PSG report (or, addendum to updated update)

[echo]

After waiting a few weeks for the magical PSG reports that mysteriously didn't show up in the mail, I stopped by the sleep clinic just to see "if they were having any problems". After some insisting, Nurse finally says "I am not authorized to give you that info." Unfazed, in my best accented foreign language I said "you are not..? not...? what, you can't do what?" She got exhasperated and went to talk to the resident doc on duty. Nurse comes back, daggers flying out of her eyes, "go sit there and wait the doctor is printing it out now." Doc comes out (young, sweet girl) and hands me 5 page report from Titration. (OMG I'm thinking to myself, wow they actualy DID it!). Then I ask, as nicely as possible, I'm sorry, this is only one of them. Could you also give me the one from the diagnostic PSG? She replies, all sweet, sure no problem, smiles and all! 5 minutes later I'm walking out of there doing cartwheels. I can still feel the Nurse's hex.

The Files:
Diagnostic PSG as a (translated) word document / Original Diagnostic PSG (with graphs/timeline) (in Dutch)

Titration PSG as a (translated) word document / Titration PSG (with graphs/timeline)(in Dutch)

Also, Lung function test (lots of acronyms), Arterial blood sampling results (help I'm bleeding and I can't get up), and of course Urine sample (just in case).

Let me know if the graphs are unreadable. The pdf's are already 7MB in size but if ya want more bits I'll give you more bits.

My translations may be somewhat incorrect so take the lingo with a grain of salt.

I hope these are enough, because I don't think they have anything else to give me besides the Raw Data. (I'll have to take my anti-dagger shield with me to ask for that).

Of interest (to me anyway), was that most of my events were in non-REM sleep, with just as many on my back as on my side or stomach. (How I managed to get on my side with all those wires is beyond me). How is that significant?

And even more interesting, I had nearly all hypopnea's, and plenty of snoring (no louder than 60dB though, sorry to say). I only hit the level of "normal conversation" with my snoring... http://www.sfu.ca/sonic-studio/handbook/Decibel.html ... Given time I am sure I would have made it to "Pneumatic riveter" at 113 dB.

During the titration I only fell asleep at 3.30am because I had the MSLT test during the day, and they didn't wake me up the two times I fell asleep (let me sleep the whole 30 minutes)... had a hell of a time getting to sleep at night.

REM was even more elusive during the titration that during the PSG.

The average CPAP pressure was 8.4 cm but they put me on 7 cm because "I was having centrals". I only had 6 the whole night, with 0 mixed apnea's, during the titration. That's not THAT significant, is it?? It's about what I get now, from the 420e (usually less, an almost always at least one or two a night - but that could also be turning around in my sleep or whatever).

I guess there are plenty of other details in there but I don't know what's significant, or relevant, if any, to my current tiredness.

Thank you in advance for anyone (anyone, anyone) who cares to view and take a look at the reports and comment with any remarks.

THANKS

[turbosnore]

The oxygen desaturation is probably due to hypopneas? And that is the treatment for?

Something I would like to know what is hypopnea and what is hypoventilation.
I have been in the impression that hypopnea is "unfinished" breathe - either too shallow or flow restricted.
If the flow is blocked then its apnea. In the PSGs you have quite high hypopnea rate but no hypoventilation.

Even if yout AHI has come down a lot, it still seems a bit high, but what do I know - I have absolutely no medical backround.

[-SWS]

Echo, I hope to look closer at those Word documents later today. But I noticed in the diagnostic portion that you had one or more marginally low oxygen dips recorded while awake.

What's the story with any pulmonary function tests (PFTs) that you might have taken recently?

[echo]

Echo, I hope to look a little close at those Word documents later today. But I noticed in the diagnostic portion that you had some marginally low oxygen dips recorded while awake.

What's the story with any pulmonary function tests (PFTs) that you might have taken over the years?

Ah yes I meant to mention those as well. I have only had one, that was right after the titration. I scored low on the gas exchange bit, all other values were OK. ** I smoke and have for about ... 15 years. The lung function test last year was a big enough 2x4 to encourage me to quit, and then I got sidetracked with all of life's problems and didn't really have the willpower to stop for good. I quit for a week here and there but couldn't keep it up. I got the happy pills from the doctor but after two weeks I was getting -- bizarre in the head -- so I had to stop them. For the last two months I have been procrastinating stopping. Probably my whole I'm feeling crap whining is just the combination of the smoking and the gerd. Ugh. Feel free to ship that 2x4 over here and I'll have the BF deliver the blows.

That said, the only thing that makes me think otherwise is that everytime I bump up the pressure, it goes really really well for a few weeks, and then back to the same-old same-old again.

May I also add, I bought a spot-check (non-medical) sports finger pulse-ox (originally thinking it was one I could use overnight ) and whenever I check my O2 during the day (which I was doing quite a bit for a while and even now check it about 2x day), I never have anything below 98%. You could of course argue that the margin of error is too high on those things.... I dunno.

When I scan in the graphs, I'll scan in the pulmo tests from last year as well.

** Here are the values that were non-normal from the pulmo tests:
Lung volumes ->
- RV : 61% of ref value
- FRC PL : 70% of ref value

Diffusion ->
TLCO : 57% of ref value

I also have the arterial blood sampling results but I guess those were all OK too. (no one said otherwise but I will scan that in too)

The sleep doc (a pulmonologist) didn't say anything beyond that I have an old person's lungs and that I should stop smoking. I realize that these values can never improve even if I stop smoking.

One other thing I'd like to mention, and this has probably no effect whatsoever on the pulmo test given I smoke, but that morning I really felt like hell, but really like hell. After the few hours of sleep, for breakfast they gave me white bread, butter, and jam. Like an idiot I ate it. (I am not diabetic but that point is also up for debate IMO). So I crashed... I almost fainted at one point, I was "seeing stars" and was very dizzy and lightheaded. I NEVER eat crap like that for breakfast, but I just wasn't thinking. Anyway, another test came back way off that day: TSH was abnormally high (6 whatever-units-they-use-here). (I guess they didn't test my blood sugar?!) I've been tested many times for TSH and it's been up to 3 before but not 6. A few weeks later I had the full thyroid panel and it all came back "normal". It's likely the pulmo test was accurate, but that was definintely not a normal morning.

Thanks, -SWS!

[echo]

Something I would like to know what is hypopnea and what is hypoventilation.
I have been in the impression that hypopnea is "unfinished" breathe - either too shallow or flow restricted.
If the flow is blocked then its apnea. In the PSGs you have quite high hypopnea rate but no hypoventilation.

A hypopnea is defined as : =>50% decrease in airflow for 10 seconds or greater with a decrease in oxygen saturation of >3%
Apnea is where the airflow is stopped completely for 10 seconds or more.
Oxygen desaturation can happen because of both apneas and hypopneas, but I don't really know how the hypoventilation fits into that whole scheme.

As for the AHI, yes it was still high during the titration, but currently I'm running at around 1.0 AHI per night.

[Snoredog]

I wonder if these are not what they are referring to as spontaneous:

2. Neurological events

Number of arousals: 94
Number of myclonics: 0
Arousal index: 27.9 / hour sleep
Arousal + awake index: 29.4 / hour sleep
Myoclonic Index: 0


29 to 30 per hours, sounds about right, you can have these with very few obstructive events. If you have nasal issues I would strongly look at that. Not impressed with their sleep lab format, can't see a timeline. REM seen a little low at 7% but at least you are getting some. Take back what I said about your reports, didn't realize you were translating them.

Nothing you can do about CPAP that looked good, but you could try seeing a ENT, maybe try a BreatheRight strip, look for improvement. Sleep architecture not that bad. Could be nothing, but that is all I see on your Report.

What are you trying to fix? Unable to get up? List out any medications you might be taking, consider them,
could be idiopathic hypersomnia. If you wake up from deep sleep all the time you will feel like poo poo.

Don't know if they prescribe it there, but you should ask your doctor for a script of zyban if you really want to quit smoking, it is simply WellabutrinSR which makes you feel happy if depressed, but it does something with your head where after 10 days or so you don't want to smoke. So it is a antidepressant as well and cheaper than smokes (it worked for me over 8 years ago).

[echo]

What are you trying to fix? Unable to get up? List out any medications you might be taking, consider them,
could be idiopathic hypersomnia. If you wake up from deep sleep all the time you will feel like poo poo.

That's EXACTLY what I feel like. If I sleep only 4-5 hours, I can get out of bed (it's very difficult but at least I hear the alarm clock). If try to get up anywhere after 6-9 hours of sleep, forget it. I am dead dead dead to the world. 10 hours of sleep is OK.

So a vicious cycle is created:
Scenario 1 - During the week I get too little sleep, crash on the weekend and sleep in (10-12 hours sleep). Sunday night go to bed at 2 or 3 am, start sleep deprivation all over again.
Scenario 2 - Wake up naturally after 10 hours of sleep, go to bed later that night, wake up even later, go to bed even later, until I'm living vampire hours.

When the "therapy is working", I am able to get up after say 7 or 8 hours of sleep. That means : I am conscious enough to actually hear the alarm clock, think to myself "it's time to get up", and the actually do it. Furthermore, I'm not a bitch-from-hell, I can laugh and take joke, I'm not overly sensitive to criticsm, and I can think clearly (and remember things).
The moment the "therapy isn't working" my sleep schedule goes to hell, and the OSA symptoms come back (except for the memory and vocabulary and patience, which fly directly out the window).

I am on no meds. No vitamins, no prescriptions, nothing.
I am taking Melatonin for the past month but not every night (only if I am not yet sleepy at bedtime).
I stopped the GERD medication so I could have the endoscopy.
I am chewing on antacid calcium tablets now and then before bed to avoid the GERD.

Thyroid and Diabetes ruled out...

The nasal issue is off and on. I'm rinsing as much as I can. It's gotten a bit worse in the past couple of weeks due to the cold weather.

I will post the timeline after dinner.

EDIT: I hardly ever have "daytime sleepiness". It is always "morning sleepiness" and "nightime nervousness".

[echo]

Okeee dokeeee .... the original PSG reports, which include the timeline and graphs that I believe Snoredog asked for, are all posted above in the first post. Watch out the PDF files are large so I hope you're not on dialup.

Thank yew all again

[-SWS]

Echo- I'm looking at the additional data you added to your original post. My first comment is that Urine Sample is out of this world. I think if any of us had to travel that far at night to go to the bathroom, we would be worn out the next day as well.

Titration Data- A higher-than-satisfactory arousal rate, even with treatment. Your arousal rate may actually increase a bit as pressures rise (temporally inconclusive data IMO).

Pulmonary Function- Okay, so you have smoked for years but you don't have COPD so far. I remember reading that the added work of breathing (WOB) is believed to contribute to exhaustion in severe COPD patients. Supposedly sleep can be non-restorative because those COPD patients in particular have to draw in volumes of air at faster-than-usual breath rates----just to compensate for pulmonary-function gas-exchange inefficiencies. Essentially the diaphram, upper accessory breathing muscles, and lungs have to overcompensate---working hard and fast around the clock. That extra respiratory-effort presumably leads to extra RERAs (respiratory effort related arousals). But the article I read also seemed to imply that sleep was non-restorative in yet two additional ways (besides RERAs): 1) biochemical cellular waste reduction and tissue regeneration related to sleep wasn't occurring properly in the pulmonary muscles, because they had to work so hard during sleep for those severe COPD patients, and 2) homeostatic O2/CO2 ratios and respiratory triggers were skewed the following day because of blood/gas inefficiencies incurred in biochemistry throughout sleep.

My anecdote: I don't have a COPD diagnosis, but my doctor thinks I'm marginal. On days that my airway seems inflamed, I always notice these two symptoms: 1) added airway turbulence noise to confirm my airway inflammation, and 2) fatigue throughout that day---presumably because of all that extra muscular effort I must make to draw the necessary volumes of air in (and I am aware of making that extra muscular effort to breathe on those episodic days).

Delayed Sleep Phase Syndrome- If you search the word "chronotype" related to circadian rhythms, you'll find that the normal population is comprised of larks (early sleepers/risers), owls (late sleep/risers), and an indifferent type (more flexible/tolerant sleep-related clocks). However, this description may put you beyond being a normal owl regarding chronotype, and instead having a bona fide Delayed Sleep Phase Syndrome disorder:

So a vicious cycle is created:
Scenario 1 - During the week I get too little sleep, crash on the weekend and sleep in (10-12 hours sleep). Sunday night go to bed at 2 or 3 am, start sleep deprivation all over again.
Scenario 2 - Wake up naturally after 10 hours of sleep, go to bed later that night, wake up even later, go to bed even later, until I'm living vampire hours.

When the "therapy is working", I am able to get up after say 7 or 8 hours of sleep.

I'm only guessing here. But I personally wouldn't assume any of the above is because CPAP therapy does or doesn't work at times. My hunch is that your spontaneous arousals during sleep just may be episodic, depending on how your lungs happen to be. Of course, smoking doesn't help. And occasional GERD eruptions into the lungs aren't out of the realm of consideration as well. But I think it's possible that your A/H/FL/VS are great because CPAP is doing its job----but that RERAs occur because you have some marginal pulmonary issues. Any extra tummy weight over the diaphragm will add to the amount of required respiratory effort you must exert during sleep---and thus RERAs may be aggravated in a confluence of two or more physiologic factors.

Morning cognition and waking can be quite challenging for anybody experiencing RERA's and/or non-restorative sleep given the above speculative scenario. And morning cognition and waking can be challenging for anybody with an ordinary "owl" chronotype. However, for the unlucky person who suffers unacceptable respiratory-effort arousals during sleep and DSPS (beyond the owl chronotype), well... there's a person who is going to have a very difficult morning life unless they work very hard at addressing both of those very formidable sleep-related issues IMO.

Those are only my unqualified guesses, echo. Take care!


p.s. Owls can be quite creative, echo (echo! echo!): http://avalon.cuautitlan2.unam.mx/mater ... 07/morning

[Snoredog]

So a vicious cycle is created:
Scenario 1 - During the week I get too little sleep, crash on the weekend and sleep in (10-12 hours sleep). Sunday night go to bed at 2 or 3 am, start sleep deprivation all over again.
Scenario 2 - Wake up naturally after 10 hours of sleep, go to bed later that night, wake up even later, go to bed even later, until I'm living vampire hours

I'm a night person, I'm afraid if go to sleep I might miss something.
If I do get one good night's sleep I'll wake felling like a million bucks,
but that is not always good, I'll be too awake to go to sleep normally the next night,
even melatonin and Unisom combined won't put me to sleep, next night
the same. finally on the 3rd night I'll be tired enough to sleep, then my avg. is only about 6.5 hrs a night.

So for me it's one night of good sleep and two awake. While I try to avoid them, if I watch TV I get bored and will nap,
then I start in with those onset events, hyperventilating over and over feeling really uneasy, where I have to get up go outside or do something else to stop it.

I have 2 machines an Aflex and 420e, I'll use one for a while get in a rut, then switch to the other and back and forth. One of these days I'm going to break down and just buy a Bipap, if that don't work the hell with it, I'll take up drinking or something.

vampire hours? I do hang upside down a lot in a inversion table - and I did watch Trueblood on HBO the other night.

[-SWS]

Echo- A standard BiLevel or auto BiLevel just might be a good machine to try----if some or most of those RERA's are related to work of breathing (WOB). The EPAP/IPAP difference reduces WOB, and setting a short rise time reduces WOB as well (although some people have difficulty tolerating either).

I personally don't see any hints of your possibly benefiting from adapt/auto SV (no CSDB, CHF, PB). And I personally don't see any hints of your benefiting by the added expense of an AVAPS machine (since no volume problems were indicated).

But those spontaneous arousals just may be related to having to make a little extra respiratory effort during sleep. As mentioned in my post above, sometimes fixing A/H/FL/VS doesn't help with those RERA's--- when they are actually related to too much WOB for yet other pulmonary reasons. Standard or even auto BiLevel just may be able to help with that. But generally speaking, there are plenty of other possible reasons for spontaneous arousals as well. And PAP machines can't fix arousals unrelated to SDB or pulmonary effort.

[StillAnotherGuest]

Pulmonary Function- Okay, so you have smoked for years but you don't have COPD so far.

I would not say that. The reduction in mid-flow measurements (FEF25-75%) and that AWFUL diffusion need to be worked up. At the time of the study echo was

a 5' 7" female, 30 years old, and currently weigh (sigh) 190 lbs.

which makes that diffusion REALLY awful. So while

you have an old person's lungs and you should stop smoking

you should extrapolate that out to conclude

when you're a middle-aged person, you'll be dead.

Take this poster's advice in Do What I Say, Not What I Do:

Your HEALTH is ALWAYS WORTH it. You can do it!

(Picky Analysis Follows)

You should get a follow up PFT, I'm just so not crazy about that one. That flow volume loop suggests a marginal patient effort, the initial "blast out" looks lackadaisical, and the lumpiness of the expiratory limb could skew values. How many times did you repeat that particular portion of the test? Did you give "best effort", as defined as "eyeballs hanging out of head when done exhaling"?

If (when) the effort was (becomes) valid, then an evaluation of an inhaled bronchodilator might be a good idea to see if the Small Airways Disease (as noted by the reduced mid-flows) is reversible.

Frankly, I don't know what to make of the diffusion. That test is done with the inhalation of a tiny concentration of carbon monoxide. If there's already a concentration of carbon monoxide in your bloodstream (and there is, your ABG shows a CO level of 4.9%, so apparently you had the PFT tube in one hand and a cigarette in the other)(NA-NA-NA-NA-NA-NA-NA CLOSE ENOUGH!!!), then the CO in the diffusion gas has to compete with the CO in your bloodstream which will skew the results.

Anemia could also affect the results, but the Co-Ox shows your hemoglobin to be 12.3.

The acute effects of cigarette smoking also reduce diffusion, so the simple act of quitting could improve that parameter somewhat.

Also, the low diffusion could be a result of operator error.

Finally, if the test results are valid, I wouldn't blame a low diffusion in a 30 year old on smoking when the other parameters are all normal or explainable. I'd be looking for another cause for diffusional impairment.

SAG

[sagesteve]

Echo, have you tried Gaviscon instead of the antacids and calcium? I find that it really works for the GERD.

[jnk]

. . . I got the happy pills from the doctor but after two weeks I was getting -- bizarre in the head -- so I had to stop . . .

. . . The sleep doc (a pulmonologist) didn't say anything beyond that I have an old person's lungs and that I should stop smoking. . . .

My understanding is that the happy pills come with a few weeks of bumpy runway before one gets airborne.

My Dad found that the problem with quitting the smokes (for him, anyway) was that once his body started craving one, he couldn't, for the life of him, remember one reason he wanted to quit. So he made a long list of the reasons he wanted to quit and put copies of it in every location he might later search for a smoke. Then each time his fingers mindlessly reached for one, they found the list, and he would make himself read the whole thing again until the words pierced through the craving. That helped him quit for good over 40 years ago. Thought I'd share the anecdote, just in case you find it helpful.

Should quitting smokes be the priority before thinking about bilevel? Maybe a low-dose happy pill until you quit the smokes? (Those questions are only pokes with a stick, not a 2x4. )

[-SWS]

Pulmonary Function- Okay, so you have smoked for years but you don't have COPD so far.

I would not say that.

COPD sounds like an avenue for further investigation, Echo. It can entail episodic highs and lows regarding airway symptoms and quality of sleep. But there are yet other possibilities to explore as SAG points out:

Anemia could also affect the results, but the Co-Ox shows your hemoglobin to be 12.3.

The acute effects of cigarette smoking also reduce diffusion, so the simple act of quitting could improve that parameter somewhat.

Also, the low diffusion could be a result of operator error.

Finally, if the test results are valid, I wouldn't blame a low diffusion in a 30 year old on smoking when the other parameters are all normal or explainable. I'd be looking for another cause for diffusional impairment.

Should quitting smokes be the priority before thinking about bilevel?

I completely agree with Jeff's rhetorical assessment above. But I also agree with how incredibly darn hard it can be to follow that wise advice about giving up the cigarettes.

But I'm thinking those spontaneous arousals are probably related to pulmonary inefficiencies that can't be addressed by simply fixing A/H/FL/VS that are probably very well addressed already. And I'm also thinking BiLevel just might eventually be your next best modality to try, hoping to decrease spontaneous arousals---arousals that are presumably RERAs related to that extra WOB having to do with non-OSA pulmonary inefficiencies. BiLevel modality itself can be inherently uncomfortable for some people---for other folks it's a therapeutic joy and blessing. So giving up the cigarettes first really does make a whole lotta sense. DSPS may be a second and simultaneous battle front. Any one step at a time toward health improvement is better than no steps at a time.