What causes repiratory effort related arousals ?

[Day_Dreamer]

It seems this is the main cause of my sleep disorder

What causes it?

what can be done in addition to CPAP to reduce it's occurrence?


Thanks in advance!

[BlackSpinner]

It seems this is the main cause of my sleep disorder

What causes it?

what can be done in addition to CPAP to reduce it's occurrence?


Thanks in advance!

It is what cpap is designed to stop. It is the effect of your throat closing up and you waking up to make it open so you can breathe. If it is still happening with cpap then your pressure is not dialled in right.

[Day_Dreamer]

Thanks

I guess its more of why are some people affected by it and others not

The air way is not completely blocked yet some people are more sensitive to this and it disrupts sleep while others sleep right through.

CPAP is helping but I want to understand they underlying reason as it may be indicative of other health issues

[Bama Rambler]

I can relate to this. Everything else on my graphs looked great except snores and RERA's. I had tons of RERA's!

I ran my machine in Auto-Trial for a week and realized that my 90% pressure was 15.1 instead of the 13 cmH2O the doc prescribed and now that I've adjusted it to 15 cmH2O my RERA's are down to about 1 to 2 per hour. My AHI has also dropped a lot. It's less than 1 now.

[jnk]

There are two types of RERAs--(1) the ones a good sleep lab reports and (2) the ones home-machines report. A RERA reported by a sleep lab is likely a true respiratory event, since the other channels of information beyond airflow help to confirm its trueness. A RERA reported by a home machine isn't of much use beyond simple trending--in other words, useful for comparing the data from one set of nights to another set of nights, to see if things are made better or worse when changes to therapy are made--since home machines only measure flow and in some cases how open the airway is. A home machine has no way of knowing if your sleep was disturbed by how you breathed at that instant.

A RERA as reported by a lab is a change in breathing that is less than a hypopnea but that appears to disturb sleep anyway. Not all labs measure them with the same accuracy and not all insurance people are willing to acknowledge that there is any such thing.

CPAP sometimes helps RERAs, sometimes does not help them, and sometimes makes them worse.

The thing to remember is that a doc is likely to point to them simply as a way to make a case for letting a patient try CPAP to see if CPAP helps the patient's sleep. In those instances, it is best to view RERAs as mere technical information rather than as a type of disorder, per se. Those patient-oriented docs would point to aliens or sunspot activity if it allowed them to let a patient try something possibly helpful. Other docs just fudge their numbers enough to call all the RERAs hypopneas. Kudos to them.

Docs who still believe in UARS are more likely to point to RERAs; docs who don't believe that UARS is a useful name for what is affecting the sleep of people with a low AHI may not talk about RERAs much. On the other hand, some docs argue for use of RDI instead of AHI, just so RERAs can be included. Few insurance people are falling for that trick, though, since in their view, it makes every human on the planet qualify for getting to try PAP therapy, and that's not what insurance people want to happen.

Some patients have gotten results by losing weight, developing very strict personal habits of sleep hygiene, not eating anything after 5pm or so, and avoiding the sleep position that is most likely to cause them to experience arousals during sleep. Others have moved on to oral appliances or surgery when they are sure that it is their breathing disturbing their sleep (and not something else, such as drugs, lifestyle, temporary hormonal changes, etc.) but they have found that PAP therapy isn't helping them at any configuration or pressure. Docs as a whole have not really settled on what is most reasonable to do for the majority of people who have disturbed sleep from breathing but low AHI. Seems to be a crapshoot.

In one sense, OSA and UARS are much the same thing--changes in breathing disturb sleep. In another sense, OSA and UARS are exact opposites--OSA people have dulled sensitivity to airway changes whereas UARS people have extreme sensitivity to airway changes. That of course is an overgeneralization, but it is meant to show how some doc/researchers have viewed things.

That said, one possible answer to your question could be this: What causes respiratory effort related arousals is a person's high sensitivity to changes in the airway. When PAP can be fine-tuned enough to stabilize the airway without further irritating the sensitivity, it can help some people with that problem. That is why some use straight CPAP or bilevel as a modality rather than APAP or auto-bilevel, since the auto-PAP modality can't be fine-tuned the way a fixed pressure, or fixed set of pressures, can be.

Keep in mind that I ain't no pro; I'm just a guy who reads way too much and then gets opinionated.

[djhall]

My understanding is this:

To be classified as an apena or a hypopnea you need to have a reduction in airflow of 50% or more for at least 10 seconds which is sever enough and an associated arousal is assumed/implied. A RERA is a reduction in airflow of less than 50% but which still causes an arousal. Think of it this way:

You are lying on your back in deep sleep and I come along and gently lay a pillow over your face. Your airflow is reduced from 100% to 90%. I press lightly on the pillow, your airflow is reduced from 90% to 80%, you start breathing a little harder to try to get enough air through the pillow. I push a little harder on the pillow and your airflow is reduced to 70% and your breathing effort gets even harder. I keep pushing and your airflow is reduced to 60%, the respiratory effort of trying to breathe though the pillow sends alarm signals to your brain, your brain reacts to those alarm signals by yanking out of deep sleep and into a lighter sleep stage where you begin to move and gasp a little. Afraid you are going to wake fully and catch me trying to suffocate you in your sleep, I remove the pillow. Your breathing effort and airflow return to normal, the alarm signals stop, the brain stops the process of waking you up and settles back into normal sleep. For minutes later I put the pillow over your face again...

This is essentially what happens with someone who has a 0 AHI but an RDI of 15 from RERA events, except it is their own throat tissue suffocating them and not me with a pillow. Technically what is happening doesn't meet the criteria for hypopneas (which assumes associated arousals), but an arousal are occurring regularly. RDI expands on AHI to include these kinds of sleep disruptions and includes Respiratory Effort Related Arousals which don't qualify for AHI based on airflow restriction severity alone.

But how does the machine know if an arousal occurred if not just using a percentage of airflow reduction? Simple, really. The machine looks for a pattern of breathing where airflow slowly and steadily decreases over time... and then suddenly changes back to normal. A sleep disruption is the most likely explanation for the sudden change in airflow, so a RERA event is logged.

[Day_Dreamer]

My understanding is this:

To
You are lying on your back in deep sleep and I come along and gently lay a pillow over your face. Your airflow is reduced from 100% to 90%. I press lightly on the pillow, your airflow is reduced from 90% to 80%, you start breathing a little harder to try to get enough air through the pillow. I push a little harder on the pillow and your airflow is reduced to 70% and your breathing effort gets even harder. I keep pushing and your airflow is reduced to 60%, the respiratory effort of trying to breathe though the pillow sends alarm signals to your brain, your brain reacts to those alarm signals by yanking out of deep sleep and into a lighter sleep stage where you begin to move and gasp a little. Afraid you are going to wake fully and catch me trying to suffocate you in your sleep, I remove the pillow. Your breathing effort and airflow return to normal, the alarm signals stop, the brain stops the process of waking you up and settles back into normal sleep. For minutes later I put the pillow over your face again...

.

I think this post is going to keep me up tonight

[Day_Dreamer]

Keep in mind that I ain't no pro; I'm just a guy who reads way too much and then gets opinionated.

your posts have been spot on as this is essentially the info my doc gave me

[jnk]

Keep in mind that I ain't no pro; I'm just a guy who reads way too much and then gets opinionated.

your posts have been spot on as this is essentially the info my doc gave me

Thanks.

I've met docs who considered me somewhat of an authority in a patient-oriented sort of way, but then I've also met docs who would probably jump at the opportunity to try djhall's pillow experiment on me.

As a general rule, I consider fellow patients to be the best people from which to get practical day-to-day CPAP-use info from. But I also believe that it is safest to listen to one's own doc for customized deeper medical info. That probably makes more sense than getting it from some guy on the Internet, even if it's me. That's why I try to remember to disclaim whenever I start pontificating the way I tend to do.

[Day_Dreamer]

Keep in mind that I ain't no pro; I'm just a guy who reads way too much and then gets opinionated.

your posts have been spot on as this is essentially the info my doc gave me

Thanks.

I've met docs who considered me somewhat of an authority in a patient-oriented sort of way, but then I've also met docs who would probably jump at the opportunity to try djhall's pillow experiment on me.

As a general rule, I consider fellow patients to be the best people from which to get practical day-to-day CPAP-use info from. But I also believe that it is safest to listen to one's own doc for customized deeper medical info. That probably makes more sense than getting it from some guy on the Internet, even if it's me. That's why I try to remember to disclaim whenever I start pontificating the way I tend to do.

I know what you mean
My doc yesterday was trying to convince me that the deviated septum is a myth and 90 % of Caucasians have it. Further that CPAP would clear any blockage due to the misaligned septum and it will not affect CPAP useage. As someone who has this issue I had to respectfully disagree. He took a look up my noose and said well it might be an issue for you.....

[Ladyflower]

My understanding is this:

To be classified as an apena or a hypopnea you need to have a reduction in airflow of 50% or more for at least 10 seconds which is sever enough and an associated arousal is assumed/implied. A RERA is a reduction in airflow of less than 50% but which still causes an arousal. Think of it this way:

You are lying on your back in deep sleep and I come along and gently lay a pillow over your face. Your airflow is reduced from 100% to 90%. I press lightly on the pillow, your airflow is reduced from 90% to 80%, you start breathing a little harder to try to get enough air through the pillow. I push a little harder on the pillow and your airflow is reduced to 70% and your breathing effort gets even harder. I keep pushing and your airflow is reduced to 60%, the respiratory effort of trying to breathe though the pillow sends alarm signals to your brain, your brain reacts to those alarm signals by yanking out of deep sleep and into a lighter sleep stage where you begin to move and gasp a little. Afraid you are going to wake fully and catch me trying to suffocate you in your sleep, I remove the pillow. Your breathing effort and airflow return to normal, the alarm signals stop, the brain stops the process of waking you up and settles back into normal sleep. For minutes later I put the pillow over your face again...

This is essentially what happens with someone who has a 0 AHI but an RDI of 15 from RERA events, except it is their own throat tissue suffocating them and not me with a pillow. Technically what is happening doesn't meet the criteria for hypopneas (which assumes associated arousals), but an arousal are occurring regularly. RDI expands on AHI to include these kinds of sleep disruptions and includes Respiratory Effort Related Arousals which don't qualify for AHI based on airflow restriction severity alone.

But how does the machine know if an arousal occurred if not just using a percentage of airflow reduction? Simple, really. The machine looks for a pattern of breathing where airflow slowly and steadily decreases over time... and then suddenly changes back to normal. A sleep disruption is the most likely explanation for the sudden change in airflow, so a RERA event is logged.

I really like your explanation! My husbands machine has this catagory on his CPAP but mine doesn't on my ASV so I was wondering what a RERA was. His RERA and snore make up a good portion of his AHI but I wasn't sure what the RERA really was. I've adjusted his pressure up a notch to see if it helps his numbers. At least now I can explain to him what the RERA's are.

[jnk]

. . . My doc yesterday was trying to convince me that the deviated septum is a myth and 90 % of Caucasians have it. Further that CPAP would clear any blockage due to the misaligned septum and it will not affect CPAP useage. As someone who has this issue I had to respectfully disagree. He took a look up my noose and said well it might be an issue for you.....

I just posted in your septum thread with a link to a respected ENT I've spoken to a few times who also is cautious about blaming septum deviation.

[Day_Dreamer]

. . . My doc yesterday was trying to convince me that the deviated septum is a myth and 90 % of Caucasians have it. Further that CPAP would clear any blockage due to the misaligned septum and it will not affect CPAP useage. As someone who has this issue I had to respectfully disagree. He took a look up my noose and said well it might be an issue for you.....

I just posted in your septum thread with a link to a respected ENT I've spoken to a few times who also is cautious about blaming septum deviation.

thanks

Just when I think I have it figured out

[jnk]

My personal rule of thumb is that, assuming it is done right, it is a surgery that is pretty safe for most, so hey why not. But I would only do if (1) I was pretty sure it was going to improve something about my breathing during the DAY in a significant way or (2) it was highly likely to solve a definite problem using PAP at night. And I think number 2 is pretty rare. I think turbinate surgery is more likely to help problem pappers, and that surgery is a whole nuther ball of wax, or wad of gauze, or whatever. I understand that empty-nose syndrome is no fun at ALL.

[djhall]

My understanding is this:

To
You are lying on your back in deep sleep and I come along and gently lay a pillow over your face. Your airflow is reduced from 100% to 90%. I press lightly on the pillow, your airflow is reduced from 90% to 80%, you start breathing a little harder to try to get enough air through the pillow. I push a little harder on the pillow and your airflow is reduced to 70% and your breathing effort gets even harder. I keep pushing and your airflow is reduced to 60%, the respiratory effort of trying to breathe though the pillow sends alarm signals to your brain, your brain reacts to those alarm signals by yanking out of deep sleep and into a lighter sleep stage where you begin to move and gasp a little. Afraid you are going to wake fully and catch me trying to suffocate you in your sleep, I remove the pillow. Your breathing effort and airflow return to normal, the alarm signals stop, the brain stops the process of waking you up and settles back into normal sleep. For minutes later I put the pillow over your face again...

.

I think this post is going to keep me up tonight

Well, if it helps you get that image out of your head, I could come up with another scenario to explain Respiratory Effort Related Arousal that involves a supermodel and a necktie...

Apparently I needed a little longer to wake up this morning as my spelling and grammar in that post was atrocious.