UARS before saying how a Bilevel or SV can help.

On the no side requires a bit of a deviation. UARS isn't just a single condition, a point SWS has been trying to get across. There is still disagreement as to if UARS is part of OSA or a seperate condition or can fit into both categories.

UARS as Flow Limitations ...
========================
Awhile back I read Dr Barry Krakow's definition of UARS as being in the OSA spectrum but above hypopneas and thus equated to a more or less constant flow limitation experienced by someone going to bed at night. He has a point but only up to a point. If the UARS is applicable to a normal OSA sufferer then yes it is a fair call to say it is the same as flow limitations. Dr Krakow runs sleep clinics and he gets to see lots of patients sent to him to have their OSA diagnosed. He made the point that many sleep clinics titrate OSA sufferers only up to the hypopnea stage & don't bother tidying up the next layer on this OSA spectrum which is flow limitations

(the spectrum is normal inspiration (nice rounded insp curve), flow limitations (some signs of flattening of the insp curve), hypopneas (flow lims that last longer than 10 secs & showing a 30% decrease in airflow & a 4% SpO2 desat - see ref [1], then apneas ).

Dr Krakow decided he should 'do the job properly' and clear the flow limitations as well so began adding a little more pressure support to his patients (setting ipap a bit higher), having experimented on himself and a colleague. He was looking for patients to return a nice rounded respiratory curve. This issue of the shape of the curve (inspiration) is important as it is evidence of healthy respiration. Any flattening of that curve is a sign of airway resistance & means that flow limitations at a bare minimum are being observed. Dr Krakow concluded from his lab observations & trials that using a bilevel and titrating epap to eliminate apneas and ipap to eliminate hypopneas then increasing ipap to eliminate flow-limitations, was the better form of titration & more effective and in relation to UARS being flow limitations in the OSA spectrum, he is probably on the mark (I think he is - even if I have concerns about that Ipap getting higher than 15/16 CMs and causing mask management problems that are worse than the RERAs (Respiratory Effort Related Arousals - arousals from flow lims), I think I'll call the mask management events MLAEs (Mask Leak Arousal Events ).

MLAEs can be as equally as bad as RERAs IF NOT WORSE ! - why ?, because they engender stress and frustration at being woken up by a squeaking leaking mask that doesn't behave as wanted. This can lead to growing anxiety and frustration if the person can't get it fixed. So much of the discussion here at cpaptalk relates to sorting out mask management issues.

Now if we look at UARS as Flow Limitations (along the lines of Dr Krakow) then a Bilevel (and IMHO an SV) should be viable (still to be fully explained in a future post )


UARS as an unrelated (to OSA) medical condition
=========================================

Then there is the situation where someone who is of normal weight, who has a normal neck structure (not prone to OSA or hereditary OSA), who experiences problems sleeping and suffers from daytime drowsiness but who does not fit into the OSA category in a sleep study (see ref[1] def of OSA). In a sleep study, they can show as having an AHI well under 5. But if their insp curve is analyzed it shows flattening. So is this a UARS flow limitation or a form of UARS unrelated to OSA ?

If the person exhibiting UARS symptoms has the condition where their internal airway vacuum is unusually high whilst trying to breath in & their heart is being stressed by the effort and their flow limitation is on its own (they don't exhibit the full OSA spectrum), then it may be fair to say they have a medical condition unrelated to OSA (this can be clearly demonstrated as fact). This is particularly so if the evidence is their upper airway resistance is not due to the classic OSA airway causes, i.e. they have a deviated septum or complications in the nasal cavity, constant nasal congestion triggered by GERD etc: etc:.

Evidence of UARS is the flattening of the insp curve and signs of inflammation in the nasal passages or airway, due to trying to breathe in air through a restricted passage (where the restriction is unrelated to classic OSA causes of obstruction). It has been described as like trying to suck air through a straw.

So, a Bilevel & SV machine may be of no benefit if it tries to force air through a restricted airway (unrelated to classic OSA obstruction). The use of xPAP devices are more than likely going to do more harm than good. So what will help those patients ?, corrective surgery may be their best option or correcting the causes of their nightly upper airway restriction if due to GERD or similar triggering conditions.

But there seem to be many patients who start off with UARS caused by some other problem, who then develop OSA as a side effect of untreated UARS. So, if there is an OSA component of their sleep, then we are back to arguing that a Bilevel (or perhaps SV machine) may be helpful.


SUMMARY
========

There is UARS & UARS, one type is really a different medical condition to OSA but the type of UARS that fits in the OSA spectrum (as classic Flow Limitations) is treatable by OSA therapy as spelled out by Dr Krakow. There is UARS that triggered OSA in a patient. Then there are going to be other forms of UARS that I haven't covered.


CONCLUSION
===========

Which type of UARS are your referring to ?

DSM





References:
==========

[1] Medicare definition of hypopnea & apnea ...
http://www.talkaboutsleep.com/sleep-dis ... nition.htm
Quote:
>>
Conclusion
CMS will revise the NCD for CPAP for the treatment of OSA (CIM 60-17) to the following: CPAP will be covered under Medicare in adult patients with OSA if either of the following criteria is met:

AHI ³ 15, or AHI ³ 5 and # 14 with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke.

The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e. the AHI may not be extrapolated or projected). Two hours of recorded sleep is consistent with current practice. Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility.
<<

2) Measuring flow limitations in UARS
http://ajrccm.atsjournals.org/cgi/conte ... 157/5/1461

ww wrote:I have been on CPAP (APAP) for a little over a year, still with multiple awakings each night. I am an engineer and have Encore Analyzer plots for this entire year with 100% compliance, BUT I am not sure they tell the entire story. CPAP eliminates snoring and reduces apneas to a low level but does not seem to produce deep restful sleep. (No pills please). Have some COPD and even after 8 to 9 hours average sleep, I still yawn and could go take a nap!

Sleep Architecture last February had zero Stage 3 or Stage 4 sleep.
At Titrated Pressure of 7 AHI was reduced from 70 REM AHI and 10 NREM AHI to 2.6 and 0.9 respectively. (34 total apneas reduced to 0)
Spontaneous Arousal Index INCREASED from 45/hr to 52/hr

Using an apap I get decent AHI numbers that seem to have a periodical sine wave distribution to them, but still do not get good sleep. If I go back for another sleep test, is it possible that a BiPap or SV will help control these multiple awakings and allow sounder sleep?

I if you're running on APAP, the first thing I'd do is try fixed pressure.

COPD can be tiring on its own - I think you may need more relief on exhale than you may be getting with your machie set at 10 (?). Do you have your pulmonologist in the loop?
O.

ww wrote:If I go back for another sleep test, is it possible that a BiPap or SV will help control these multiple awakings and allow sounder sleep?

I doubt very much that an ASV type of machine would help at all. Just my opinion. At the pressure you were titrated to, I doubt if you'd see any benefit (for ease of exhaling) from a BiPAP that you can't already get with A-Flex in your Auto with A-Flex. But if I were going to ask to try a different machine, I'd want to try a BiPAP...not an SV machine.

As ozij mentioned, it's always a good idea to try a fixed pressure. You can set the autopap to still operate in auto mode, and set the min and max pressure to the same number (like 10 cm.) Then it will treat you just like "cpap" while giving you the same events info you've been seeing in Auto mode. However, if you set it for "cpap" mode, no flow limitation data will show up. To have the machine look for flow limitations as well as the AHI, leak, and snore data, it has to be in auto mode.

I'm sure not a doctor, but in my opinion, there can be a multitude of things causing spontaneous arousals that have nothing to do with optimum "CPAP" (any kind of PAP machine) treatment. Untreated or undertreated acid reflux for one. Pain (arthritis, for example) for another. Side effects from some meds can disturb sleep.

I'd check into the possiblity of acid reflux first:
http://www.sciencedaily.com/releases/20 ... 080008.htm
"These are patients without significant heartburn symptoms, who are experiencing acid reflux during sleep," explained William C. Orr, Ph.D. of Lynn Health Science Institute in Oklahoma City, OK. "'Silent reflux' may be the cause of sleep disturbances in patients with unexplained sleep disorders."

----

"All patients with sleep apnea should be evaluated for gastroesophageal reflux," said J. Barry O'Connor, M.D., of Duke University Medical Center, one of the investigators.
__________________________________________

dsm wrote:Dr Krakow decided he should 'do the job properly' and clear the flow limitations as well so began adding a little more pressure support to his patients (setting ipap a bit higher), having experimented on himself and a colleague. He was looking for patients to return a nice rounded respiratory curve.

A little more, and setting IPAP a bit higher? When you look at Dr. Krakow's experiment on himself and on his sleep tech, Dr. K's idea of doing the job properly resulted in IPAP pressures that were considerably higher than what I'd call "a little more" and "a bit higher."

viewtopic.php?p=232163#p232163

BarryKrakowMD wrote:I wanted to try bilevel right away as did my lead sleep tech at the time, Dominic Melendrez. Using a zero tolerance attitude about flow limitation, Dom titrated me to 18/14 (which we both thought insane since I’d been using APAP of 8 to 12 and rarely 10 to 14), and I titrated Dominic to 20 over whatever. It was around 4 am, and the assigned sleep tech kept saying, “are you sure that’s flow limitation?” My response, “I’m not sure, but it’s not rounded, so keep increasing until it rounds,” which it did at IPAP of 20.

From that point forward I started using bilevel at pressures around 14/10 and fairly rapidly worked my way up to 18/10…”and loving it!” to quote the immortal secret agent Maxwell Smart. Now, I'm at 21/12.5.

Rested Gal

I need to clarify, I was meaning a little higher than already titrated to clear hypopneas. I didn't really make that point clear but did think I had spelled out the process with these words "and ipap to eliminate hypopneas then increasing ipap to eliminate flow-limitations".

I still tend to agree with you that his Ipap settings are higher than I would try to set, rounded insp curve or not.

I must say I have learned a ton from the discussions on UARS & while I believe Dr Krakow was right within the context of his sleep lab and titrating OSA patients, I fully accept the notion that there is a UARS condition that can clearly be shown to not be classic OSA and thus understand the argument that that form of UARS is a separate medical condition related to stress on the heart and an upper airway resistance caused by a variety of conditions.
One other comment one might add re Dr Krakows view of Flow Limitations & him running sleep study clinics is "If I only have a hammer to work with, then everything sticking out starts to look like a nail"

Thanks for all you have posted on the UARS topic, there has been lots of excellent stuff to work through.

Doug

Hello, ww. The SV machines are not really recommended for COPD by the manufacturers:

After a 3-minute initial collection period, the Adapt SV then sets a minute-ventilation target that is 90% of the previous minute volume. Hence there is a weak downward force on total minute-ventilation that nudges the PCO2 upward 2 or 3 millimeters of mercury, decreasing or eliminating the frequent CO2 dips below the apnea threshold that drives the central events. Because of this 90% target, the manufacturer cautions that the device should not be used in patients who have a condition that might result in hypoventilation (severe COPD, neuromuscular disorders, etcetera).

http://www.sleepdt.com/_journal/v2n44/h ... page20.asp


And we recently discussed a possible similar minute-window downward force via a sustained stepped impedance that was described by gobears regarding his own cyclic UARS presentation:
viewtopic.php?f=1&t=39643&p=349550#p348755 (additionally see quoted excerpt by Stephen E. Brown, MD, DABSM)


However, Dr. Krakow does currently have what he calls a "working theory" about using fixed BiLevel to treat UARS----by nicely rounding out the patient's inspiratory and expiratory flow curves:
search.php?keywords=bilevel+uars&terms= ... mit=Search

Also, here's a recent thread discussing Dr. Krakow's UARS views and experimental BiLevel work:
viewtopic.php?f=1&t=40009&st=0&sk=t&sd= ... 30#p350274

Additionally, both fixed BiLevel and AVAPS platforms are sometimes used for COPD patients to help with the work of breathing and other COPD ventilatory problems. But I also agree with that point mentioned by ozij about first trying to optimize pressure on your current machine.

Yes, I know it is a controversial subject, but I have spent a year trying to beat it, and trying to decide what to do next to improve my therapy is difficult. I definitely have OSA, but no one seems to be able to explain the spontaneous arousals or even say if it is UARS or whether it is treatable or not!

In the first 10 months, I did use Afrin to be able to breath, but quit that completely and haven't had many nights where congestion was not a problem since. Nose broken in Junior High School and deviated Septum is a real possibility, but there is considerable resistance to any quick breathing in through my nose! I had the procedure to fix this explained to me about 20 years ago and it didn't sound good at the time just to be able to breath a little better through your nose, but times change. I have not seen an ENT specialist, since.

Flow limitation is recorded only in auto mode and runs from as low as .1 to about 1.0 each night. It is also somewhat sinusoidal (or varies in a somewhat periodic manner).
Hypopneas also vary considerably and run from about 5 to 50 per night. Apneas run from about 1 to 25 per night. Best control seems to be in the auto mode with a minimum of 11 and a maximum of 15 cm. When run in cpap mode for several weeks at a time at 10, 10.5, and 11 cm only slightly worse data was obtained, but where something made the auto results vary over time, the same thing happened at the fixed cpap levels and results just simply got considerably worse since it could not auto adjust the pressure for these specific events.

I have seen a non-responsive apneas recorded on a couple of the worst nights for apneas. Apneas are definitely recorded by the respironics auto machine for pressures in excess of 10cm. Does this have any implications on the use of a bi-pap?

Although not a perfect correlation, periods of low variable breathing seem to coincide with some of the best results. Variable Breathing runs from about 25 to 50%, but with best results when it is down to about 15%.

I definitely have a much harder time breathing without Aflex or Cflex. My sleep doc is also a Pulmonologist, but have only seen him once in 13 months.

Yes, I hope a bi-pap would help, but I suspect it will wind up private pay, so would like to get the best feedback as to whether it will help before making that investment. A few months ago, the tank auto Respironics Bi-paps with biflex were fairly reasonably priced, but haven't seen them listed in a while. I do take Omneprozole and sleep on an adjustable bed with the head raised for acid reflux.

ww wrote:In the first 10 months, I did use Afrin to be able to breath, but quit that completely and haven't had many nights where congestion was not a problem since. Nose broken in Junior High School and deviated Septum is a real possibility, but there is considerable resistance to any quick breathing in through my nose! I had the procedure to fix this explained to me about 20 years ago and it didn't sound good at the time just to be able to breath a little better through your nose, but times change. I have not seen an ENT specialist, since.

I'd probably be inclined to get a good evaluation by an ENT before deciding what to do next.

Although I believe getting an evaluation from an ENT is in order, I have managed to survive quite well with Breath Rite Strips, nightly Sinus rinses and saline nose spray . The worst thing that seems to happen is once in a while I have to get up an hour or two early and repeat the above cycle. Is this really a major part of the issue of what therapy would be best for me?

As mentioned in the previous post, I have seen a non-responsive apnea recorded on a couple of the worst nights for apneas. Apneas are definitely recorded by the respironics auto machine for pressures in excess of 10cm. Does this have any implications on the use of a bi-pap since the lower pressure is set to eliminate apneas and the higher pressure is set to eliminate hypopneas and/or flow limitations? Since I am recording several apneas a night at 11 cm or higher pressure, does this mean a Bipap will have to be run at a considerable higher pressure to be effective?

ww wrote:Although I believe getting an evaluation from an ENT is in order, I have managed to survive quite well with Breath Rite Strips, nightly Sinus rinses and saline nose spray . The worst thing that seems to happen is once in a while I have to get up an hour or two early and repeat the above cycle. Is this really a major part of the issue of what therapy would be best for me?

It's absolutely a major part of the issue for many people IMHO.

ww wrote:I have managed to survive quite well with Breath Rite Strips, nightly Sinus rinses and saline nose spray .

Excessive nasal resistance potentially contributes to SDB etiology in two main ways: 1) by significantly heightening required Respiratory Effort (which in turn can generate Respiratory Effort Related Arousals also known as RERAs), and 2) by contributing to apneas and hypopneas via an increased transluminal pressure placed across the human airway (think Starling Resistor model; think collapsing straw; think of either a passive or active partial airway closure that is significantly worsened during inspiration by that suction type pressure).

So in essence you may have adversely-high nasal resistance, and you clearly have excessive arousals of an undetermined etiology. Might those arousals be nasal-resistance based RERAs? So I'm not so positive that you can confidently say you have survived "quite well" so far by not allowing an ENT to take a closer look at your nasal resistance problem(s). You might have developed enlarged turbinates or nasal polyps over the years, or yet other nasal resistance problem(s), in addition to that deviated septum. Excessive nasal resistance can absolutely be a PAP therapy spoiler in some cases. Just my message-board opinion there. And it's worth exactly what you paid for.

But an evaluation by a good open-minded and SDB-friendly ENT may turn out to be money very well spent. Just try to avoid the heavy-handed surgery hawks.


If it turns out that easily eliminating excessive nasal-resistance via routine surgery is plausibly what it might take to eliminate your excessive arousals, then you may very well decide to better address your nasal resistance problem(s). Your subsequent PAP settings and even platform would then conceivably be based on those surgical corrections. That's the basis of why I would personally seek a good ENT evaluation before deciding exactly what my next strategical therapeutic move might be. It's a prominent variable or factor in this particular SDB equation that requires further elucidation. Good luck however you decide to proceed!

-SWS wrote: So in essence you may have adversely-high nasal resistance, and you clearly have excessive arousals of an undetermined etiology. Might those arousals be nasal-resistance based RERAs?

Bi-level or SV will never guarantee you 'deeper' sleep.

If I had COPD, I would want a bi-level. You will need to see a sleep doc for a bi-level or SV script. Then give it a try and let us know your results.

The SV works for me because it can and does force air through a straw, and does allow me to breathe at night. In the future, I may experiment with a BiPAP Auto SV as compared to my Adapt SV to see if does do the 'deeper' sleep thing, as dsm suggests, and my early experience on AVAPS seemed to indicate.

Banned

Sir Banned wrote:The SV works for me because it can and does force air through a straw, and does allow me to breathe at night.

Well, that's really the premise of any obstructive based or targeted PAP machine: to force more air through that collapsing elastic straw or airway. Not only does the pressure-based stenting or airway dilation process itself help, but the end-to-end or transluminal pressure deltas contribute to that goal as well.

But to assume that you received your better SV results primarily because your nasal impedance was better addressed neglects all the other possible reasons why you might have received better results on SV---such as ventilation issues as suggested by the manufacturers. With that said, it's entirely plausible that your nasal resistance became better addressed along the way IMO.

If I had COPD I would personally avoid the SV and strongly consider BiLevel or even AVAPS, though.

Good to see you, Banned!

-SWS wrote: If I had COPD I would personally avoid the SV and strongly consider BiLevel or even AVAPS, though.

Ditto. And if I had copd I would not make pressure changes on any machine without talking to my doctor.

O.

-SWS wrote: I'd probably be inclined to get a good evaluation by an ENT before deciding what to do next.

I will see an ENT, although it will probably take a little time. I live in a very rural area and it is an hour and 1/2 drive to an area with that kind of specialization. I really had no idea that this could be affecting my sleep apnea therapy in such an adverse matter. Thank you SWS, Rested Gal, Ozzie, dsm, and and everyone who has responded so far!!! Wonderful that this forum exists and has so many great people participating in it.

ww wrote:I really had no idea that this could be affecting my sleep apnea therapy in such an adverse matter.

Alternately, your outstanding arousals may be even more related to excessive respiratory effort associated with your COPD. But respiratory effort is influenced by the sum total of all contributing resistance factors. RERAs can thus conceivably result from compounded breathing problems in etiology. Bear in mind that "spontaneous arousals" are essentially "mystery arousals" or "arousals of unknown origin". So there's even a chance that your spontaneous arousals have absolutely nothing to do with how much respiratory effort you must exert while trying to sleep. But in light of your multiple airway problems, excessive respiratory effort while sleeping is probably a darn good place to start wondering when it comes to those mystery arousals.

You might even find it useful to view your own Sleep Disordered Breathing problem as an onion of sorts----a problematic onion that may require a multi-layered approach. You have at least these three problematic layers contributing to your SDB etiology: 1) apnea/hypopnea, 2) COPD, and 3) excessive nasal resistance. The nasal resistance problem may turn out to be the easiest contributing layer to fix. And fixing that layer may even come in darn handy down the road, should your COPD progress.

ozij wrote:if I had copd I would not make pressure changes on any machine without talking to my doctor.

Agreed. I'd definitely want my doctors in the loop for a compounded SDB challenge like this. The pulmonologist may even decide to modify COPD management, based on that daytime somnolence or fatigue. And one of those possible management techniques may be employing BiLevel at night to help with COPD's own excessive work-of-breathing (WOB). That same BiLevel strategy can conceivably help with nasal-resistance associated WOB as well.

Again, good luck, ww! ...Please keep us posted!