High events maybe 2x per month

[Tranquilsky]

Untreated my OSA was 44 AHI. With CPAP, the vast majority of the time I am at less than 1 AHI. However, 1-2 nights per month my AHI will be randomly high-- like anywhere from 5-20.

I just got a new sleep doctor who looked at the 90 day report and claims I need to come in for another sleep study (i've already had two in the past 1.5 years). He claims that the 1-2 nights a month I'm having a high AHI is leaving me vulnerable to stroke and so forth. I told him I'm not inclined to shell out thousands of dollars for another study to figure out a random phenomenon that only happens maybe 3-5% of all nights. He got super angry at this and told me I was welcome to find another physician.

So he's a bit of an ass, but is he right? Is having high events, albeit fairly rare, leaving me still in high danger of other health issues? I feel amazing now that I'm on CPAP. I don't relish the idea of messing with my pressure again (i feel finally titrated to the right pressure and if I raise it higher I start mouth breathing).

What would you do in this scenario? Any advice appreciated.

[Respirator99]

From what you've said, your doc is either super-cautious or else super greedy. What are the chances of a single night sleep test showing up an event that only happens once or twice a month? Yes, every apnea increases your chance of stroke or whatever, but such a low occurrence seems pretty innocuous to me. (Of course, I'm not a medical professional, just some bloke on the internet).

Are you using the Oscar software? If so please post some daily charts showing a normal night and one of these high apnea nights. If you're not using it, please download and install Oscar then let us see the results. That may give us some pointers as to what exactly is happening to cause these high apnea rates (of course 5 - 20 is not really that high).

Can you also let us know what machine you're using and what the settings are?

[Tranquilsky]

Thank you! I'll try to attach an example Oscar file here.

I have a Resmed Autoset for her, however, I was previously titrated to a constant pressure of 7. I preferred the constant pressure and seemed to tolerate it better than auto. I have also bumped it up to 8 (constant) and it caused me to start mouth breathing.
I wear a F&P Brevida nose pillow mask, which I love. I really hate full face masks.

[Tranquilsky]

Last image attached.

[Pugsy]

First thing to do is figure out if you are awake or asleep when the ugly cluster happens.
http://freecpapadvice.com/sleepyhead-free-software

If you aren't really asleep when the ugly happens it doesn't really count for anything except that you aren't sleeping so great.

[Tranquilsky]

My apologies, what readout do you need from Oscar/Sleepyhead to find out if I'm awake during that time? I'm about 90% sure I'm asleep when these event clusters happen.

[Tranquilsky]

Here are a couple of readouts zoomed in on the ugly, if that helps. To me it looks like these are real events since there are little plateaus in the respiration pane?

[Pugsy]

My apologies, what readout do you need from Oscar/Sleepyhead to find out if I'm awake during that time? I'm about 90% sure I'm asleep when these event clusters happen.

Zoomed in flow rate sections of the ugly cluster. Explained in the videos at the website I gave you the link to.
We don't always remember arousals so I don't rely on memory alone.

Example...asleep breathing circled in red in images below. All the flagged stuff after the circled in red flow rate is arousal/awake related and don't count.





Now if it is proven you were indeed asleep then we look at what might be going on.
Which could be the following....most likely you needed more pressure for some reason (either you were on your back on in REM stage sleep) and with the fixed pressure the OAs weren't prevented and very well could have caused arousal centrals/CAs. At this point a lot of WAGs is all we can do and I don't like doing WAGs unless I have no choice. You've got more detailed data available. Lets see if if helps or not. WAGs...are wild ass guesses and while sometimes we do have to make a stab at something....I won't do it without at least trying to figure out the problem from available data.
To fix any problem you first have to identify the problem if at all possible.

I don't think that another sleep study at this point is going to be all that helpful
What are the chances that you will have another sleep study on one of the 1 or 2 nights a month that you have this off the wall results????

[Tranquilsky]

What are the chances that you will have another sleep study on one of the 1 or 2 nights a month that you have this off the wall results????

Exactly! That was my argument too. I think I'm mostly ticked off at the new doctor. It felt like they wanted to do another study no matter what. I'd like to give the benefit of the doubt but it feels like a money grab.

[Tranquilsky]

Please let me know if the zoomed in images above are adequate. Thank you so much for your help.

[Pugsy]

Omit the mask pressure for now...include it only if requested.
The only graphs we need right now are
Events
Pressure (only if using auto adjusting mode)
Flow rate
Leaks
Flow limitation only if using auto mode OR your FL graph is very active (which yours isn't).
You can fit this easily on one screen shot...all those other graphs aren't need and just making more work for you and us.
See this thread.
viewtopic/t158560/How-to-post-images-for-review.html

When doing zoomed in sections for review you need to also include the time in the flow rate where nothing happens.
Not the middle of a big cluster but instead the very beginning of the cluster to see if we can spot asleep breathing flow rate changes.

Go to the Events tab on the left side of your detailed report. Click on it to open it and you will see the 3 categories of events.
Click on CA...clear airway events...also known as central apneas on ResMed machines.
Scroll down the list until you see the first CA flagged at right before that 5:00 time frame. I can't tell exactly when that will be but somewhere around 4:45 maybe.
Click on that first CA event. The software will then zoom in on that first flagged Central and put it in about the middle of the graph. Giving us a good look at the flow rate breaths going on just before that flag.
Take a screen shot and post it. We need to see if you were really asleep prior to that flag at around 4:45 or whenever it occurred.

[Tranquilsky]

Thank you. One image is following your instructions and the other is a zoom that I did manually to show a little more context. I hope I did this correctly.

[Tranquilsky]

so sorry for the multi posts. Below is the one that just shows the CA in the middle.

[Miss Emerita]

Please do use the video from Pugsy to help you understand awake vs asleep breathing.

Just looking at the screenshots you've posted, I wonder whether you have positional apnea. This could be from rolling onto your back, as Pugsy suggests, or it could be from tucking your chin down toward your chest, which somewhat constricts your airway and makes it easier for OAs to happen.

If you use a high pillow, or several pillows, try switching to a fairly low, firm pillow. And try using a soft cervical collar at night. You want it loose enough to be comfortable, but not so loose that your chin can sneak down under the edge of the collar. It's an easy, safe experiment, and I'll be curious what happens.

[Pugsy]

Below is the one that just shows the CA in the middle.

Pretty sure that the first flagged event follows an obvious arousal breath.
We just don't breathe that way when asleep.
See the big gulps of air at 04:51:00???? That's an arousal breath and the irregular breathing prior to that big breath also points to not being sound asleep.

I am leaning towards you weren't sound asleep and the bulk of that ugliness is arousal related.
Now why the arousal???? Unknown really but since it happens infrequently and you report actually feeling quite decent overall...and feeling like you are sleeping decently....I don't know that I would worry much about it.
Awake/arousal breathing false positive flagged events aren't going to be something that negatively affects your overall health...meaning I don't think that these are going to cause a stroke or anything like that because I don't think you were sound asleep. If we aren't asleep...they just don't count.

What you might consider doing is adding a recording pulse oximeter overnight and see when you finally have another ugly cluster if you happen to have some sort of desat of the oxygen levels going on at the same time.
Just for extra peace of mind.
Since the ugly clusters are rare you may have to use the pulse ox for several nights until you happen to catch it happening again.

Your leaks seem to be a bit higher during the cluster and just prior to the beginning of the cluster...not enough to really impact therapy quality but they might be enough to impact sleep quality. So it's not impossible for the leaks to be an underlying factor in the arousal flagging. Something to think about and maybe try to work on just in case. Look back on your other clusters....what did those leak graphs look like???

We breathe irregularly all the time while awake and it doesn't present a danger to us. It's no different when we are asleep.

Here's an example of a real asleep flagged event. Note the nice smooth boring flow rate (breathing) just prior to the event before and after.



And this one at the beginning of the night....all those flagged events are false positive. I circled in red the flow rate at the end of the graph on the right where this personal finally went to sleep...and the events flagged stopped.



And this one you can see the irregular breathing with the flag ...another false positive.



Your flow limitation graph is really pretty uneventful. I would assume a much more dramatic result showing up on the flow limitation graph if those flagged OAs were real asleep flagged events. I just don't see someone having that many real asleep OA flagging and not having a corresponding ugly Flow Limitation graph.

Overall...if this were my report I would lean towards the bulk of the ugly being false positive related since I wasn't also reporting feeling like crap and sleeping like crap...and it only seemed to happen once or twice a month.
I don't know if I would do anything more than shrug my shoulders but I might try some little tweaks just to see if I could for sure isolate a potential cause. The problem is you would have to make a change of some sort and give that change a long time (since the ugly is so rare) to see if the change makes any difference or not. That's going to take a lot of will power and prolonged experimenting and it's going to be hard for most people to maintain such a prolonged experiment.

To be honest I just don't know if a once or twice a month ugliness justifies that much work and devotion for a "maybe" situation because if these are indeed awake related flagging....nothing is going to fix it except fixing the awakening or sleep disruption problem itself.

If you aren't sleep...those flagged events don't mean anything except your sleep was disrupted to some extent.
The fact that you don't remember it....doesn't mean much because we can often be awake and not remember it.
Sort of half asleep kind of thing. I know I do it all the time...and don't necessarily remember it.

Your choice if you want to investigate further and do any experiments to resolve or answer the questions.
First thing you do need to do though is educate yourself on identifying asleep breathing vs awake/arousal related breathing and that's going to take a lot of work on your part. Gotta look at hundreds and hundreds of zoomed in flagged events and low rate sections.

Finally...it wouldn't be impossible for there to be a combination of arousal and asleep positional factors going on here.
Meaning a potential real asleep flagged event could happen and cause an arousal...which in turns increase the chance of of false positive flagging happening and you get in sort of a vicious circle. I don't see it here on the examples you posted but that doesn't mean it didn't happen elsewhere.
Awake/arousal flagged events aren't dangerous to your overall health.