Treating hypopneas, and only hypopneas

Good morning!

I finally got a copy of my sleep studies (I've been on xPAP since '09), and was surprised to note that in the first one I had lots of hypopneas with desats, no centrals and 2 obstructive apneas during the whole night study (7.2 hours). At my titration, I had no obstuctives and 7 centrals, also with lots of hypopneas and desats during the hypopneas.. But my conclusion (I am not a professional) is that my problem is not apneas, but only hypopneas. Both studies show arousals throughout the study periods.

Anyway I was put on a bilevel machine set at 16/10. Unfortunately, the tech forgot to turn off the "auto" feature, which I only learned this week, so I've actually been on a titration schedule all this time. And I still don't feel rested or any better than I did before I began treatment.

So -- what is the treatment for hypopneas only? They seem to have been ignored in my titration, which reduced the few obstructives only to create a few centrals.

And what are PLMS? The ones with arousals coincide with the arousals shown higher on the chart, but most were without arousals. I don't know what that means.

Thanks for any explanations or suggestions you may have to offer.

The short answer: You treat an excessive number of hypopneas the same way you treat an excessive number of apneas: by xPAP of some sort. And "excessive number" is defined the same way: A total AHI > 5 indicates mild OSA, AHI > 15 is moderate OSA, and AHI > 30 is severe even if the AI by itself is 0 or close to 0.

And note that in some of the literature, the acronym OSA is being replaced by OSAH in order stress that hypopneas by themselves are a problem. (See http://emedicine.medscape.com/article/302773-overview for example).

As for hypopneas showing up on the titration study: Because the tech changes the pressure levels in response to events, there will be hyponeas and apneas in the titration study. The idea, however, is that the pressure level chosen for the prescription should reduce or eliminate the apneas and hypopneas. Usually the AHI is broken down to AHI for each pressure level tried during the titration. Look carefully at your sleep report. Can you find the AHI for 16/10? It should be as low or lower than the AHI for other pressure settings.

You say that your BiPAP has been running in Auto the whole time you've had it. Can you figure out how to determine your 90% pressure settings for the last 7 and 30 days? [It should be on one of the LCD's menus, I think.] And compare that to your titrated pressure. And while you are at it, can you determine the 7 and 30 day averages for the AHI (also should be on one of the machine's LCD menus). That's a start in trying to figure out why you are still not feeling any better. Getting the software and card reader for the machine will give you much more data and much more insight into why you are not feeling any better and what to try to make BiPAP work better for you.

Thank you, Robysue, for your helpful reply. I will look into the data you suggest. I do have the card and reader for my system, but the software doesn't work on my Linux computer, so I have an old Windows XP laptop that I use for that. Right now the XP computer is in the shop for repair. I hope to get that back next week, so I can look at the more recent data.

for an explanation about PLM's see kteague

robysue wrote:
And note that in some of the literature, the acronym OSA is being replaced by OSAH in order stress that hypopneas by themselves are a problem. (See http://emedicine.medscape.com/article/302773-overview for example).

Since the Obstructive A and the Hypopneas are combined in the AHI, doesn't it mean that each has a similar medical treatment?

However, this: At my titration, I had no obstructive and 7 centrals, also with lots of hypopneas and desats during the hypopneas.. But my conclusion (I am not a professional) is that my problem is not apneas, but only hypopneas. Both studies show arousals throughout the study periods, might tilt the treatment toward Central Apnea.

The true fact is that all of us are really guessing about Hypopneas, while knowing nothing about it. We don't even know if during PSGs any clinics distinguish between obstructive and central hypopnea. But judging from posters in this forum a hi rate of hypopneas indicates a probabilty of CSAS or Complex Apnea Syndrome.

avi123 wrote:p.s. Don't we need Pugsy to explain it?

In regards to OP question I think Robysue has covered things quite well.

avi123 wrote: However, this: At my titration, I had no obstuctives and 7 centrals, also with lots of hypopneas and desats during the hypopneas.. But my conclusion (I am not a professional) is that my problem is not apneas, but only hypopneas. Both studies show arousals throughout the study periods, might tilt the treatment toward Central Apnea.

If above is in reference to your own personal history, I decline to comment. It is already apparent that you prefer to keep things at your status quo and follow your own medical professionals advice. I respect that is your choice and I am not going to try to change your mind nor try to explain anything to you because it is more than apparent that my common sense approach to things does not suit you.

Pugsy wrote:

avi123 wrote:p.s. Don't we need Pugsy to explain it?

In regards to OP question I think Robysue has covered things quite well.

avi123 wrote: However, this: At my titration, I had no obstuctives and 7 centrals, also with lots of hypopneas and desats during the hypopneas.. But my conclusion (I am not a professional) is that my problem is not apneas, but only hypopneas. Both studies show arousals throughout the study periods, might tilt the treatment toward Central Apnea.

If above is in reference to your own personal history, I decline to comment. It is already apparent that you prefer to keep things at your status quo and follow your own medical professionals advice. I respect that is your choice and I am not going to try to change your mind nor try to explain anything to you because it is more than apparent that my common sense approach to things does not suit you.

No, I am actually seeking advice. I just said the above in order to explain what I observe and deduce (two separate actions). I am perfectly willing to be corrected. Perhaps my conclusion is wrong -- then please don't attack me, just correct me.

What I really want to know is what is the best approach to treating hypopneas? If it is the same as centrals or as obstructives, that info will be helpful to me.

katcw wrote: then please don't attack me,

No, no, no. I was responding to avi123 and his little snide poke at me. Not you at all. Please don't think that.
Robysue already said anything I would have said and probably more. I just didn't want avi123 to derail your thread with his comments about his data and treatment (which he often does) and your problem get lost in the ensuing discussions he brings forth.

Katcw,
Avi123 included your data in his comments and I didn't catch that fact. So sorry, I can imagine that it looked like I was commenting on your results. He often interjects his own data and I just didn't catch it was yours. He was goading me and I bit.

Robysue has pretty well covered what I might have thought to mention. I have pretty much zero experience with bipap machines except in general principle. Same thing with PLMS. I just don't have anything to comment that Robysue has not covered and she obviously has the experience and covered things very well.

I just pretty much stick to run of the mill, common sense approach to some of the basic OSA and therapy issues where I have my own experience and medical background to draw upon. Yours is going to be a very unique situation and probably going to take much more detective work to figure out what works best for you. Someone like Robysue with Bipap experience is much better able to answer your questions than I am. Heck, my machine doesn't even score centrals.

Please, don't be upset. I certainly never meant to cause you any distress at all. I would never, ever do that to someone asking for help. In fact, I would do anything I could to help if I thought it was within my skill level to do so.

Brenda

katcw: You've gotten good, solid advice from robysue and pugsy, and an excellent link from cflame1.........I think many individuals who have been around longer than you try to protect newbies from advice that may be off the mark or self-promoting, until you figure out the separation between the wheat and the chaff so to speak.

Hang in there..........you can trust Pugsy completely. She is so patient and helpful to so many here. I have really learned a lot from her posts and her personal messages.

As you make one adjustment at a time in your treatment, it usually takes 7-10 days for the numbers settle out..........and then make another, asking advice as you need!

katcw wrote:I still don't feel rested or any better than I did before I began treatment.

When you get the computer back with EncoreViewer on it could you post one of your usual detailed reports that you see?

My basic things to look at when someone comments that they aren't feeling better are the reports and confirm first that therapy at least seems optimal per the reports. Leak okay, AHI acceptable, look for groups or clusters of events even if overall AHI is okay., stuff like that. Sometimes a few "clusters" of events within a small time frame can still make us feel suboptimal the next day.
Enough Hyponeas back to back will do as much damage and cause as much stress as an apnea. They will cause the oxygen to drop and in general all the things that apneas do.

Once we determine that the therapy, at least on paper, seems optimal then we take a hard look at other possible factors. Number of hours asleep, awakenings during the night, pain, meds, general health... stuff like that.

That's my basic common sense approach to this therapy. I, myself, got my therapy fine tuned within about 2 months when I started but to be honest, other than the nighttime pee breaks, not a whole lot of improvement. Maybe tiny bit of more energy but I still needed to nap during the day, maybe not as much but I still would nap. I knew pretty much that my issue was pain and it would cause me to wake (even a little to toss and turn) and these frequent awakenings interrupted the normal restorative sleep cycle. It took 18 months of whittling away, trying different things to finally see marked improvement. Not saying that is your problem, only that often we may have other factors affecting the restorative powers of sleep. Robysue has the insomnia monster that is her demon to tame. Weezy seems to have finally had some marked improvement by adding tryptophan to her OTC oral meds. Sometimes it takes a lot of hard work and time to find out why we don't feel so great but we have to start with the therapy itself first.

Feel free to bounce ideas. While I don't use bipap the general picture of either optimal treatment or not is fairly easily seen on a report. Then we start from there.

What I really want to know is what is the best approach to treating hypopneas? If it is the same as centrals or as obstructives, that info will be helpful to me.


Hi, if you go over the following you'll see that Hypopneas can tilt toward Obstrucive or Central. The optimal treatment would depend on which side does it tilt to. You might geather info from the symptoms as mentioned below. If it's toward Central Apnea then an under medical condition might be involved more than in Obstructive.
If you get ResScan Flow graphs then they might show typical Obstrutive Apnea patterns.

Hypopnea is a medical term for abnormally shallow breathing or slow respiratory rate. This differs from apnea in that there remains some flow of air. The direct consequence of hypopnea (as well as apnea) is that the CO2 in the blood increases and the oxygen level in the patient’s blood decreases proportionate to the severity of the airway obstruction. This disruptive pattern of breathing generates disruptive sleep patterns, the consequences of which being that those individuals exhibit increased fatigability, lethargy, decreased ability to concentrate, increased irritability, and morning headaches. Basically, those individuals are extremely tired due to their inability to get a good night’s sleep. Hypopnoeas can be either central (i.e., as part of a waxing and waning in breathing effort) or obstructive in origin. During an obstructive hypopnoea, in comparison to an obstructive apnoea, the airway is only partially closed. However, this closure is still enough to cause a physiological effect (i.e., an oxygen desaturation and/or an increase in breathing effort terminating in arousal).

A hypopnea index (HI) can be calculated by dividing the number of hypopneas by the number of hours of sleep. The apnea-hypopnea index (AHI) is an index of severity that combines apneas and hypopneas.Combining them both gives an overall severity of sleep apnea including sleep disruptions and desaturations (a low level of oxygen in the blood). The apnea-hypopnea index, like the apnea index and hypopnea index, is calculated by dividing the number of apneas and hypopneas by the number of hours of sleep. Another index that is used to measure sleep apnea is the respiratory disturbance index (RDI). The respiratory disturbance index is similar to the apnea-hypopnea index, however, it also includes respiratory events that do not technically meet the definitions of apneas or hypopneas, but do disrupt sleep.

The most common hypopnea symptom is excessive sleepiness, which results from constant sleep interruption. People with hypopnea often have loud, heavy snoring that is interrupted with choking sounds or loud snorts followed by periods of silence, because not enough air can flow into the lungs through the mouth and nose. The periods of silence can last 20 seconds or longer and can happen many times each hour, resulting in poor sleep and reduced levels of oxygen in the blood.

Other symptoms of hypopnea may include depression, forgetfulness, mood or behavior changes, trouble concentrating, loss of energy, nervousness, morning headaches. Not all people with hypopnea experience all of these symptoms and not everyone who has these symptoms has hypopnea.

Hypopnea is a disorder that results in excessive daytime sleepiness and compromised quality of life, including traffic accidents, diminished productivity in the work place and emotional problems. Cardiovascular consequences of hypopnea include myocardial infarction, stroke, psychiatric problems, impotence, cognitive dysfunction, hypertension, coronary heart disease, and memory loss.The most common treatment for hypopnea is continuous positive airway pressure (CPAP). CPAP is a treatment in which the patient wears a mask over the nose and/or mouth. An air blower forces air through the upper airway. The air pressure is adjusted so that it is just enough to avoid the upper airway tissues from collapsing during sleep but apnea episodes return when CPAP is stopped or it is used improperly. For people with neuromuscular disorders the most common treatment is the use of BIPAP or other non-invasive ventilation.

Source:Google

Thank you, RobySue, Pugsy and all the rest of you, for offering these insights. I will post some graphs once I get the XP computer back. You have helped me understand this situation much better, and made some excellent suggestions.

Meanwhile, I am getting longer sleep times now that the RT helped me get the Quattro FX fitted properly. That is encouraging (woo-hoo for small steps forward!). I also feel I've found a good DME with 2 excellent RTs on full time staff, so that too is a step forward! (double woo-hoo!!) As with most things xPAP, several steps forward with a long way yet to go.

Thanks again!!!!!

katcw, do you have an explanation yet why you were put on a bi-level? It sounds like you had noticeable symptoms prior to treatment; are you experiencing any improvement yet?

BTW, it is my understanding that during the initial stage of acclimation to xpap treatment, there is often a temporary increase in centrals as the body gets used to better regulated breathing.


avi123, Google is not a source per se; it does not publish data, only indexes posted text so we can search it. But that’s a tangential aside.


What really caught my attention in the excerpt posted.....I'll post on another thread, because I don't want to hijack this one.

The prescription is for a bilevel, but not an auto. I've been working on this for nearly 2 years - mostly struggling with leaks until I found my Quattro, and now the Quattro FX, wish works well now that I've had help adjusting it.

Anyway, when my computer comes back I'll look at this week's readings to see if the lower leaks are making any real difference.

Thanks, all!