apnea on inhalation or exhalation

[bouncer]

Can anyone tell me if it is it common to have apneas on exhalation, as I do? I gather (maybe incorrectly) that most people cannot breathe in and wake up snorting air in but I have trouble breathing out and wake up with sharp mouth exhalation; or is it all the same type of apnea?
Hoping that someone can clear up my confusion!
Thanks
Bouncer

[LoQ]

Can anyone tell me if it is it common to have apneas on exhalation, as I do? I gather (maybe incorrectly) that most people cannot breathe in and wake up snorting air in but I have trouble breathing out and wake up with sharp mouth exhalation; or is it all the same type of apnea?
Hoping that someone can clear up my confusion!
Thanks
Bouncer

I would love to know the answer to that. I have that identical problem. I'm sorry I haven't got an answer for you. In three years on this board, I still don't know.

[imsleepynomore]

I had the same problem before CPAP any info would be nice.an inquiring mind would like to know

[Mary Z]

Wish I had an answer as I'd like to know, too. I makes sense that the airway could collapse after an inhalation. No one has an EPAP of 0.
Sounds like you (two of you) are living proof.

[billbolton]

Can anyone tell me if it is it common to have apneas on exhalation, as I do?

It depends what you mean by common.

Users who experience most/all of their apneas on inhalation are generally far more prevalent in OSA treatment presentations than those that experience most/all of their apneas on exhalation, but on the other hand experiencing apneas on exhalation does certianly occur in a non-trivial percentage of presentations.

Cheers,

Bill

[DoriC]

Can you list your machine, mask and pressure you're using? You may just need to tweak your settings.

[bouncer]

Thank you for your replies - good to know I am not the only one but I'd still like to find out why it happens and is there any difference in the two "types" as far as what is physically going on in the throat is concerned.
I have an old Resmed S7 Auto Spirit (since 2002) with Swift LT nasal pillows - I usually only have two or three true apneas per night on the machine but without it I start getting the exhalation ones before I even drop off. (all started after chemotherapy and hysterectomy, so there's got to be some sort of link there) - trouble is, I'm now getting problems with my sense of smell which I feel pretty sure must be to do with the cpap use (although the ENT clinic says this could not be the cause); so I'm thinking of buying the S9 and changing to a full face mask .....
Bill, would the latest Resmed S9 be able to detect and report on whether apneas are on inhalation or exhalation?
and would the ability to reduce the exhalation pressure be of any help? (logic tells me that having air blown down my throat makes exhalation more difficult anyway and therefore exhalation apneas worse - but I know from my data that this is not the case ... so my ignorance is making me truly confused)
Regards
Y. (Bouncer)

[billbolton]

I have an old Resmed S7 Auto Spirit (since 2002)

That might be an S6...... the S7 came along somewhat later than 2002.

Bill, would the latest Resmed S9 be able to detect and report on whether apneas are on inhalation or exhalation?

Not detect and report, but there are flow graphs that you can review in ResScan software on a PC or laptop. It seems to me that those graphs would be useful in determining whether an apnea occurred on inhalation or exhalation.

and would the ability to reduce the exhalation pressure be of any help?

It depends what is causing the obstruction in your airway. You need to get some idea of the physiology involved in your particular case, to determine whether EPR would do anything beneficial for you.

Cheers,

Bill

[Bons]

could you mean this?
From Wikapedia:
"Catathrenia, a rapid eye movement sleep parasomnia consisting of end-inspiratory apnea (breath holding) and expiratory groaning during sleep, is distinct from both somniloquy and obstructive sleep apnea. The sound is produced during exhalation as opposed to snoring which occurs during inhalation. It is usually not noticed by the person producing the sound but can be extremely disturbing to sleep partners, although once aware of it, sufferers tend to be woken up by their own groaning as well. Bed partners generally report hearing the person take a deep breath, hold it, then slowly exhale; often with a high-pitched squeak or groaning sound.

Catathrenia typically occurs during REM sleep, although it may also occur to a lesser degree during NREM sleep. Often the groaning occurs toward the end of the sleep cycle, within a couple hours of waking. In many cases it occurs exclusively during REM sleep. Catathrenia begins with a deep inspiration. The sufferer holds her or his breath against a closed glottis, similar to the valsalva maneuver. After a period of time and some blood oxygen desaturation, there is an arousal, followed by expiration. Expiration can be slow and accompanied by sound caused by vibration of the vocal cords or a simple rapid exhalation with no sound."

[bouncer]

My goodness - thank you so much Bill and Bons. It appears, Bons, that I may have been barking up the wrong tree for the last 9 years! I need to check this out.

Thank you once again.
Best wishes
Y. (Bouncer)

[TalonNYC]

could you mean this?
From Wikapedia:
"Catathrenia, a rapid eye movement sleep parasomnia consisting of end-inspiratory apnea (breath holding) and expiratory groaning during sleep, is distinct from both somniloquy and obstructive sleep apnea. The sound is produced during exhalation as opposed to snoring which occurs during inhalation. It is usually not noticed by the person producing the sound but can be extremely disturbing to sleep partners, although once aware of it, sufferers tend to be woken up by their own groaning as well. Bed partners generally report hearing the person take a deep breath, hold it, then slowly exhale; often with a high-pitched squeak or groaning sound.

I've got this myself (have caught myself doing it while waking up). I did bring it up to my sleep doc on several occasions, and he never seemed concerned about it.

[McSleepy]

Years ago, when I was first diagnosed with OSA, I was initially given a constant-pressure CPAP machine. However, I wasn't able to get used to it and was quickly given a bi-level machine, to which I adapted quite easily. The main reason for not being able to use the constant-pressure machine was that I just wasn't able to exhale reliably after falling asleep, even at a pressure low enough to be otherwise useless for my OSA. Last year I went through the reassessment process (mostly to get a new machine) and I was reminded of this problem after trying to use the new machine I was given. Long story short, I switched to the VPAP Auto 25, which worked for me, and the important observation was that a little change in the parameters made a huge difference: between major discomfort trying to sleep and an AHI of nearly 40, to complete comfort and an AHI around 0 (as reported by the machine).

Using the right variable-pressure machine, with its advanced breathing pattern tracking features, could help with this kind of problems. The setting that is relevant to this discussion (I should note that I'm not using it in VAuto mode but in Spontaneous mode) is the "Cycle sensitivity", which can vary in 5 levels, from Very Low to Very High. In addition, in VAuto mode, you "can adjust the Exhalation rate so the rate of pressure drop is at a level that is most comfortable for the patient", which would not directly address the problem but might allow a more aggressive cycle sensitivity selection. For example, you could set the cycle sensitivity to "very high" and then set a "slow" exhalation rate to prevent the lungs from emptying too fast and diminishing ventilation, as well as possibly allowing the soft palate to collapse upon completing exhalation. The high sensitivity to cycle (which is the natural initiation of exhalation) would allow the machine to drop its pressure upon the slightest indication and help the person exhale, as opposed to a constant-pressure machine, even one with features, such as the ResMed EPR, whose sensitivity is not adjustable and its range is quite limited (certainly for my needs). There are some other settings, like Ti (Inspiratory Time Control) that can be used, e.g., to limit the time spent in IPAP and thus induce exhalation forcefully.

Naturally, everyone is different and what works for one person is not guaranteed to work for anyone else (as evidenced by our beloved DME technicians' attempts), so I am not trying to make any claims nor specific suggestions. I just hope to give some information that could generate ideas that might ultimately help.

McSleepy

[Sireneh]

Fascinating. I would have otherwise forgotten, but now that I'm reading this I remember experiencing a brief period years ago when I did this.

[midwestosa]

Great topic!! Before I was diagnosed with OSA or even knew what it was I can recall waking up a couple of times from my sleep not being able to exhale. The only way I can describe it is it feels like a one way valve and the more pressure I apply to exhale the tighter the valve gets. I actually have to inhale a little before my airway will open and I can breathe in again. I can reproduce this go some degree when I'm awake. This occurred frequently before I started cpap therapy. I have constant pressure and have only been doing it 2 weeks but do not recall having this type of exhalation blockage using cpap although according to the data I still have between 1-3 ahi/night I'm guessing these are occurring during inhalation.

I told both my sleep dr and the rt about this and neither of them said anything about it. I'm guessing that it is the soft pallet collapsing on the pharynx. I'm planning on scheduling an appointment with a ent that has experience with OSA patients to see if I can get more information on it. For many years i have been experienceing a tremendous amount of nasal drip/drainage and thought maybe my nasal/pharynx anatomy is a little out of whack and that's exacerbating the OSA.

My feeling is that apnea occurring during exhalation is not widely understood and the feeling is it doesn't make too much of a difference since the treatment is the same using some sort of cpap/bipap machine. Im very curious if anyone else knows more about this however. And a distinction needs to be made that this is not caused by dificulty over oming the pressure of cpap but a separate issue that occurs even w/o cpap.

My .02 cents

[McSleepy]

midwestosa, what you are describing seems very different and reminds me of another issue I had years ago. It only happened to me a few times before I could figure out what it was and how to take care of it, but when it happened, it was among the scariest experiences of my life. The event would occur in the middle of the night, as I am soundly asleep. Suddenly, I would awake unable to breathe - neither inhale nor exhale. I would jump off the bed, yank the mask off and start gasping, trying to move any air - to no avail. At one point, after maybe 20-30 seconds and after having thoroughly scared my wife, I would finally shake off the obstruction and regain the ability to breathe. After this happened to me a few times over a couple of years, I figured out it was the larynx that was being paralyzed and, thus, unable to open. The reason - acid reflux. My excellent gastroenterologist helped me figure this out and recommend a course of action. Besides the standard GIRD treatments (e.g., taking proton pump inhibitors), he also had me raise the head of the bed to cause an incline that makes it harder for stomach acids to reach up the esophagus, and to avoid acidic drinks later at night (I would occasionally drink orange juice before bed). I haven't had any such episodes since then.
Of course, it doesn't have to be that bad. Simply having acid vapors emanate from your stomach and deposit around the larynx could cause it to experience a lighter from of paralysis, making it so that you could occasionally experience blockages upon exhaling or inhaling. Again, this is just one possibility but given how easy it is to diagnose and treat GERD (which one should do regardless of OSA), it is something to seriously consider.

McSleepy