Wow, Crazy Polysom Results, Folks!

[montana user]

Are you talking about the new rules the American Academy of Sleep handed down? I understand what they mean by raising top pressure for hypopneas and bottom for obstructives....BUT you still have to keep a closer split ( usually a 4 split 11/7) the new rules stated things such as how soon to raise pressures and such. I am going to call a few of my sleep tech friends and look more into this for you.

[socknitster]

Thanks. I just have this feeling that there is some misunderstanding of the "official recommendation" on this topic by that particular sleep lab. I just can't believe that anyone who has experienced such a wide split, as you put it, would recommend its use for ANYONE. It is incredibly uncomfortable. I'll post again when I have had a chance to discuss this finding with the actual sleep doc in September. I'll be very curious to see what he has to say about all of this.

[montana user]

so I checked with a few other techs a different sleep labs in the area and none of them would ever do more than a 4 split difference on Bi-level. I think that tech just read the rule wrong or understood it differently? The only time we do more of a split is for COPD patients so they can exhale alot easier and not have back pressure. Is there anyone else in your area that could look over your results and see what they think?

[twasbrillig]

Hi Sock,

Perhaps I am missing something, but I didn't see where your polysom results showed respiratory effort related arousals. Is it possible that your spontaneous arousals are not really that spontaneous after all, but are in fact a response to inspiratory flow limitation? This might explain how you have no apnea in your study, but still feel you benefit from CPAP?

I found that I had strange titration experiences, too, because the techs were flummoxed by someone who had lots of sleep disruption but no overt apnea. SO... I would guess that if your sleep lab doesn't identify RERAs, then you are going to have trouble getting the right pressure(s)

I have UARS and it seems to be a puzzle. Just a thought...

Twas

[sleepmba]

That is a strange study indeed. Like Montana User, I'm a sleep tech too. I'll touch on a few points made here.

Central Apneas- The amount of central apneas you had are well within the normal range. You shouldn't worry about that. I'm actually surprised there wasn't more with all of your arousals. Check out my blog for some more on normal Central Apneas: http://www.sleepandcpap.blogspot.com

Your study showed many arousals and alpha intrusion. Here is my take on it. It sounds like the pressures they had you on were very uncomfortable. When something is that uncomfortable, it will disturb your sleep, hence all of the arousals. I bet all the alpha they were seeing was you being awake and trying to go back to sleep on the odd pressures they had you on. I bet that big of a spread in BiPAP can cause alpha intrusion too (since it is so uncomfortable). During your titration, as you were exhibiting all of the arousals (because of your discomfort), your tech thought you needed more air and bumped you up in IPAP. In the titration world, it is usually frowned upon to increase pressure for arousals. Pressure should only be increased for respiratory related arousals (caused by apneas, hypopneas, snoring, RERA's). But then again, I wasn't there for your titration.

I think a retitration is in order

PS I think you did the right thing to change your pressure.

[NotMuffy]

Your study showed.. alpha intrusion.

Where does it show that?

I bet that big of a spread in BiPAP can cause alpha intrusion...

You'd lose.

NotMuffy

[NotMuffy]

so I checked with a few other techs a different sleep labs in the area and none of them would ever do more than a 4 split difference on Bi-level. I think that tech just read the rule wrong or understood it differently?

Well, here's "The Rule":

4.3.1.6 The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential
is 10 cm H2O

NotMuffy

[sleepmba]

Your study showed.. alpha intrusion.

Where does it show that?

I bet that big of a spread in BiPAP can cause alpha intrusion...

You'd lose.

NotMuffy

Sorry, I thougth that the Original Poster was told that she had Alpha Intrusion. Now that I go back and read more carefully, the OP came up with this on her own.

Edit: We'll leave that bet for another thread.

[socknitster]

so I checked with a few other techs a different sleep labs in the area and none of them would ever do more than a 4 split difference on Bi-level. I think that tech just read the rule wrong or understood it differently? The only time we do more of a split is for COPD patients so they can exhale alot easier and not have back pressure. Is there anyone else in your area that could look over your results and see what they think?

I will be going over this data in detail with my sleep doctor in September.

Perhaps I am missing something, but I didn't see where your polysom results showed respiratory effort related arousals. Is it possible that your spontaneous arousals are not really that spontaneous after all, but are in fact a response to inspiratory flow limitation? This might explain how you have no apnea in your study, but still feel you benefit from CPAP?

I found that I had strange titration experiences, too, because the techs were flummoxed by someone who had lots of sleep disruption but no overt apnea. SO... I would guess that if your sleep lab doesn't identify RERAs, then you are going to have trouble getting the right pressure(s)

I have UARS and it seems to be a puzzle. Just a thought...

Interesting, Twas. I know they had bands around my chest and abdomen, but I don't know the answer to your question. I will bring this up with the sleep doc in Sept. I don't think this lab tests for UARS--don't they have to put something like a wire down your throat to test for that? You are right though, flow limitations were not even mentioned. You are right though, this is a possible answer--I may have to go to a larger city to get a more specialized test. I am also very tempted to do a split night to see what my sleep would be like without cpap altogether.

Central Apneas- The amount of central apneas you had are well within the normal range.

Thanks sleepmba, I didn't know that. That is very reassuring. I'll be sure to check out your blog!

I bet that big of a spread in BiPAP can cause alpha intrusion too (since it is so uncomfortable). During your titration, as you were exhibiting all of the arousals (because of your discomfort), your tech thought you needed more air and bumped you up in IPAP. In the titration world, it is usually frowned upon to increase pressure for arousals. Pressure should only be increased for respiratory related arousals (caused by apneas, hypopneas, snoring, RERA's).

That is interesting. It seems like there were a lot of arousals during the three hours they had me on 8/4, though, which should have been fairly comfortable. I had the fewest spontaneous arousals at 9/4 and also had the most REM at that pressure. Interestingly, I was also on my left side at that time. I only had REM on my left side--twice I turned onto my back during REM and popped right out of REM. That might speak to these flow limitations being a problem since we all know back sleep is bad. Also, it does seem a bit odd that I would turn over during REM, doesn't it? Aren't we supposed to be paralyzed during REM? I sometimes experience REM immediately upon falling asleep at night too. The nurse practicioner for the Sleep Doc said I didn't have narcolepsy since this didn't show up during my titration, but suggested that the part of my brain controlling sleep/wake wasn't functioning properly and that is why they recommended the nuvigil to help me wake up in the morning. I tried it for two weeks and it seemed to help but I had to give it up because of side effects.

Sleeping on the back is terrible--yet it is cpap itself that forces me to do it, ironically. Aerophagia is positional and has trained me to sleep certain ways. For a LONG time I couldn't even sleep on my left side. Now, thank goodness I can, but my right side=BALLOON BELLY.

I guess I could be experiencing REM upon falling asleep just from simple REM deprivation.

I kinda feel like no one really knows what is going on and I worry that while we are all scratching our heads, the poor sleep is doing permanent damage to my brain and body. Sometimes I get so frustrated I could just scream. I know this isn't cancer or anything, but it seems like sleep is so simple--something we need as much as food and water and yet no one has a clue how to fix it. I sure hope I get more answers in September. I will surely come prepared with lots of questions.

NotMuffy, thanks for the info. I think this rule is dumb. It isn't taking the patients COMFORT into account. Who is going to be compliant with a bipap set like that? You set a newbie up like that and you are basicly INSURING they will not be compliant. The "head honcho" at the sleep lab when I called had the audacity to ask me if I had biflex. I almost laughed. No amount of biflex is going to make that kind of spread comfortable. Not unless a whole new algorithm is written specifically for this kind of split with the patients comfort in mind.

Jen

[sleepmba]

When you first fall asleep, are you having dream like visions? These may be Hypnagogic Halllucinations. Here is something that touches on that...look a couple of paragraphs down. http://en.wikipedia.org/wiki/Hallucination

[NotMuffy]

Perhaps I am missing something, but I didn't see where your polysom results showed respiratory effort related arousals. Is it possible that your spontaneous arousals are not really that spontaneous after all, but are in fact a response to inspiratory flow limitation? This might explain how you have no apnea in your study, but still feel you benefit from CPAP?

If the spontaneous arousals were RERAs then they would/should have responded to the increased IPAP. Perhaps that was the rationale for the increased IPAP during the study (they didn't have a report that said "no RERAs", they had a bunch of arousals). However, the scoring of flow limitations during BiPAP can be debated in that one must be aware that all breaths, technically, are pressure-, and consequently, flow-limited. In other words, the waveform may be determined by the machine instead of the patient.

She had no apnea because she was always on at least 8/4 BiPAP (although as noted, there is no supine REM).

I found that I had strange titration experiences, too, because the techs were flummoxed by someone who had lots of sleep disruption but no overt apnea.

There's a million things that cause sleep disruption. SBD is only one of them.

Flummoxed?

I know they had bands around my chest and abdomen... I don't think this lab tests for UARS--don't they have to put something like a wire down your throat to test for that?

If the belts were "RIP" belts, that would have been an acceptable surrogate for esophageal balloon.

I am also very tempted to do a split night to see what my sleep would be like without cpap altogether.

Now THAT makes far more sense than a simple "retitration" because you had no events at any pressure (although again, supine REM was not examined). Just make sure it's a LONG split.

I sometimes experience REM immediately upon falling asleep at night too.

I don't think you do.

The nurse practicioner for the Sleep Doc said I didn't have narcolepsy since this didn't show up during my titration...

If she means you didn't have SOREM, that could have been masked by the Celexa.

I guess I could be experiencing REM upon falling asleep just from simple REM deprivation.

That's the Celexa.

I think this rule is dumb.

Don't shoot the messenger.

You kids wanted The Rule.

That's The Rule.

NotMuffy

[socknitster]

When you first fall asleep, are you having dream like visions? These may be Hypnagogic Halllucinations. Here is something that touches on that...look a couple of paragraphs down. http://en.wikipedia.org/wiki/Hallucination

Well, I guess I'm not entirely sure from that description WHAT exactly I'm experiencing. If I am experiencing a dream-like phenomenon as I fall asleep, I guess I assumed it was REM, but perhaps there isn't any rapid eye movement at that time and it is a hallucination--it certainly feels very dream-like. I don't really know since it did not happen during the sleep study and has actually happened with less frequency lately (although it did happen last night and I've been off Celexa for three weeks now, Muff.)

When I was in the worste throws of the chronic fatigue syndrom onset--I was also experiencing paralysis upon wakening--these two symptoms (as well as a history of getting really weak whenever I laugh really hard or get mad--not exaclty cataplexy, but maybe a mild version of it) is what led me to ask specific questions about narcolepsy of the NP for the sleep doc. She felt it was worth exploring with a nap session before my sleep study but after the psg she dismissed it altogether. That's fine. She is the expert. I don't know if having a diagnosis of mild narcolepsy, if it is even there, would do me any good anyway.

Sorry, Muffy, I appreciate your help. I was commenting on the rule and not the messenger.

Hopefully this will all work out in time. I'm hopeful that when I see the Sleep Doc next month he will order a Long Split as you suggest, Muffy, because I'm really beginning to wonder about whether the tonsilectomy I had three years ago didn't cure my OSA. That is a very expensive 3 years of treatment and a lot of discomfort, but its really shame on my for not insisting on retesting sooner. I hated my old sleep doc (total jerk--very dismissive and belittling of me) and it took getting sick for me to find a new one and explore my sleep as a possible source of some of my symptoms. I actually feel really lucky to have found this new clinic. So far, the NP has been very helpful and understanding.

[NotMuffy]

Well, I guess I'm not entirely sure from that description WHAT exactly I'm experiencing. If I am experiencing a dream-like phenomenon as I fall asleep, I guess I assumed it was REM, but perhaps there isn't any rapid eye movement at that time and it is a hallucination--it certainly feels very dream-like.

There is also dreaming in NREM. Did this "dream" depict "normal" stuff?

She felt (narcolepsy) was worth exploring with a nap session before my sleep study but after the psg she dismissed it altogether.

If that was based on the absence of SOREM, that will play out in the next PSG if you are Celexa- (or any other REM-suppressing drug-) free.

NotMuffy

[socknitster]

There is also dreaming in NREM. Did this "dream" depict "normal" stuff?

I didn't realize we dreamt in NREM. Huh. Yes, well all my dreams are usually quite bizarre. I would define most of my dreams as sci fi/alternate reality. Weird. Things are never as they seem--the laws of physics need not apply. Not average, mundane stuff. Otherwise, I'm not sure what you mean.

[LoQ]

Maybe one of the sleep techs would comment on this, because I'm curious. Before I started CPAP therapy, my dreams were always negative, and many times they were nightmares. Now I mostly have positive dreams. Negative means negative emotions associated with the dreams. Positive means positive emotions associated with the dreams.