CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

[dsm]

I was going to suggest that since it's your thread, you should say a few words, since you've made forum history. You know, something meaningful.

Ladies and gentlemen. Lend me your ears. Today we have witnessed a great moment in history, one that will take a place of honour in the an(n)als of great moments (in time). Remember that generations to come will build on the foundation of our toil, guided toward the light as ships passing stormy seas with firm resolve to stay afloat. You were here to partake in this sacred event. Hold your head high knowing that, regardless of your insurance excess, you participated in building the MOAT. Hail Caesar! God bless the Queen! Sacrifices to the Asteroid God!

BB

I am about to file a request to the US Library of Congress Web Archives to include this thread in their history of great Internet material.

A very auspicious honor should they agree. http://www.loc.gov/webarchiving/

DSM




Hmmm maybe I have to be a US citizen to make such a request - ahh well the idea was a good one

[blizzardboy]

I was going to suggest that since it's your thread, you should say a few words, since you've made forum history. You know, something meaningful.

Let's take stock of how things have progressed to this point in time:

1. The original problem that I wanted to fix is EDS and fatigue; I am being treated with 20mg fluoxetine for mild depression and anxiety; I am hypersensitive to touch and sound.
2. After a home PSG I was diagnosed with moderate OSA and assigned to use an Auto-titrating Continuous Positive Airway Pressure (CPAP) machine.
2a. Lacking confidence in the OSA diagnosis, I organised a hospital PSG and took myself off fluoxetine 2 weeks prior to the diagnostic PSG and 4 weeks prior to the titration PSG.
3. After the hospital PSG I was diagnosed with CompSA and PLMs (450/night) and recommended CPAP+/-ASV.
4. I purchased an Adapt SV and commenced treatment with Dr recommending another 6 months on ASV until my breathing stabilised
5. After 6 months already on CPAP I still suffered from mild EDS and fatigue
6. I noticed that I also tended to have hyperventilation (under breathing), bradycardia (slow heart rate) and hypotension (low blood pressure)
7. Hence I posed the question to this forum: "CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?"
7a. Forum members thought that I might have a good case to test for hypothyroidism.
7b. As seen in my daily CPAP logs (DLs), my respiration when asleep under ASV/fixed CPAP is seen to been disordered, unstable, chaotic and minute ventilation under par.
7c. I have unresolved air flow limitation during CPAP use according to my CPAP DLs (-SWS; DSM).
7d. -SWS suggested that my hypersensitivity and anxiety fitted well with Dabrowski's "five overexcitabilities" phenotype (I can relate very much to this).
8. Following an appointment with my (2nd) sleep doctor (D-day) I was told that I was an unusual case (being on ASV at a young age) and that "instability begets instability". Dr thought that my lungs and heart were fine (not interested in tests) and that I could have a blood test if I really wanted to test for hypothyroidism, but he didn't seem too interested in this explanation.
9. My bloods were taken and returned normal values according to the GP (inc. thyroid, iron, RBC, magnesium)
10. I developed joint pain during the course of CPAP use.
11. Since being on CPAP my energy levels and EDS have improved to the point I now better support my wife, play with my kids, and do my job.
12. I obtained my detailed PSG data from the Sleep Centre.
13. On seeing my PSG data, Muffy observed Alpha Wave Intrusion (AWI) in the delta waves of my deeper sleep levels. AWI is not the reason for my respiration instability, but possibly reduces the restorative benefits provided to me during deep sleep.
14. Muffy also pointed out that the centrals seen in my PSG were a normal feature of the transition back to sleep following arousal. So no CSA problem for me.
14a. Muffy (kindly) showed us an example of my chaotic breathing during stage 2 NREM from the diagnostic PSG.
14b. Muffy suggested that my PLMs are severe enough to warrant treatment (a point also suspected by kteague).
14c. Muffy saw no evidence for OSA and suggested that I could possibly be a candidate for UARS.
15. The cause of my arousals needs to be ascertained.
15b. No settings on the ASV or fixed CPAP used to date have produced a quick fix (e.g. over a period of one week) to my breathing instability
15c. I also suffer from aerophagia when CPAP gets above about 10cmH2O.
16. Fluoxetine, joint pain, mental illness, higher BMI (currently 26kg/m2), alcohol, caffeine, poor sleep hygiene, UARS, GERD, fibromyalgia (whatever that is ), lowered pCO2 arousal threshold, childhood meningitis and CO2 retention (my idea only ) are possible causes of my arousals
17. I am currently maintaining fluoxetine, getting fit, improving my sleep hygiene, reducing caffeine and alcohol, sleeping on a bed wedge and using ASV (EEP=10, PS=3.8->8.8; my most comfortable settings to date; fairly stable RR). I will stay with these ASV settings for now (no more dial whingin' ).
17a. I aim to wean off fluoxetine once I am physically fit (i.e. good aerobic fitness, increased exercise level, hopefully reduced BMI).
17b. My GP preferred I take Proton Pump Inhibitor (PPI) medication rather than have a GERD diagnostic. I am not currently taking this medication.
17c. I score 18/18 on a fibromyalgia pressure point test and continue to awaken with joint pain in the morning (esp. hands, feet, neck and shoulders)
18. On 23 June I have another appointment with my (3rd, and probably final) sleep doctor during which I will provide my PSG data for review, request (insist on, if I'm brave) a complete PFT, talk about the latest techniques to keep one in deep sleep discussed at the 2010 ATS meeting in New Orleans, PLM treatment, AWI, etc. At the end of the last appointment this Dr concluded that my problems were probably related to mental health issues. I find this explanation hard to accept as I am light years away from where I was a few years ago - my family say I am a new man. Let's see what comes of the next appointment.
19. The journey (battle?) continues...giddy up!

Cheers,
p.s. please let me know any improvements to this list and I will sort it out. Its a fair bit to keep in my mind so I may well have made a whoopsy.

[blizzardboy]

I am about to file a request to the US Library of Congress Web Archives to include this thread in their history of great Internet material.

Every coffee table should have a copy. Cheers,

[dsm]

BB

That is a pretty durned good summary - that brain of yours seems to be working well enough to me

DSM

[blizzardboy]

Thank you wonderful Internet advisers...

Hear, hear.

[-SWS]

At the risk of confirming what may have previously been only suspected - I'm as lost as a ball in high weeds. Is a K-complex caused by those sensations I described leading to a movement? Are you saying the sensations I described are a known phenomenon? Can one see a K-complex indicating a PLM is impending then see an arousal, yet the arousal not be counted with LM arousals as it was too far in advance of a movement? Can an arousal interfere with the onset of a movement? Cause if so, theoretically one could have arousals related to their PLM's but never attributed to them

I'll at least attempt to help with part of that...

Is a K-complex caused by those sensations I described leading to a movement?

Probably... However, two things about K-complexes worth noting according to this article, Kathy: 1) K-complexes are a normal, healthy part of sleep, and 2) K-complexes are also theorized to facilitate suppression of stimuli-based cortical arousals. K-complexes are thus neither frank arousals nor constituent to the underlying sleep disturbance itself according to that particular theory.

Restated, that last conjecture implies that the K-complex isn't so much a preliminary contributor to the arousal process; rather it is likely the brain's attempt to stave off whatever arousal process happens to be underfoot. When K-complexes time-associate with PLMs, but there are no subsequent cortical arousals, then the K-complex probably succeeded in maintaining sleep according to that theory. However, a competing theory thinks the K-complexes are a primary phenomenon, and can even be responsible for non-restorative sleep in excessive numbers.

I don't think PSG methodology can neatly attribute each K-complex's ulterior sequence or causation. Science doesn't even agree on the underlying pathophysiology of PLMs just yet...

Also, Muffy makes a great suggestion here IMO:

IIWY, I would go back and get my sleep study to find out exactly what was happening EEG-wise with your movements. For instance, if the frequency of your movements are every couple of seconds or so, then they can't be PLMs because they're too fast. If they occur at sleep onset, you could be looking at hypnagogic foot tremor. If you're looking at REM, it could be REM behavior disorder.

__________________________________________________________________________________________________________________


Blizzardboy, there's plenty to go in your thread. Now that the celebrations have settled down, Muffy might resume... I hope.

[Muffy]

I have unresolved air flow limitation during CPAP use according to my CPAP DLs (-SWS; DSM; Muffy)

I believe Muffy said you have "one" event that had persistent flow limitation in the data reviewed thus far, and that was on ambient:

viewtopic.php?f=1&t=51063&p=472128&hili ... on#p472128

Was there another area where this was discussed (I mean, there's "lost in the weeds" and there's "Honey I Shrunk The Kids" lost in the weeds)?

Muffy

[blizzardboy]

I believe Muffy said you have "one" event that had persistent flow limitation in the data reviewed thus far, and that was on ambient...Was there another area where this was discussed

Hi Muffy, Probably not. Funny you should point that out as including your name in that list was the one thing that I wasn't confident of when writing the summary. I think I went for a bit of a shotgun approach on that one...I'll remove your name from that list.

I still haven't received a reply back from DME re: S9 DLs. Cheers,

[Muffy]

This is a 30-second Epoch of Stage 1 (and shabby at that). While there is some flow limitation seen in the nasal pressure channel, the break in sleep continuity (arousal) is most likely due to the PLM. Interestingly, there is the aforementioned K preceding the arousal.

A quick review of all respiratory events (without regard to sleep stage, so if it were a period of wake, no respiratory events could be counted) revealed only 7 with potentially obstructive quality.

On 23 June I have another appointment with my (3rd, and probably final) sleep doctor

One epoch down, 1007 to go. It's going to be close.

Muffy

[blizzardboy]

One epoch down, 1007 to go. It's going to be close.

I can't tell you how much I appreciate your time and effort Muffy.

[jnk]

That is one amazingly impressive and well-put-together list, in my opinion, BB. Especially, point 17: "getting fit, improving my sleep hygiene, reducing caffeine and alcohol, sleeping on a bed wedge and . . . no more dial whingin'."

[SleepingUgly]

Muffy, when you score hypopneas, do you use the Chicago Criteria, the AASM Recommended, or the AASM Alternative criteria?

[ozij]

How can I go to bed knowing that any second Mother is going to apologize for favoring my brother, Blizzardboy , and will profess her enduring love for me!!! I'm waiting, Mother!!

I will let you in on a secret...I am ruddy and hirsute. Put the rug over your back and approach Mother quietly. She is quite old now and will think you are me and give you the blessing. Go with my haste my sister. GO!

I'm confused. That advice was supposed to come from Rebbecca.

[Rebecca R]

How can I go to bed knowing that any second Mother is going to apologize for favoring my brother, Blizzardboy , and will profess her enduring love for me!!! I'm waiting, Mother!!

I will let you in on a secret...I am ruddy and hirsute. Put the rug over your back and approach Mother quietly. She is quite old now and will think you are me and give you the blessing. Go with my haste my sister. GO!

I'm confused. That advice was supposed to come from Rebbecca.

But then the sister should be a brother and the mother a father. I'm confused too.

[SleepingUgly]

One epoch down, 1007 to go. It's going to be close. Muffy

BB, why don't you just mail Muffy a DVD of your sleep study? Wouldn't that be easier for both of you?