CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

[-SWS]

I am one of those easily awakened by noise, light, movements (even too much air circulation). Although CPAP therapy has raised the threshold for awakenings from these, I still experience multiple frustrating nightime wakeups.

Back to topic, that hypersensitivity issue keeps coming back again and again. I wish they did some studies on that. Is there no way to measure hyper-sensitivity in the brain, maybe via functional MRI or SPECT/PET? They have shown for example that some people's pain perception is related to hypersensitivity in the brain (as in phantom limb syndrome) rather than in the nerves.... would be interesting to look at hypersensitivity & arousals during sleep.

If you happen to score borderline or high on this non-scientific HSP screening questionnaire then I personally suspect that your stimulus/response equation to poor sleep and EDS is probably highly multifactorial as a matter of both hypersensitivity and hyper-responsiveness.

FWIW I scored 21/25 - bit touchy, eh?

If you happen to score borderline or high on this non-scientific HSP screening questionnaire then I personally suspect that your stimulus/response equation to poor sleep and EDS is probably highly multifactorial as a matter of both hypersensitivity and hyper-responsiveness.

I've seen this questionnaire cited several times on this forum. I don't know what established construct it's trying to measure, or anything else about its validity or reliability. It almost seems to be some kind of measure of sensory issues, as in sensory integration disorder.

Dr. Park holds that those with UARS have a hyperarousable nervous system, and that Dr. Guilleminault thinks that's why they tolerate CPAP as well (although I have yet to see anything Dr. Guilleminault has written along those lines). There is lots of information about people with UARS having lots of functional somatic syndromes, such as Irritable Bowel, Fybromyalgia, etc. I was under the impression that much of this resolves when the underlying SDB is treated. So IF there is a hyperarousable NS in UARS patients, I wonder if it's the chicken or the egg. In any event, other than being a very light sleeper, and a few other mild symptoms such as startling when a bird crashed into my window 3 feet from my head just now, leaving the contents of his GI track all over it, I don't think I qualify for whatever it is this scale is measuring.

SU, if you don't mind I'll put a placeholder on my own conversation and even conjecture about the above until after Muffy's, jnk's, Rebecca R's, et al's informative PLM & RERA discussion. THAT'S the kind of useful information I would focus on right now regarding your own past and future sleep studies. Excellent PLM information so far IMHO... Also hope to hear any PLM or RERA thoughts Kathy and others might have as well.

But I'll certainly relish coming back to discuss the above a bit more... Sleep study priorities and practicalities precede Prozac and Pool in River City IMO.

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There's so much great clinical dialogue in this thread that I hate to dilute it with a side discussion about arousal-prone sleepers. However, we seem to have more than a few on this message board!

So I think I'll soon start a thread (with poll) to explore the topic. I'm hoping highly sensitive sleepers can unite to share tips, tricks, and even groans about heightened arousability during sleep.

[blizzardboy]

Can you get the download from the ASV?

Muffy

Hi Muffy - Thanks for the insight on the home PSG epoch. So would appear that I was having centrals prior to arousal?

I just picked up my brand new ASV. I'm excited! I also obtained Rescan v3.3 and the serial cable. Give me a few days to post up some of my new data.

For now, please look to my website in the ASV folder to see the download from the first few days of using the ASV during my trial.

[blizzardboy]

I had a blood test about one and half years ago and there were no anomalies inc. thyroid function and iron. I will have a look to see if any of the above were checked.

Did you have any of your current problems 1.5 yrs ago when your iron was tested?

Hi SU, I just can't remember. Its all a bit of a blur to me. Its only in the last year or so that my life became settled and stress-free enough that I could actually question whether I was sleeping right. My inner world was kind of like a tangled ball of string until only relatively recently. Its probably only in the last 12 months that I have really begun to develop a sensitivity towards my own needs and to then learn about healthy self management. I had flogged myself hard for years and was not very self aware. I think my EQ was probably below average.

[blizzardboy]

Somewhat common "silent GERD" would be GERD without symptoms. I have silent GERD.

I look forward to hearing about your upcoming trial, blizzardboy. Good luck!

Hi -SWS, Aaargh! What a bother that some diseases lurk around in the shadows plying their trade in secrecy. Pesky little urchins!

Always a fun one to explain to work colleagues: "Gee, you like tired today." "Yeah, my sleep is interrupted by silent GERD."

[-SWS]

Blizzardboy, here is your March 1st graph that shows 8 hours of tidal-volume oscillations: http://users.adam.com.au/sixsome/ASV/ASV_6a.jpg

OK, so right off the bat you can get rid of hypoventilation, hypercapnia, bradycardia, and vagal events.

And now he can justifiably start thinking about those again.

The tight ASV tidal-volume oscillations show that you are spending significant amounts of time at the 200 ml mark. By contrast, we can see more normal oscillation density of tidal volume on page 7 of dsm's ASV report here: http://www.internetage.com/cpapdata/dsm ... -jul08.pdf

That very tight oscillation density---that happens to be sustained throughout the whole night----might be indicative of: 1) hypoventilation, or 2) periodic breathing with hypoventilation (biological undershoot) during characteristic downswings.

[-SWS]

Somewhat common "silent GERD" would be GERD without symptoms. I have silent GERD.

I look forward to hearing about your upcoming trial, blizzardboy. Good luck!

Hi -SWS, Aaargh! What a bother that some diseases lurk around in the shadows plying their trade in secrecy. Pesky little urchins!

Always a fun one to explain to work colleagues: "Gee, you like tired today." "Yeah, my sleep is interrupted by silent GERD."

At least there's a Christmas Carol that converts easily to a Silent GERD tribute song.

[-SWS]

Blizzardboy, here is your March 1st graph that shows 8 hours of tidal-volume oscillations: http://users.adam.com.au/sixsome/ASV/ASV_6a.jpg

OK, so right off the bat you can get rid of hypoventilation, hypercapnia, bradycardia, and vagal events.

And now he can justifiably start thinking about those again.

The tight ASV tidal-volume oscillations show that you are spending significant amounts of time at the 200 ml mark. By contrast, we can see more normal oscillation density of tidal volume on page 7 of dsm's ASV report here: http://www.internetage.com/cpapdata/dsm ... -jul08.pdf

That very tight oscillation density---that happens to be sustained throughout the whole night----might be indicative of: 1) hypoventilation, or 2) periodic breathing with hypoventilation (biological undershoot) during characteristic downswings.

This one reflects a fair amount of hypoventilation as well:
http://users.adam.com.au/sixsome/ASV/ASV_8a.jpg

[blizzardboy]

Blizzardboy, here is your March 1st graph that shows 8 hours of tidal-volume oscillations: http://users.adam.com.au/sixsome/ASV/ASV_6a.jpg

OK, so right off the bat you can get rid of hypoventilation, hypercapnia, bradycardia, and vagal events.

And now he can justifiably start thinking about those again.

The tight ASV tidal-volume oscillations show that you are spending significant amounts of time at the 200 ml mark. By contrast, we can see more normal oscillation density of tidal volume on page 7 of dsm's ASV report here: http://www.internetage.com/cpapdata/dsm ... -jul08.pdf

That very tight oscillation density---that happens to be sustained throughout the whole night----might be indicative of: 1) hypoventilation, or 2) periodic breathing with hypoventilation (biological undershoot) during characteristic downswings.

Yes, that was why I first started wondering if I might hypoventilate during sleep. I once looked up a formula for recommended ventilation rate for use by paramedics and my vitals implied 5.3L/min.

So what now? Sell me off for dog meat while I am still relatively young?

[blizzardboy]

As jnk reminded us, the low night-time BP also sounds a bit strange...

Also I wouldn't underestimate the power of getting good exercise to help you sleep better. I know, easier said that done Been there done that.

Hi echo...echo, How good does the recliner seem in the evenings? On the other hand, the exercise bike seems cruel and onerous...

I am looking forward to monitoring my BP once I get a good run on the ASV. I'll post any interesting data if it emerges.

[-SWS]

So what now? Sell me off for dog meat while I am still relatively young?

No way, my friend!

I think you need to get those volume graphs back to your clinicians. If you're in between clinicians, then you need to find some who are central hypoventilation knowledgeable. Remember when we talked about that narrow-targeting window? I think that sliding 4-minute recent-average window is not working here---likely because on some nights you sustain hypoventilation longer than 3 or 4 minutes.

For persistent hypoventilation, S/T mode BiLevel with fixed IPAP & EPAP is sometimes used. Your ASV machine can be set up to nearly approximate that modality, and that just might suffice. Sometimes persistent hypoventilation is addressed with AVAPS or even a ventilator that can also do BiLevel with volume assurances turned on.

But the first thing you need to do is get with some clinicians who can find out exactly what's going on during those nights when your tidal volumes stay low like that. Some hypoventilatory disorders are even fixed with medications: http://www.google.com/#hl=en&q=%22alveo ... cbbf06dc4f

[Muffy]

Thanks for the insight on the home PSG epoch. So would appear that I was having centrals prior to arousal?

Keeping in mind that the study was done during ambient conditions (so these are not pressure-induced events), I believe the sequence of events is:

Obstructive hypopnea (because of the flattening in the pressure waveform)
Post-arousal central (normal response, leave it alone)
Wake or Wake/Stage 1 centrals (normal phenomenon, leave them alone, too)

The first course of action there would be CPAP to resolve the flow limitation and those 2 snore events (although arguably, the snores, short as they are, could just be artifact)

OK, so right off the bat you can get rid of hypoventilation, hypercapnia, bradycardia, and vagal events.

And now he can justifiably start thinking about those again.

No he can not (or should not). The true measure of hypoventilation is pCO2, and he has documented evidence of hypocapnia on low-level ASV during NREM in NPSG:





which normalizes during REM.

The ETCO2 profile has the appearance of a CompSAS patient, and although did not cascade into the characteristic cyclical pattern of central apneas (even on ASV, he should have cycled a little bit) given the scored hypopneas there:



he appears to have some hyperresponsiveness. ASV doesn't prevent the cycles, it treats them by allowing pCO2 to increase, and in this case, it never did (don't count REM).

That very tight oscillation density---that happens to be sustained throughout the whole night----might be indicative of: 1) hypoventilation, or 2) periodic breathing with hypoventilation (biological undershoot) during characteristic downswings.

Well, "IMHO", that's a pattern of a patient on a machine that doesn't like sleep instability.

Muffy

[Muffy]

...he has documented evidence of hypocapnia on low-level ASV during NREM in NPSG...

But don't anybody say "Hey! How 'bout some of them thar 'Buteyko Breathing' crap?"

Muffy

[Muffy]

Some hypoventilatory disorders are even fixed with medications: http://www.google.com/#hl=en&q=%22alveo ... cbbf06dc4f

You give that boy theophylline and you'll be scraping him off the ceiling with a spatula.

Muffy

[-SWS]

Some hypoventilatory disorders are even fixed with medications: http://www.google.com/#hl=en&q=%22alveo ... cbbf06dc4f

You give that boy theophylline and you'll be scraping him off the ceiling with a spatula.

Muffy

I surely wouldn't administer anything to blizzardboy other than friendly marching orders to yet more clinical investigation.

Lemme do the devil's advocate thing a bit with your take on hypocapnia and sleep instability, which I think is probably the correct take...

[SleepingUgly]

if GERD severity is variable (and it is) how do I know when I'm under-treated?

What was the cause of the food sticking? What did they see on endoscopy that led them to believe you have GERD, and what did they see to make them conclude you're under-treated?