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No respiratory events but still lousy sleep

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Expand view Topic review: No respiratory events but still lousy sleep

Re: No respiratory events but still lousy sleep

Post by ohwhatanight on Fri Feb 24, 2012 7:33 pm

Thanks for all the nice detailed answers. I think I will wait a while before getting a Zeo - right now it would probably just add more anxiety as one more thing for me to analyze to death. I had a pretty decent night last night (finally) without all the usual anxiety about whether or not I would get enough sleep, so I guess I need to go with that for a while. I'm still really exhausted during the day but I think I have a heck of a lot of sleep debt to make up for. Also, air leaks around my eyes is making them really dry and tired during the day so that may make me feel sleepier than I really am. Hopefully that will be taken care of with a new mask (if I can ever get one!)

I think you are probably right about the respiratory rate roller coaster being related to me just getting used to the whole thing. I'll compare in a few weeks and see if it settles down some. The same for the snoring - it isn't bothering anyone else right now and I don't seem to be waking up (that I am aware of) at the same times it looks to be the loudest. My doctor said she didn't have my snore data, which seemed odd to me, so I doubt she will raise my pressure yet.

Re: No respiratory events but still lousy sleep

Post by deltadave on Fri Feb 24, 2012 7:12 pm

robysue wrote:The Zeo doesn't tend to pick up extremely short arousals----the device just isn't that sensitive and it lacks an EEG sensor on the BACK of your head, which seems to be important in picking up arousals---at least according to what someone at Zeo was telling my hubby the other day.

Electrodes at the back of the head (occipital) are used to differentiate Wake from Sleep. Arousals are scored from electrodes on the top of the head (central) although interestingly, O’Malley et al showed improved detection of cortical arousal following obstructive respiratory events using frontal leads.

Whoa. I see ol' Dave and Bob came up there, too.

Small world.

Re: No respiratory events but still lousy sleep

Post by robysue on Fri Feb 24, 2012 6:23 pm

ohwhatanight wrote: I've quit using the ramp altogether because at the lower pressure, I feel like I am suffocating.
On the PR System One you should be able to INCREASE the beginning RAMP pressure from the PATIENT's set up menu. So if you want the ramp, but can't handle the low starting pressure, increase the starting ramp to maybe 1cm lower than your normal beginning pressure.

I am considering getting a Zeo so I can see how much deeper sleep I am getting on a nightly basis. I've seen mixed reviews - especially about the false sleep readings when you are awake. If it accurately measures the deeper sleep, I can live with it being off on the other. Opinions/Advice? (empahsis added)
My hands on experience with the Zeo indicates it is far, far more likely to misscore my REM or LIGHT as WAKE rather than the other way round. I often see "long wakes" in the Sleep graph that I know are not there because they don't correspond to any time I remember even vaguely as being awake or restless. So my take is either the zeo is misscoring REM/LIGHT as WAKE or I really am the weird insomniac who consistently OVERESTIMATES my total sleep time instead of underestimating it. (Studies have indeed shown that most chronic insomniacs pretty seriously underestimate their total sleep time and pretty seriously overestimate the amount of time they lie in bed awake. One major part of CBT for insomnia is to both learn AND accept this truth and then actually apply it in daily life when reflecting on the question of "how much sleep did I get?" each morning.)

And near as I can tell my Zeo seems to score Stage 3 (Deep) pretty accurately.

I'm also learning to put together the Zeo data AND the wave flow data in SH to get a pretty good idea of just when the zeo has seriously misscored something. Sleep breathing once you're getting quality sleep is much more regular than wake breathing and once you get used to zooming in on the wave forms to the point where you can see five minutes worth of the individual breaths, it's not that difficult to pin-point when something is markedly different or weird. Sometimes, of course, the weirdness is easy to associate with OSA events. But sometimes it's out of the blue and that usually indicates (for me) a wakeful/restless period that is usually picked up by the zeo unless it is very short. The Zeo doesn't tend to pick up extremely short arousals----the device just isn't that sensitive and it lacks an EEG sensor on the BACK of your head, which seems to be important in picking up arousals---at least according to what someone at Zeo was telling my hubby the other day. (Hubby has a professional interest in modeling sleep cycle data using something called a hidden Markov model. So once I got my Zeo, he started contacting folks at zeo; eventually he got lucky and managed to get an email and phone conversation with someone there who knows something about the particulars of how the Zeo works.)

The SleepyHead program is only showing about 3-4 RERAs a night so I figure that probably isn't a big deal, though I still don't know what these are exactly. I had a RERA index of .53 last night. Anyone know if that is good, bad or average?
RERAs on a sleep study are best understood as arousals that follow evidence of increasing respiratory effort---i.e. you arouse yourself to fix the breathing before the situation is "bad enough" to be flagged as a hypopnea or an apnea. They go into the RDI and if you have lots of them you can still wind up with a diagnosis that leads to CPAP therapy even if you have no hypopneas or apneas at all.

RERAs scored by the System One are based on a proprietary algorithm. PR has studied the wave forms from many, many PSGs and they think they've identified characteristics in the wave flow that indicate a high probability that a PSG RERA has occurred based on the shape of the wave flow. When I look at RERAs scored by my machine, sometimes I can spot a a bit of ever so slightly ragged breathing followed by a sudden deep inhale (a recovery breath) and sometimes I can't see a damn thing suspicious in the data. If you're only getting 3 or 4 RERAs a night, then forget about them for now.

I am also confused about the Vibratory Snore #2 events. I have an average of 130 a night of those with a max around 40. Again, is this good, bad or average?
Snoring is something I've not yet figured out on the System One. My own snores are split into VS #2's and VS #1's because I'm running in AUTO mode. (The VS #1's increase pressure, the VS #2's don't.) What the heck the criteria for scoring a VS #1 or a VS #2 is seems to be a mystery. My own snoring numbers bounce around rather dramatically. I'll have several nights in a row where there are less than 10 or 20 VS#2. And then I'll have a monster night with 50 or more. Last spring during tree pollen season, I'd have nights where there were over 100 VS2's, but not many. I've also noticed that my VS#1 and VS#2 numbers and indices in SH appear to have little in common with the VSI as reported in Encore Viewer. And half the time when the machine says I'm snoring, hubby says he heard nothing. And sometimes hubby says he hears snoring and the machine didn't pick it up. (Maybe he heard his own snoring, which is highly intermittent, not bad on a nightly basis, but can get really awful every now and then.)

My guesses:

1) Snoring is considered a "precursor" to OSA events---i.e. where there's snoring, there's evidence that the upper airway may be compromised and more prone to collapse. And that's why it's scored. Snoring can also cause arousals of the person doing the snoring. And you may or may not remember the arousal. Or you may or may not remember the snoring that lead to the arousal---i.e. you may remember waking up, but not remember that it was your own snoring that woke you up. You might want to call the sleep doc's office and ask what the snoring numbers looked like in Encore and whether the sleep doc is worried about them.

2) The pattern of the snoring may also be important. Some folks have reported that the System One is prone to scoring VS2's when there's no snoring going on. The hose rubbing against the table edge is thought to be a culprit by some folks.

3) No-one really knows what the scale on the snoring graph represents---this graph is NOT available in Encore Viewer or Encore Pro. But it's there in the data. Our best guess is that larger numbers indicate louder snoring. What is "roof-raising" snoring? I don't know. My own snoring on my PSG was described as "soft snoring". On my worst nights, I sometimes see the snore graph get peaks up between 20 and 30. I don't know what my highest snore graph value is right off the top of my head.

4) Some folks have more problems snoring when on their backs. Some folks have more problems with their snoring when they are also fighting nasal congestion. So those are two other things to consider about the snoring.

5) If you want to try a small increase in pressure to see if that brings the snoring numbers down, then you might eliminate one more source of wakefulness.

One more question - is it normal to have my respiratory rate all over the place? It looks like a crazy roller coaster ranging from 10-30 all night long with no consistent pattern. What is the significance of the resp. rate?
The respiratory rate is the number of breaths you are taking each minute. Average at rest (while awake) respiratory rates for healthy adults are usually reported to be somewhere in range of 10-20 breaths. (Different sources will cite different "average rate" ranges that are tighter than what I've given. But this range seems to encompass all of the ones I'm familiar with.) In sleep, the average respiratory rate for adults seems to be in the lower half of that range: Most typically it's reported to be somewhere between 12 and 16 breaths per minute.

The respiratory rate should not look like a crazy roller coaster. But when I go back and look at my early data, there's a lot of crazy roller coaster mixed in to it and many of those nights are the "really rough" nights according to my journal. My guess as a patient who has been there and done that: Some of that roller coaster is simply due to anxiety, which can often trigger rapid breathing, and some of the roller coaster stuff may be due to restless sleep. Wakeful breathing is not as regular as normal nighttime breathing is supposed to be and so when you're restless and moving in and out of WAKE and light sleep, there's going to be more variation in the respiratory rate than when you are sound asleep.

It's not that normal sleep breathing will have a completely constant respiratory rate, but it will pretty much stay in a rather small range and not bounce around that much. When I'm sleeping well, my respiratory rate typically stays between 10 and 15 for most of the night, for example, and most of the changes are gradual rather than sudden jumps. When I'm sleeping poorly, there's more variability: It may peak above 15 far more often and even when it doesn't it will more rapidly go from 10 to 15 rather than very slowly increasing or slowly decreasing. Other things that affect the respiratory rate on a short term basis include: changes in sleep stage and moving around in bed. When you change sleep stages, there can be a change in the respiratory rate, but it shouldn't look like a roller coaster. And when you start moving around in bed the respiratory rate can go up as well.

So my guess is that most (or all) of that roller coaster respiratory rate is just you figuring out how to breath with the machine. And I think I've read somewhere that some folks tend to hyperventilate a bit (high respiratory rate) when they start CPAP; it could just be part of the acclimation process, or it could be triggered (or at least aggravated) by anxiety and worry.

So for NOW, I'd recommend that you not worry at all about the respiratory rate. What you need to focus on is teaching yourself how to sleep well and how to sleep with a six foot hose on your nose. Don't give yourself more things to worry about just yet.

Re: No respiratory events but still lousy sleep

Post by HoseCrusher on Fri Feb 24, 2012 5:34 pm

robysue wrote:But I'm not sure how an oximeter would help to detect wakes---particularly wakes that are NOT the result of an arousal caused by OSA.


Remember that a pulse oximeter records two channels of data. Oxygen saturation and pulse rate.

Arousals are frequently (always?) accompanied by a change in pulse rate. If the parameters are properly set, these can show up as pulse events.

Re: No respiratory events but still lousy sleep

Post by ohwhatanight on Fri Feb 24, 2012 9:13 am

I've been getting better (but still not great) sleep for the past couple of nights. My AHI is around 1.6 so I guess that is good, but they are sometimes clustered pretty close together so for those time periods my AHI is probably a lot higher (this is consistent with my original study where I had a total AHI of 8.7, but it an AHI of 76.4 when I was in REM sleep). I still think I am waking up more than I should but I had to stop turning off and on my machine because it was messing up the data that my DME was getting from me (over a modem). They only got one hour's worth of data one day when I had actually had 8 full hours. I've quit using the ramp altogether because at the lower pressure, I feel like I am suffocating.

I am considering getting a Zeo so I can see how much deeper sleep I am getting on a nightly basis. I've seen mixed reviews - especially about the false sleep readings when you are awake. If it accurately measures the deeper sleep, I can live with it being off on the other. Opinions/Advice?

I'm tolerating the CPAP better but called my DME today to see if I can try a nasal pillow instead since I am not thrilled with the mask I have and am getting a lot of leaks around my eyes which is causing really bad eye dryness all day. (I've watched the videos for fitting several times - I think the mask just doesn't fit my chubby face shape well.) I wake up with dents all over my face and strap marks even though I have it sitting pretty darn loose. If, I get a Zeo, I'd have to have a different mask since the one I have has a big old honkin' forehead piece.

The SleepyHead program is only showing about 3-4 RERAs a night so I figure that probably isn't a big deal, though I still don't know what these are exactly. I had a RERA index of .53 last night. Anyone know if that is good, bad or average? I am also confused about the Vibratory Snore #2 events. I have an average of 130 a night of those with a max around 40. Again, is this good, bad or average?

One more question - is it normal to have my respiratory rate all over the place? It looks like a crazy roller coaster ranging from 10-30 all night long with no consistent pattern. What is the significance of the resp. rate?

Re: No respiratory events but still lousy sleep

Post by robysue on Fri Feb 24, 2012 8:24 am

First,

A thank you to DeltaDave. You managed to translate it into something that makes some sense to me. Thanks for clarifying what equipment is needed to detect RERAs in an NPSG.

Next,
Gazhacks wrote:I got to the cottonballs then I lost it, went first to shout on my other post. Wouldnt a zeo or maybe a Oximeter register awakenings? also with a 90 minute sleep cyle wouldnt it be plausable that some people would wake to a fashion when the cyle restarts.
The Zeo gives a good guesstimate---if the wake is long enough. But the zeo can also misscore both REM and Light sleep as Wake (and vice versa). The makers claim it's about 75% accurate, which, given its cost and small footprint on both your head and bedside table is pretty remarkable. My own data indicates sometimes the Zeo seems to correspond exceedingly well with both my own memory of the night and the record of my turning Kaa off and on during the night. And sometimes the Zeo shows some remarkably long wakes that I have no memory of and for which there's no strong evidence in the wave form of a wake----as in the wave form is showing a remarkably stable, remarkably regular breathing pattern.

But I'm not sure how an oximeter would help to detect wakes---particularly wakes that are NOT the result of an arousal caused by OSA.

kteague wrote:
ohwhatanight wrote: I saw your suggestion on another thread of turning off the CPAP and back on again when you wake up to record how many times you actually wake up. That's a great idea and would keep me from getting as obsessed about it as writing it down would. I'll hide my clock tonight too.


I think that's a great way to get an idea about awakenings without waking up to note them. Not sure if you use use a ramp feature or not, but I would suggest that anyone who restarts their machine several times a night either does not use the ramp feature or else sets it to just a few minutes. I was one who woke frequently, each time restarting my ramp, but fell almost immediately back to sleep. Didn't realize that most of my sleep time I was in ramp - not effective treatment.
Kteague brings up a good point to keep in mind about my idea. I tend to forget this is an issue for many folks because I use such low pressure: My min EPAP=4, which means there is no ramp option for me. And even when my prescribed pressures were higher, they were never very high, and hence going back down to a pressure of 4 was not creating a problem for me. But for folks whose beginning ramp pressure is much below 2 or 3 cm below their prescribed pressure, either shortening the ramp time, increasing the beginning ramp pressure, or turning it off are all good ideas. By the way, on the PR machines, you have to press the RAMP button to start the ramp---when you turn the machine on without pressing the ramp button, you don't get the ramp.

Re: No respiratory events but still lousy sleep

Post by Gazhacks on Fri Feb 24, 2012 5:39 am

I got to the cottonballs then I lost it, went first to shout on my other post. Wouldnt a zeo or maybe a Oximeter register awakenings? also with a 90 minute sleep cyle wouldnt it be plausable that some people would wake to a fashion when the cyle restarts.

Also, isnt it worth looking at other things other than OSA. I fall asleep in the daytime most days although my AHI is under 5, I have no leaks, then I ask myself would I have fell asleep if I didnt have osa, probably as there are just to many variables to count :D

Re: No respiratory events but still lousy sleep

Post by deltadave on Fri Feb 24, 2012 4:33 am

robysue wrote:Is this the standard belts and thing they stick under your nose on the diagnostic PSG?

It is "standard" only if the Center in question is "following the standard" (AASM 2008).

There are belt types other than RIP (like piezo) and things they stick under your nose other than nasal pressure transducer (OK, it's not the transducer itself, it's nasal prongs)(stickin' a tranducer up there would hurt)(like thermistor)(the thermistor wouldn't hurt, the transducer would hurt)(cause see, the transducer is actually in this case thing) that would not qualify (for the standard).

robysue wrote:Can you translate that to something the rest of us understand?

Upon review, I'd say probably not.

Re: No respiratory events but still lousy sleep

Post by robysue on Thu Feb 23, 2012 9:51 am

deltadave wrote:
robysue wrote:
deltadave wrote:
ohwhatanight wrote:The 130 spontaneous arousals I had during the first study turned out to be RERAs. So all 241 arousals were respiratory related (meaning I didn't have any mysterious other reasons for arousals) and can benefit from CPAP therapy. During the titration study, I was down to 68 total. My arousal index went from 74.5 to 13.3.

That does not seem correct to me. If original Sleep Time was 194 minutes and AHI was 8.7 and there were 111 respiratory arousals, then that meant there were 28 apneas and hypopneas, leaving 83 as RERAs for an RDI of 34.3.

Spontaneous arousals, by definition, are non-respiratory, non-PLM-related.

DeltaDave,

I agree with what you are saying, but ...

What if the lab doesn't use the esophageal manometry needed to measure the esophageal pressure drop that marks a RERA? In that case, could the arousals be labeled as "spontaneous"?

Negative. Although use of esophageal pressure is the preferred method of assessing change in respiratory effort, nasal transducer with respiratory inductance plethysmograhy is acceptable.

Can you translate that to something the rest of us understand? Is this the standard belts and thing they stick under your nose on the diagnostic PSG?

Thanks for clearing up what has to be done to measure RERAs for us. It's appreciated!
Robin

Re: No respiratory events but still lousy sleep

Post by stage0 on Thu Feb 23, 2012 6:23 am

I have some insight if your arousals still persist
look into ORHS at this link http://www.sleepreviewmag.com/issues/ar ... -07_03.asp
you will not notice it until your sleep study is look at over a 3-5 minute slice of time. look specifically at the respirations. this can cause small arousals

also look into some time release melatonin. as ppl get older the amount of this hormone decreases to be made in the brain. check with your doc, but i take it all the time.

lastly, i did not see if you have any chronic pain as a symptom. i have seen many studies that actually show arousals from this.

Re: No respiratory events but still lousy sleep

Post by kteague on Thu Feb 23, 2012 12:00 am

ohwhatanight wrote: I saw your suggestion on another thread of turning off the CPAP and back on again when you wake up to record how many times you actually wake up. That's a great idea and would keep me from getting as obsessed about it as writing it down would. I'll hide my clock tonight too.


I think that's a great way to get an idea about awakenings without waking up to note them. Not sure if you use use a ramp feature or not, but I would suggest that anyone who restarts their machine several times a night either does not use the ramp feature or else sets it to just a few minutes. I was one who woke frequently, each time restarting my ramp, but fell almost immediately back to sleep. Didn't realize that most of my sleep time I was in ramp - not effective treatment.

Another idea I've read was to keep a handful of cottonballs under your pillow and every time you wake up, toss one to the floor, to be countd in the morning. It will only give you a count though. With hitting the button on the machine, then you could possibly correlate wakings with events, if there is any relation. Also, the timing of the wakings may even hold a clue.
Let us know how things progress.

Re: No respiratory events but still lousy sleep

Post by deltadave on Wed Feb 22, 2012 7:54 pm

robysue wrote:
deltadave wrote:
ohwhatanight wrote:The 130 spontaneous arousals I had during the first study turned out to be RERAs. So all 241 arousals were respiratory related (meaning I didn't have any mysterious other reasons for arousals) and can benefit from CPAP therapy. During the titration study, I was down to 68 total. My arousal index went from 74.5 to 13.3.

That does not seem correct to me. If original Sleep Time was 194 minutes and AHI was 8.7 and there were 111 respiratory arousals, then that meant there were 28 apneas and hypopneas, leaving 83 as RERAs for an RDI of 34.3.

Spontaneous arousals, by definition, are non-respiratory, non-PLM-related.

DeltaDave,

I agree with what you are saying, but ...

What if the lab doesn't use the esophageal manometry needed to measure the esophageal pressure drop that marks a RERA? In that case, could the arousals be labeled as "spontaneous"?

Negative. Although use of esophageal pressure is the preferred method of assessing change in respiratory effort, nasal transducer with respiratory inductance plethysmograhy is acceptable.

And that technology is required, so I believe that the spontaneous arousals are indeed, "spontaneous" in this case.

Re: No respiratory events but still lousy sleep

Post by robysue on Wed Feb 22, 2012 8:31 am

deltadave wrote:
ohwhatanight wrote:The 130 spontaneous arousals I had during the first study turned out to be RERAs. So all 241 arousals were respiratory related (meaning I didn't have any mysterious other reasons for arousals) and can benefit from CPAP therapy. During the titration study, I was down to 68 total. My arousal index went from 74.5 to 13.3.

That does not seem corrrect to me. If original Sleep Time was 194 minutes and AHI was 8.7 and there were 111 respiratory arousals, then that meant there were 28 apneas and hypopneas, leaving 83 as RERAs for an RDI of 34.3.

Spontaneous arousals, by definition, are non-respiratory, non-PLM-related.

DeltaDave,

I agree with what you are saying, but ...

What if the lab doesn't use the esophageal manometry needed to measure the esophageal pressure drop that marks a RERA? In that case, could the arousals be labeled as "sponataneous"?

Re: No respiratory events but still lousy sleep

Post by Carmen on Wed Feb 22, 2012 4:37 am

Welcome to the club--I wake up all night long. What's really frustrating is that the doctors don't seem to consider it to be a particularly urgent problem to fix. For months now, it seems to be some random test and we'll see you in a few weeks. I keep bringing up the hormonal issue because I am, after all, a menopausal woman, and keep getting the "estrogen causes cancer" speech. After a while, it feels like you're slogging through quicksand.

Re: No respiratory events but still lousy sleep

Post by deltadave on Wed Feb 22, 2012 4:24 am

ohwhatanight wrote:The 130 spontaneous arousals I had during the first study turned out to be RERAs. So all 241 arousals were respiratory related (meaning I didn't have any mysterious other reasons for arousals) and can benefit from CPAP therapy. During the titration study, I was down to 68 total. My arousal index went from 74.5 to 13.3.

That does not seem corrrect to me. If original Sleep Time was 194 minutes and AHI was 8.7 and there were 111 respiratory arousals, then that meant there were 28 apneas and hypopneas, leaving 83 as RERAs for an RDI of 34.3.

Spontaneous arousals, by definition, are non-respiratory, non-PLM-related.

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