Help! Still Sleepy, MyEncore Reports, etc.

[StillAnotherGuest]

..if so you might want to consider a decongestant like Claritin-D (it may also make you sleep better, but don't take more than 3-4 days), you would also need to take it before bed about 1hr.

Actually, I would avoid Claritin-D like the plague, it contains pseudoephedrine, which will commonly generate nervousness, anxiety, insomnia and/or fragmented sleep, especially if taken right before bedtime. It's also used in clandestine labs to make methamphetamine.

If you really need to take a decongestant, you might want to look at something with phenylephrine, which might give you a better shot at maintaining sleep quality.
SAG

[StillAnotherGuest]

Well, there are a few points noted in the sleep study.

Most glaring is the absence of REM. Knowing how you behave in REM is essential to planning treatment.

OSA tends to be far worse in REM vs NREM (can you imagine, worse than AHI 114?) Probably not AHI-wise, but desaturation-wise. I can't imagine you never having any REM (this situation can occur with some medications as well as OSA)(well, usually not none) and it might be interesting to offer another explanation for the areas of increased pressure in the 12/4 study. They are roughly 90 minutes, or a multiple of that, apart. Which would make them occurring approximately at periods of REM, so there could be a reason why increased pressure might actually be necessary if there is a significant REM-dependent component.

Alternatively, if the OSA was less severe or non-existent in REM, you could make a case for CSBD, which would explain the inconsistent pressure responses. If you really want to make a case for centrals, that tendency will pretty much always be there, and the relatively high ending pressure during CPAP titration could be the result of an ineffective titration punctuated by unresponsive or worsening AHI in the face of increasing pressure (BTW, do you have that study? There may be clues there).

The lack of severe desats in the face of a horrendous AHI is somewhat curious. Another BTW, the nadir of 81% occurs during what is most probably artifact (note reference line at 80%):


so your nadir looks more like mid-to-high 80's. And that's probably academic now with the 30 pound weight loss (until we're sure about REM).

All those PLMs are buried in the respiratory events. Generally, PLMs cannot be scored if they're contained within respiratory events, but we can check that further in the titration statistics once the respiratory events are resolved.

The overall sleep architecture is a wreck, with all the Wake/Stage 1/Stage 2 stage changes. We'll have to see if Sleep Percentages normalize and overall architecture improves with CPAP.

I see you've got a 251 second respiratory event in the report there.

That's pretty long.
SAG

[StillAnotherGuest]

That arousal index of 159 per hour (including respiratory, PLM and spontaneous arousals) is practically unheard of. The spontaneous index at 43.1 alone is higher than most folks total, so it would also be a good idea to insure that that was addressed in the titration.
SAG

[Snoredog]

[quote="StillAnotherGuest"]That arousal index of 159 per hour (including respiratory, PLM and spontaneous arousals) is practically unheard of. The spontaneous index at 43.1 alone is higher than most folks total, so it would also be a good idea to insure that that was addressed in the titration.
SAG

[kteague]

The technicalities of this discussion have been fascinating and way beyond my knowledge of the intricasies of data interpretation. I just know that the results of 5 sleep studies I've had since 1999 were so "all over the board" that one would think they were from different people. PLMD totally obscured the OSA in the first study, so I went undiagnosed for the next 4 years, though I was symptomatic. With treatment for the PLMD, the degree of OSA was dependent on time of night, how bad my movements were, and levels of medication in my system. The movements were intense enough that they certainly affected my breathing. What a nightmare for those looking for patterns.

[StillAnotherGuest]

PLMD totally obscured the OSA in the first study, so I went undiagnosed for the next 4 years, though I was symptomatic. With treatment for the PLMD, the degree of OSA was dependent on time of night, how bad my movements were, and levels of medication in my system. The movements were intense enough that they certainly affected my breathing. What a nightmare for those looking for patterns.

Then you have consider if the Medicare scoring criteria are being used, where you can't call a hypopnea a respiratory event unless there's a desaturation (although you should call it a RERA) and if all you've got is an APAP (and event criteria can vary significantly) you'll never figure it out. As an example, here's a PSG that has all these factors:

While the respiratory pattern shows an overall pattern of flow limitation (the breathing waveforms are all flat on the top) with breakthrough snoring, in this particular run the sleep disturbance is undoubtedly caused by the severe PLMs (noted in the LEGS channel). There is a subtle difference in the timing (OK, that and observation with a $40,000 infrared video system that is screaming "PLMs!") that puts the chicken back in the egg, err, whatever. At any rate, if you're using Medicare criteria, the respiratory component couldn't be called apneas because they're not reduced enough and they're not hypopneas because there's no corresponding desaturation. You could get away with identifying the arousals as RERAs (temporarily), but if it turns out that flow limitation becomes corrected with the same CPAP level (i.e., sleep continuity by itself can contribute to airway stability) then you gotta say it's the PLMs.

Of note, the first event could appropriately be called a RERA or UARS-type event, since there is an increasing pattern of effort (as noted in the chest and abdominal effort belts) culminating in the arousal, and there it's the PLM that is coincidental.

But if all you have to look at is a single channel (like an APAP or a Sleep Strip) it's gonna be tough.
SAG

[CollegeGirl]

SAG -

Can other allergy medications cause fragmented sleep? For example, Allegra-D? Now you have me wondering. Is it something that happens to all that take it, or just a rare side effect?

[-SWS]

Yep I'm pretty proud of her, nah she's still in school (think she just likes being a full time student), she just finished up her final final in obtaining her Masters degree in Oral Biology, she already holds BA's in English and Psychology and of course finishing up her doctorate in Denistry, she is getting a lot of pressure to stay and go through the Periodontal course where she can do oral surgery and implants which is what she really wants to do. She is still taking 42 units a semester, seeing 2-3 patients a day, a ridiculous schedule if you ask me.

Congratulations to your daughter on her fine accomplishment, and congratulations to Snoredog on his fine accomplishment of a daughter as well. Speaking of relatives, Aunt Florence is in town once again with her crystal ball. She says your dental bills are on the verge of going down considerably. .

[cillakat]

snoredog wrote:
<<you could have some kind of a food allergy>>

carla does have some kind of food allergy. Her current diet does not reflect an, um, adequate respect for how much these food allergies/intolerances affect her overall health.

It definitely plays a role in her GERD. Definitely plays a role in overall systemic inflammation that can only worsen this complex issue.

C.....you're planning a pregnancy soon. You can't be pregnant with this severe apnea. It's dangerous for you over the long haul and dangerous for a developing fetus I'd have to imagine.

I'll come visit sometime soon and we'll make a plan of action:) that includes a new doc. Hey! You could come to atlanta and see Kimball. She's awesome.

I started getting and URI at the same time you had yours. This time, i treated agressively wtih my whole A/zinc/zicam/lomatium osha thing (which i always do) but in addition I did inhaied steriods (not flovent but similar.....a dry powder inhaler whichh i liked better). And for the first time ever, i used 1 tiny sudafed twice a day (it did help) and most importantly an anti-cholinergic....which is basically an ant-mucous drug:
http://en.wikipedia.org/wiki/Ipratropium

I didn't take atrovent but the newer generation of that class - simply b/c that's what the doc had samples of. It was *amazing*. My illness ended up being fairly mild (b/c of the zinc/A/zicam/lomatium osha etc ) but also, the symptoms affected me less ito the choking/gaggin sensations of tons of mucous in the back of my throat and in my lungs.

I could only do the atrovent-like drug once a day and one day i purposedly skipped it b/c i was feeling too dry, but over all, i know it had a signficant effect.

Also, I did a fair amount of guaifenisen, which is *very* safe and afaict doesn't afffect sleep at all. It helps thin/loosen mucous secretions which for me, lessens the need for something like sudafed or atrovent. Oh, and i used albuterol (inhaled) as needed which was probably only twice. You've got all of this stuff on hand b/c of Ian right?

Have you seen an allergist or pulmonologist? Now is the time:)

k

[curtcurt46]

College Girl.
The decongestant in Allegra-D is known for disrupting sleep especially late in the day. I have only been able to take one in the morning and then a regular Allegra in the evening.

[Snoredog]

cillakat wrote:

C.....you're planning a pregnancy soon. You can't be pregnant with this severe apnea. It's dangerous for you over the long haul and dangerous for a developing fetus I'd have to imagine.

While I'm no expert on anything, I think that one needs to be run by her specialist, looks to me she already has 2 great looking kids so far and they appear to be healthy and fine from the pictures I've seen.

I agree that the saturations could be a problem, but if she stays on any kind of cpap pressure even if less than optimal pressure her oxygen levels should stay within acceptable levels, if not supplemental oxygen could always be added.

Some of the research I've read in the past on other disorders including blood disorders like Lupus and the like, didn't preclude someone from a pregnancy.

So many changes take place during pregnancy it is hard to say exactly what her sleep disorder may look like during that time, there is even a good chance that supplemental vitamins consumed during pregnancy could even assist with her sleep disorder severity, that we just don't know for sure but nearly all medications one might be taking beforehand are eliminated that are shown to cause harm to a fetus, that alone could help.

I would certainly suggest a SP02 monitor during sleep with any pregnancy and consulting with Specialist trained in both fields.

I would start with a ABSM certified doctor:
http://www.absm.org/Diplomates/listing.htm

I would look for a Pulmonologist over say a Neuro, click on your state, use your browser to find the nearest town, see the Certified doctors in your area.

[cillakat]

when i said she 'couldn't' be pregnant with this severe apnea, i didn't mean 'couldn't'......of course she *can*. but everyday, we learn more about how sensitive babies brains are to the slightest insult. a good example is the emerging evidence that a plethora of environmental contaminants are responsible perhaps in large part, for the rapidly rising numbers of kids with ADHD among other things. even vitamin D deficiency is likely soon going to be linked to various developmental brain issues soon. cutting edge researchers in the field are just starting to make the link. anyway, it's my own personal little nudge to a very dear friend to take Very Very Very seriously this issue which is definitely affecting her own health and also could possibly permanently, perhaps even in small ways, the life of a child she might have. i mean, if it's the difference of changing brain function even a little little bit that can mean huge differences in say, mood stability, impulse control and other things that very much affect quality of life over the long haul.

snoredog, if the vitamins and minerals taken during pregnancy could help, then there's no reason they shouldn't be taken, *now* by anyone dealing with sleep apnea. afaik off the top of my head there's no evidence that zinc, vitamin A, D or any the common prenatal vite inclusions could help sleep apnea.....but i could put together a pretty reasonable argument that some of them could (esp zinc, A and D) help some things that could in turn lessen to some degree *possibly* some of the factors that contribute to apnea. *maybe*. but it's not a bad idea for anyone to be getting optimal amounts of zinc, b vites, A, D, magnesium and various antioxidants. and most people aren't. especially the zinc, A, D and mangesium.


k

[StillAnotherGuest]

Can other allergy medications cause fragmented sleep? For example, Allegra-D? Now you have me wondering. Is it something that happens to all that take it, or just a rare side effect?

I think that you can pretty much count on all the pseudoephedrine-containing drugs to have an adverse effect on sleep, the only question would be to what extent that effect could be. The effect could vary from things you would notice directly (delayed sleep latency or sleep maintenance insomnia) to things you would notice indirectly (EDS the following day because of sleep fragmentation).

The drug variables are many (dosage, age of patient, etc.) but an important consideration is that if the half-life of pseudoephedrine is about 4-6 hours (and of course, longer in the time-released forms), so taking it just prior to bedtime is pretty much asking for a poor night's sleep.

And with a PSG result like the one shown above, where there is already significant sleep fragmentation, adding a pseudoephedrine-containing drug will undoubtedly make things exponentially worse.

The nature of this drug as a sympathomimetic amine would make these side effects common throughout all groups. Depending on the drug or combination of drugs, the incidence of insomnia can be as high as 25%. Course, that brings us to what the definition of insomnia is. Perhaps a better criteria would be to employ Sleep Efficiency (Time Asleep/Time in Bed). If you're at 85%, or the use of a medication gets you to 85%, that's a problem. At 75%, that's a big problem. But being able to objectively measure this, and certainly the degree of sleep fragmentation, is certainly not possible outside of the sleep laboratory. Maybe just sticking with the generic "interferes with your daytime activities and ability to function" is the way to go.

I think you'd need a really good reason to use a pseudoephedrine-containing drug, use it sparingly, don't use it immediately before bed and have a real low tolerance for switching to something else if sleep quality appears to be getting worse.
SAG

[carla]

Data for the last two nights is up again....
http://family.wiseoak.com/charts3.html

Nothing as good as that first night of changes...My nights were never very consistent though, so I think I'll keep at these settings for week, and then maybe try a straight 9 for comparison.

Oh, how I'd love to have an oximeter to see another layer of what's going on. On a good note I did finally pick a new sleep lab and doctor, so I hope to have a new PSR fairly soon.

-Carla

[Snoredog]

Data for the last two nights is up again....
http://family.wiseoak.com/charts3.html

Nothing as good as that first night of changes...My nights were never very consistent though, so I think I'll keep at these settings for week, and then maybe try a straight 9 for comparison.

Oh, how I'd love to have an oximeter to see another layer of what's going on. On a good note I did finally pick a new sleep lab and doctor, so I hope to have a new PSR fairly soon.

-Carla

I see nothing but improvement, your last charts and these new ones show 7.0cm to 8.0cm is your ideal pressure. If you are going to try straight anything, I would just lower your autopap's Max pressure down to 8.0cm. You can leave your Minimum at 6.0 if you want.

Your EncorePro reports shows some flat-lining, but I suspect those are central events wanting to "runaway" and the 10cm limit prevented that from happening. I mentioned before that 10.6cm pressure was the pressure I thought where centrals skyrocket (actual is 10.5cm), your latest AHI vs Pressure report bears that out:



Your report also shows at 16cm your AHI is low, IGNORE that, there is no reason to DOUBLE your pressure only to reach that other dip.

Because of your aerophagia, the new settings I would suggest are:

Min.=6.0cm
Max.=8.0cm (it will still probe at 9cm).
CFlex=2

You should note the benefits of using lower pressure it is found throughout your report especially with the leak report, lower pressure fewer leaks, quieter machine and mask, the benefits are many.



I stand by my previous theory that the machine was misreading your apnea and was triggering pressure induced central apena even though they didn't note anything on your PSG (I would use another sleep lab with more experience at next titration). Autopap machines are good, just not that good, always error towards the conservative side.