Update on - what do you make of these graphs of FLs?

[jagzoo]

OK here is why I am posting:

I always have FLs but my AHIs are usually under 1 and I sleep pretty good - don't wake up, at least not much or not fully awake enough to remember (well, I do wake up enough in the middle of the night to take med for my hypothyroidism). But, every once in a while the FLs seem out of hand - like the run last night.

I have never had the "usual" OSA symptoms of falling asleep in the day & waking with morning HAs, but do require a lot of sleep -9-10 hours is the norm for me. I never wake up feeling "ready-to-go", just that "oh well time to get going". I was initially referred for a sleep test 3 yrs ago by a rheumatologist who was responding to my "always feel tired", NOT sleepy though. As it turned out, I don't have RA but have some undiagnosed (despite many, many tests etc by a major medical center where I have been hospitalized 3 times due to being unable to walk, in severe pain, and in an altered reality cognitively) "idiopathic inflammatory condition with neurological components". The sleep test showed moderate OSA of 20 AHI, O2 decelerations down to 71%, sleep efficiency of 63%, no deep wave sleep & PLMs of 25 events/hr.

So I have been on APAP for the past 3 yrs and tolerating it well, with the usual hiccups. I do take minimal medication each night for RLS and also Gabapentin, only at night, for my idiopathic peripheral neuropathy pain. Other meds are prednisone for my inflammatory disorder as well as meds for hypertension and hypothyroidism, along with various vitamins etc. I don't take any pain meds - except for an occasional one during a bad migraine. It does seem like a lot of us have other medical conditions - wonder what came first? (edit: actually I do know, or at least believe, what happened to me: 6 yrs ago I had a scuba diving accident, caused by faulty equipment. I needed to be resuscitated etc. MRIs show changes and I was left with some intermittent verbal difficulties etc. 6 months later all my "troubles" began!) My inflammatory disorder is under good control. I am female, age 70, physically active and have a BMI of 22 (which is actually an increase for me due to the prednisone). I might have a small glass of wine with dinner. This is probably TMI, but am trying to give some background.

The first image is of a "normal night".The Flow Limitations are of normal, or slightly reduced quantity. I am using a P10 pillow mask.

The next 2 images are of last night and give an example of nights when I have a a lot more.

Tuesday Night:


Last night overview:



Last night zoomed in on particularly nasty run:


Since my AHI is so low should I just keep ignoring these? Or do I increase max pressure more? - But then I run into aerophagia (at least I did with the 560). We will be going camping soon and part of that time will be "off grid" so I will have to use my 560 on CPAP mode in order to use my battery back-up system. Anything over 10.5 on CPAP with the 560 gives me aerophagia.

I just don't know if I should be chasing these FLs more. Or just say the "gremlins" were acting up?

I really would appreciate any insights or suggestions. Thanks for even reading this far!

[palerider]

Since my AHI is so low should I just keep ignoring these? Or do I increase max pressure more? - But then I run into aerophagia (at least I did with the 560). We will be going camping soon and part of that time will be "off grid" so I will have to use my 560 on CPAP mode in order to use my battery back-up system. Anything over 10.5 on CPAP with the 560 gives me aerophagia.

I just don't know if I should be chasing these FLs more. Or just say the "gremlins" were acting up?

I really would appreciate any insights or suggestions. Thanks for even reading this far!

I recently had a discussion on the irc chat with okcsleepdoc about flow limitations, and the gist of the conversation was that, yes, flow limitations ARE a problem in and of themselves, and should not be ignored.

I believe this is the study that he referenced: http://www.ncbi.nlm.nih.gov/pubmed/24179299

basically, when your flow limitations get more severe, they disturb sleep, and can cause higher levels of breathing effort.

the typical answer to curbing them is to allow the machine to increase pressure further to open up your airway.

what I'd suggest is keeping a log of how you feel on a given day, and then afterwards, check the data, and see if you find a correlation "I felt great on the 3rd, and going back and checking my data, I had low FLs that night, but I felt worse on the 5th, and had higher FLs." that would be pretty clear evidence that you should consider raising your max pressure.

[Danimal74]

What makes that study reliable, Palerider? And if I'm not mistaken that study wasn't peer reviewed. So, can you explain why why we should believe the study is reliable and would you post some evidence of pèr review. If not, you shouldn't be posting information of questionable value, should you?

[OKCSleepDoc]

What makes that study reliable, Palerider? And if I'm not mistaken that study wasn't peer reviewed. So, can you explain why why we should believe the study is reliable and would you post some evidence of pèr review. If not, you shouldn't be posting information of questionable value, should you?

If you look at the citation, the article is from the journal SLEEP. Straight from their website, SLEEP indicates that it is "It is a monthly, peer-reviewed scientific and medical journal that is published online." So it IS a peer reviewed journal, and your post now loses all credibility Danimal.

[PEF]

I believe this study makes a lot of sense, peer reviewed or not. It jibes with the work done by Dr. Steven Park. I am pretty sure I do not have OSA, but a sleep disordered breathing condition called UARS. There are also some interesting articles about the connection between SDB and Fibromyalgia.

I began CPAP because, in addition to very bad insomnia, I had some somatic disorders (nighttime acid reflux, morning headaches, sore throats, heart palpitations, etc.), for which the medical establishment always wanted me to take anti-depressant meds that almost never helped. I also had symptoms of fibromyalgia. It is well known that people with fibromyalgia have sleeping problems. So, after doing quite a bit of research and getting no help from my doctors, I decided to try CPAP.

In the 4 months I have been using it, I generally have experienced an improvement in my bad symptoms. My situation is complicated because of having trouble with masks. I now use nasal pillows, but must tape my mouth and cannot raise my max pressure above 6 due to mouth leaks waking me up all night. My machine always tells me that AHI is under 1, sleep time is 8 to 9 hours, and my mask fits well. I finally found a FFM (hybrid) that fits, so I am going to try to get used to sleeping with it (Amara View). I hope that I will be able to raise my max pressure once I can use the FFM. Unfortunately, it is taking me a long time to get Sleepyhead up and running because of ISP problems here. So I cannot see my FL,s. But I bet they are problematic. I will know once I have information from Sleepyhead.

I wish there was somewhere to get an idea what pressure settings to use for UARS. Some sites say low, some say high.

Is it possible you could have UARS also?

[Jay Aitchsee]

I really would appreciate any insights or suggestions.

Jagzoo, you might want to try a soft cervical collar similar to this one:
http://www.amazon.com/gp/product/B000FZ ... g121_i1_bs
When I used a collar, I noticed a dramatic reduction in Flow Limitations.
If you don't want to buy one, you can make one from a piece of 1X3X6 inch foam wrapped in a bandana and tied around the neck. Similar to that of member kiralynx's brandy keg. viewtopic.php?f=1&t=97710&p=905777&hili ... dy#p905777

[jagzoo]

Hi Jay,
I do use a soft cervical collar, every night. It completely eliminated my leaks from my mouth (escaping air through my lips) but has had no effects on the FLs. But thanks for the suggestion.

[Guest]

Since my AHI is so low should I just keep ignoring these? Or do I increase max pressure more? - But then I run into aerophagia (at least I did with the 560). We will be going camping soon and part of that time will be "off grid" so I will have to use my 560 on CPAP mode in order to use my battery back-up system. Anything over 10.5 on CPAP with the 560 gives me aerophagia.

I just don't know if I should be chasing these FLs more. Or just say the "gremlins" were acting up?

I really would appreciate any insights or suggestions. Thanks for even reading this far!

I recently had a discussion on the irc chat with okcsleepdoc about flow limitations, and the gist of the conversation was that, yes, flow limitations ARE a problem in and of themselves, and should not be ignored.

I believe this is the study that he referenced: pubmed/24179299

basically, when your flow limitations get more severe, they disturb sleep, and can cause higher levels of breathing effort.

That's not what that article says at all.

It says 30 to 56% of your breaths can be FL and you can still be normal.

[OkyDoky]

Since my AHI is so low should I just keep ignoring these? Or do I increase max pressure more? - But then I run into aerophagia (at least I did with the 560). We will be going camping soon and part of that time will be "off grid" so I will have to use my 560 on CPAP mode in order to use my battery back-up system. Anything over 10.5 on CPAP with the 560 gives me aerophagia.

I just don't know if I should be chasing these FLs more. Or just say the "gremlins" were acting up?

I really would appreciate any insights or suggestions. Thanks for even reading this far!

I recently had a discussion on the irc chat with okcsleepdoc about flow limitations, and the gist of the conversation was that, yes, flow limitations ARE a problem in and of themselves, and should not be ignored.

I believe this is the study that he referenced: pubmed/24179299

basically, when your flow limitations get more severe, they disturb sleep, and can cause higher levels of breathing effort.

That's not what that article says at all.

It says 30 to 56% of your breaths can be FL and you can still be normal.

I think you are reading something in the study that it didn't say. No mention of 30 to 56% breaths that I could find. Here is their suggested conciusion:

This suggests that only levels of inspiratory flow limitation > 30% be considered in the process of diagnosing obstructive sleep apnea in the absence of an apnea-hypopnea index > 5 and that < 30% of inspiratory flow limitation may be a normal finding in many patients.

[ChicagoGranny]

I just don't know if I should be chasing these FLs more.

Looking at your chart for 1/28 from about 2:30 to 3:45 your pressure goes to the max setting of 12.0 and stays there. This is an indication that you need a pressure higher than 12 during that time. My philosophy on the max setting is to leave it open at 20 cm. If my machine senses a need for higher pressure than usual, it will raise the pressure. If it doesn't sense a need for higher pressure, it won't raise the pressure.

So, my recommendation would be to change your max pressure setting to 20 and monitor the results. I would do it all in one night, but you could also raise it a cm or two per night and continue to monitor the results.

Anything over 10.5 on CPAP with the 560 gives me aerophagia.

It can be seen from your charts that your body needs a pressure higher than 10.5 for much, if not most, of the night. Running straight CPAP, it could have been that your pressure was still not high enough to prevent most apneas, and in the struggle to breathe you developed aerophagia. It would take some experimenting with APAP settings to see what level of pressure is well tolerated.

I just don't know if I should be chasing these FLs more. Or just say the "gremlins" were acting up?

Personally, I concentrate on a well treated AHI (less than 2.0 most nights) and ignore the FLs. But, I do use a max pressure of 20, so it may be doing the job needed on my FLs.

I never wake up feeling "ready-to-go", just that "oh well time to get going".

Some comments on these feelings and your drug use:

prednisone

Prednisone absolutely wrecks my sleep, and many others report the same. But, if it is medically necessary, ya gotta do it.

medication each night for RLS and also Gabapentin

What do you take for RLS besides gabapentin? Gramps takes 900 mg gabapentin at bedtime for RLS, and he says it treats his RLS very well. It does leave him groggy in the bed, even after 8 hours of sleep. So, he has to make an effort to get out of the bed and get going. He is fine after he is up and moving for about 15 minutes.

[Guest]

I think you are reading something in the study that it didn't say. No mention of 30 to 56% breaths that I could find. Here is their suggested conciusion:

This suggests that only levels of inspiratory flow limitation > 30% be considered in the process of diagnosing obstructive sleep apnea in the absence of an apnea-hypopnea index > 5 and that < 30% of inspiratory flow limitation may be a normal finding in many patients.

That's just the abstract. You need to read the actual article:

In summary, our study demonstrated that only 5% of normal individuals present with > 30% of the total sleep time with IFL, establishing a value for IFL below which one statistically cannot invoke OSA in otherwise healthy individuals. Despite the observation that some individuals of the “normal” group presented up to 56% of IFL, the 95th percentile of a distribution (eg, 30% for % IFL) is conventionally used to statistically establish a likely boundary between health and disease. This is further supported by the increase in % IFL found in patients with mild OSA (AHI 5-15 and no symptoms) and OSAS (AHI 5-15 with clinical symptoms). Thus, values of up to 30% of IFL should be considered “within normal limits” and only values > 30% can support the likely presence of abnormality.

[jagzoo]

ChicagoGranny,

Thanks for the "to the point" suggestions. We have a week before we leave - I'll try your suggestion of increasing my max pressure to 20 and see what happens. The worse would be that I would wake in pain and put the max down some.

It's possible that the way the ResMed (in "for Her" mode) handles increases in pressure may make a difference in my developing aerophagia? I was using APAP in the 560 and found that when I went much higher that 11, I got uncomfortable. I only used the straight CPAP when I needed to be on battery; even then my AHI was usually less than 1. Most of the time we are camping I will be able to connect to power so I will use the ResMed Autoset 10 for Her - I am using the "for Her" algorithm .

Yeh, it's difficult to know what the meds contribute but I am miserable and in pain without them) but I was feeling this tiredness before I took any of the meds - less energy since the "accident". But can hike 8-10 miles so it's more a "feeling" rather than inability. Thank Goodness.

Again, thanks for the suggestions- will post how things go!

[ChicagoGranny]

It's possible that the way the ResMed (in "for Her" mode) handles increases in pressure may make a difference in my developing aerophagia?

Hopes for that being the case and that you sleep and breathe restfully.

[OkyDoky]

I think you are reading something in the study that it didn't say. No mention of 30 to 56% breaths that I could find. Here is their suggested conciusion:

This suggests that only levels of inspiratory flow limitation > 30% be considered in the process of diagnosing obstructive sleep apnea in the absence of an apnea-hypopnea index > 5 and that < 30% of inspiratory flow limitation may be a normal finding in many patients.

That's just the abstract. You need to read the actual article:

In summary, our study demonstrated that only 5% of normal individuals present with > 30% of the total sleep time with IFL, establishing a value for IFL below which one statistically cannot invoke OSA in otherwise healthy individuals. Despite the observation that some individuals of the “normal” group presented up to 56% of IFL, the 95th percentile of a distribution (eg, 30% for % IFL) is conventionally used to statistically establish a likely boundary between health and disease. This is further supported by the increase in % IFL found in patients with mild OSA (AHI 5-15 and no symptoms) and OSAS (AHI 5-15 with clinical symptoms). Thus, values of up to 30% of IFL should be considered “within normal limits” and only values > 30% can support the likely presence of abnormality.

I did read the whole article and this is in what you quoted: the 95th percentile of a distribution (eg, 30% for % IFL) is conventionally used to statistically establish a likely boundary between health and disease. So their conclusion is based on the 95th percentile. And the >30% is of total sleep time with IFL not breaths.

[Guest]

I did read the whole article and this is in what you quoted: the 95th percentile of a distribution (eg, 30% for % IFL) is conventionally used to statistically establish a likely boundary between health and disease. So their conclusion is based on the 95th percentile. And the >30% is of total sleep time with IFL not breaths.

Therefore:

...30 to 56% of your breaths can be FL and you can still be normal.