Question about how the S9 scores hypopneas

[ozij]

My apnea is moderate (and on the mild side of moderate). And during my diagnostic study, there were no o2 desats. My main problem was with "hypopneas with arousal" (RERAs), not apneas or hypopneas with desaturations on the diagnostic study.

Robysue,
ResMed's don't respond to hypopneas, be they S8 hyponpnea, or by they S9 hypopneas. So the scoring of those is not really relevant to the quality of therapy you are getting. Resmed's do respond - aggressively - to flow limitations, but those have to happen in order of the machine to respond to them.

Somehow, it does not make sense to me to leave a person who has many respiratory effort related arousals at a miminal pressure that lets those happen. I would say that both your APAP experience at home and your BIPAP titration hint that your minimum pressure should be 7.8 at least.

My personal experience with the S9 makes me think its response to flow limitations (of which I have many) is different from the S8's, in that that S8 would raise pressure and stay there for 20 minutes. The S9 -- if I'm reading my charts correctly -- drops back down far sooner. You may be setting yourself up for repeated arousals by leaving your minimum too low.

If it were me, at this point, and until I had a bi-level machine to try, I would try to run the S9 at a fixed pressure of 7.8 (or 8), and an EPR of 2. That's almost like a bi-level with IPAP=7.8 (or 8) and EPAP=5.8 (or 6).

O.

Somehow, it does not make sense to me to leave a person who has many respiratory effort related arousals at a miminal pressure that lets those happen.

What markers/events do you consider credible as indicative of a "respiratory effort related arousal"?

My apnea is moderate (and on the mild side of moderate). And during my diagnostic study, there were no o2 desats. My main problem was with "hypopneas with arousal" (RERAs), not apneas or hypopneas with desaturations on the diagnostic study.

What I consider is really irrelevant -- it's what the PSG and robysue report. robysue reports having had many respiratory effort related arousals (RERA's) on her PSG.

In robysue's case - where her PSG indicated that her fundamental problem is "hypopneas with arousal" - and since, as you have pointed out previously, the S9 algorithm does NOT respond to hypopneas, do you consider the possibility that the ResMed algorithm just may not be the one best-suited for robysue's particular condition?

Of course. For any algorithm on any machine, there are people who are not well treated by that alogrithm. It is quite possible that the S9 auto algorithm cannot give robysue the type of therapy she needs. If your low flow periods cause arousals, and the S9 algorithm is not responding to them, robysue, then that automatic algrithm in not good for you.

>>My personal experience with the S9 makes me think its response to flow limitations (of which I have many) is different from the S8's, in that that S8 would raise pressure and stay there for 20 minutes. The S9 -- if I'm reading my charts correctly -- drops back down far sooner. You may be setting yourself up for repeated arousale be leaving your minimum too low.<<

For many people, and robysue stated similarly upthread, higher pressures are problematic.

True again. Higher pressures can be intolerable.
If robysue cannot tolerate the pressure that will keep her from having RERA's then she is in trouble. And your question, robysue, about when CPAP may cause more sleep disruption than your OSAH syndrome is valid (not that I have a reply...).

The doc seems to think IPAP=8 EPAP=6 may solve the problem... based on 17 minutes of sleep.

Further, rapid changes in pressure are contributors to arousals. In that respect, the S9 may be creating more arousals with either/both rapid pressure increases/decreases. It seems so in my experience with the S9.

True again. Which is why I suggested the following:

If it were me, at this point, and until I had a bi-level machine to try, I would try to run the S9 at a fixed pressure of 7.8 (or 8), and an EPR of 2. That's almost like a bi-level with IPAP=7.8 (or 8) and EPAP=5.8 (or 6).

Did you notice the word fixed in the above suggestion?
Do you agree, DHC, that this may be one way of having therapy at pressure lower than the intolerable 9, higher that a minimun of 7, and avoiding the arousals caused by changing pressures?
Do you agree that EPR=2 at fixed pressure may give robysue a rather consistent EPAP of 6?
Do you agree that is worth trying while waiting for a Respironics BIPAP?

[DHC]

Did you notice the word fixed in the above suggestion?
Do you agree, DHC, that this may be one way of having therapy at pressure lower than the intolerable 9, higher that a minimun of 7, and avoiding the arousals caused by changing pressures?
Do you agree that EPR=2 at fixed pressure may give robysue a rather consistent EPAP of 6?
Do you agree that is worth trying while waiting for a Respironics BIPAP?

O.,

The answers to your questions are contained in my post upthread - here -- viewtopic.php?f=1&t=58272&st=0&sk=t&sd=a#p548568 (paying close attention to the closing paragraph).

Cheerio!

[SleepingUgly]

And during my diagnostic study, there were no o2 desats. My main problem was with "hypopneas with arousal" (RERAs), not apneas or hypopneas with desaturations on the diagnostic study.

In you sleep study, was your problem was with hypopneas OR with RERAs? They are not the same. The S9 is supposed to report hypopneas. It does not report RERAs.

[robysue]

[
In you sleep study, was your problem was with hypopneas OR with RERAs? They are not the same. The S9 is supposed to report hypopneas. It does not report RERAs.

That's the $64,000 dollar question. And I think that is the root of my much of my frustration: they are not the same and I don't know which is the root of my problem. On the diagnostic sleep study there are some thing like 14 obstructive apneas in about 3 1/2 hours of actual sleep time and 70 "hypoponeas with arousal." These "hypopneas with arousal" are NOT counted towards the AHI on the diagnostic sleep study, but they are counted towards the RDI. The diagnosis of moderate sleep apnea was based on my RDI being 23.4, not my AHI being 3.9.

At the time I met with the sleep doctor, he just said, "you stop breathing 23 times an hour" and I hadn't seen the sleep study and was too stunned to realize what to asked about.

Since studying the results, I've met with the PA and ask her about what the "hypopneas wiht arousal" are and why they weren't counted toward the AHI; but she only gave me a vague answer.

And the lab that did the test is accredited by the AASM. So go figure.

[Big Daddy RRT,RPSGT]

Well your respiratory events may be well treated (Many people are quite pleased on the S9 with AHIs less than one). However you report you feel worse now and during your titrations it doesn't sound like you slept very well.

You seem to be comitted to therapy and report that you are using it nightly, not c/o mask issues and I assume mouth breathing has been looked at. On myself I would try a higher pressure just to see if it helps but you already reported that you did much worse on 9 cmH2O. IMO after 4-6 weeks of compliant nightly use if your not sleeping/feeling somewhat better something needs to be adjusted and they did...a home titration and lowered you to 7-8cmH2O (Again assuming mask is good, mouth breathing is in check, humidity is adequate). You report a slighlty better result but still feel worse. After several more weeks of nightly use you should have been sent for a BIPAP.

To qualify for BiPAP the Medicare guidline says...these criteria must be met...Mask is appropriate and the patient is using w/o diffiuclty AND CPAP prevents the patient from tolerating the therapy and a lower pressure was tired but failed to....(one of these must apply)...Adequately control the symptoms of OSA OR Improve sleep Quality OR Reduce the AHI/RDI to acceptable levels. It sounds like your daytime symptoms persist, and/or it has failed to improve sleep quality.
BiPAP might help you, good luck!

[robysue]

BigDaddy,

Mouth breathing has not been an issue---unless you can mouth breath and have leak rates of 0.0 consistently for the 95% on the S9 with the mask setting properly set.

The BiPAP titration was done about a month ago. I pick the BiPAP up tomorrow. Pressure settings will be 8/6 based on a whopping 17 minutes of sleep right at the end of a third rather troubled sleep study in the lab.

I'm hoping it will work. But I am feeling more and more like both I and the the doctor are shooting in the dark hoping to get in a lucky shot and it ain't happened yet.

And last night was once again a really horrible night and I'm again feeling like something the cat drug in this morning. And I had really horrible nasty bad and weird dreams (but NOT involving drowning or my not being able to breathe folks). So I'm quite sure I was in REM for some of the night. But then I don't think I ever had REM deprivation with my apnea. And given the horrid headache I have this morning, it feels like I must have had one or more nasty clusters of events last night, and certainly the the number of apneas for the night (as computed from the S9's AHI) is high enough to make that likely.

So here's sincerely hoping that the third time's the charm when I pick up the BiPAP tomorrow.

[SleepingUgly]

On the diagnostic sleep study there are some thing like 14 obstructive apneas in about 3 1/2 hours of actual sleep time and 70 "hypoponeas with arousal." These "hypopneas with arousal" are NOT counted towards the AHI on the diagnostic sleep study, but they are counted towards the RDI. The diagnosis of moderate sleep apnea was based on my RDI being 23.4, not my AHI being 3.9.

At the time I met with the sleep doctor, he just said, "you stop breathing 23 times an hour" and I hadn't seen the sleep study and was too stunned to realize what to asked about.

Since studying the results, I've met with the PA and ask her about what the "hypopneas wiht arousal" are and why they weren't counted toward the AHI; but she only gave me a vague answer.

And the lab that did the test is accredited by the AASM. So go figure.

It may be that the criteria they use for hypopneas is that they must cause desaturations, so they aren't counting them toward the AHI; nevertheless, they are acknowledging them, and therefore counting them toward the RDI (Did you have desaturations?). I would forget about the AHI and focus on the RDI. You have hypopneas that disturb your sleep. If they didn't say anything about RERAs, then either you don't have them or they don't score them at that lab. It would be good to know if they titrated you to eliminate RERAs. If they did, then in theory your titrated pressure should take care of all your respiratory events. If they didn't, then who knows whether your pressure is adequate to eliminate them.

I haven't been back for a sleep study since my surgery, but I did about 5 days on a pressure of 4cm, under the (perhaps faulty?) assumption that 4cm is pretty close to no pressure. My AHI was <5, but my flow limitation graph on the S9 doesn't look good. So did my surgery move me from hypopneas to RERAs? I don't know. I'm going to try to titrate up and look at the flow limitation graphs. I am trying to decide where to have another sleep study. My doc's lab doesn't score RERAs, so I'm UARS now, I don't know if that's a good choice...

I always dreamed, and in fact, my big problem is in REM (much more significant OSA in REM). Nowadays I'm dreaming, dreaming, dreaming. I feel like I'm up all night dreaming, and often I'm waking up a lot, so perhaps that's why I remember it. It may be time for me to bite the bullet and go back on the hose with my experimenting... Sigh.

[jnk]

It is possible to have "lip flutters" with a nasal mask that do not show up on your leak numbers but that do affect sleep architecture. In other words, making motor-boat sounds on and off all night can ruin sleep, much like snoring can.

A bilevel can be very comfortable to sleep with, but a 2 cm spread between IPAP and EPAP barely falls under the category of bilevel treatment. The AASM suggests (or recommends, or hints at, or mentions anyway) a minimum PS (pressure support; or, delta) of 4 cm, as I understand it.

If I were having your troubles, I'd want a team with a lot of experience treating UARS, regardless of what diagnosis was submitted to insurance.

[robysue]

No desats listed on any of the sleep studies that I can find. Min O2 sat on the diagnostic study is listed as 91%. Min on the first titration study is 92%. MIn 02 on the second titration study is 91%.

In all three of my studies, AHI, RDI, and spontaneous arousal index are worse in NREM than in REM (maybe that's why I get into REM?).

In the first titration study the AHI was reduced to 0.0 (representing no events for 30 minutes at end of night) at 9cm. In the second, the AHI was reduced to 3.5 (representing 1 hypopnea with arousal in 17 minutes right at the end of the night) at an IPAP/EPAP of 8/6. On that second titration study, by the way, there were a total of 2 apneas (one obstructive and one central) and 5 hypopneas with arousal during the course of some 120 minutes of sleep while being titrated.

The idea that lead to the bi-pap titration was that I could not tolerate straight 9cm (original titrated pressure) due to pressure in eyes (from inside my head) and severe aerophagia and significant worsening of daytime symptoms, a week of autotitratration leading to a marginal reduction in pressure (now on an apap range of 7--8 cm) that appears to control the apneas as well as the 9cm did (if you look at the S9's AHI numbers), but no real improvement in daytime functioning. And there are no mask issues---I find the mask comfortable and I'm not leaking. And I used my own mask on the third titration so I think that if mouth breathing, lip pursuing or any other mask problems were really an issue, they would likely have been noted either by the tech on that night or my husband at some point, who's told me that the snoring and other noises I used to make are no longer an issue.

So I'm grateful to my team for working with me and not just giving up. But I also do feel a bit like we're still just shooting in the dark hoping something will somehow work soon. And since I am feeling worse now than I did before starting CPAP some 12 weeks ago, I'm getting really tired of therapy making me feel sick instead of better. (Sorry for the rant.)

And right from the start I've been puzzled by the S9's numbers because it always reports that I have 0--2 hypopneas overnight and anywhere between 5 and 10 (and on bad nights 15--20+) apneas. Now remember---on my diagnostic sleep study I only had a total of 14 apneas. Now it is true that the S9 is running about twice as long as I actually slept during that diagnostic sleep study most nights and I'm sleeping quite a bit longer than the 3 1/2 hours than I slept on that diagnostic sleep study night. But still I find it puzzling that on most nights the S9 says that I'm still having a significant fraction (1/3 to 2/3) of the number of apneas that I had before CPAP and none of the much more numerous hypopneas. From what I've read, the apneas are supposed to disappear first with the pressure, and then the hypopneas, and then the RERAs. Am I just an outlier?

[jnk]

. . . No desats listed on any of the sleep studies that I can find. Min O2 sat on the diagnostic study is listed as 91%. Min on the first titration study is 92%. MIn 02 on the second titration study is 91%.

In all three of my studies, AHI, RDI, and spontaneous arousal index are worse in NREM than in REM. . . . Am I just an outlier? . . .

Maybe just straddling the fence between OSA and UARS?

http://www.ucsfcme.com/2010/slides/MOT1 ... tIsNew.pdf