How important is it to keep down VS (Vibratory Snore)

[dae3dae3]

My AHI is staying in the range of 1.0 +- a little bit each day. A few weeks back I finally got the software and found that my AHI was staying in that range but my VS number was in the 200's. It was almost a solid bar on the graph for a lot of the night. I bumped my pressure from 15 to 15.5 and this brought the VS down into the range of 5 to 25 from night to night. My AHI hasn't changed much and I think I am getting better sleep. My wife says she never hears me snore so I don't know what the machine is picking up.

How important in general is it to try to keep that VS number low? Even though my AHI hasn't changed much I'm not waking up with my heart racing anymore which is what caused me to get the software to try to figure out what was going on. I tried raising the pressure to 16 one night and the VS number went even lower but I slept terribly so I'm trying to see if I need to bite the bullet and raise it back to 16 again and go through the adjustment period again of getting used to the higher pressure.

[robysue]

I'd say that you've probably discovered the sweet spot at 15.5: AHI is nice and low; VS is down significantly; and you sleep well.

At 15, the VS is ten times higher AND you say you don't sleep as well.

At 16, the VS is (marginally) lower, BUT you also say you don't sleep as well.

So how important is it to get the VS down? Well, I'd say in your case, how you feel indicates a VS of 200 is way too high, but a VS below 30 seems to be just fine.

[mayondair]

Ditto Robysue, If you feel good at 15.5 and your AHI is low that may be your sweet spot. Another thing to consider is that your machine may be scoring hose movements as VS, especially if your hose is dragging or rubbing on something. I wouldn't get to worked up about those numbers, also consider how you feel. Kathy

[jnk]

My understanding (limited) is that the significance of snores is highly individual.

Without a PSG to see exactly what the snores are doing to your sleep, you can only judge their significance to YOU by the way you feel, remembering that comfort can be as important to good sleep as "the numbers."

It is a judgment call, and it sounds to me that you are weighing the correct factors and that the suggestions about using 15.5 may pay off. BUT, you still have to go by feel, not just numbers, when judging the significance of the numbers in your personal case without PSG info, IMO.

Some words from RG on VS: viewtopic.php?f=1&t=48881&p=447822#p447822

[DoriC]

Your hose might need a hose cover in case it's scraping over the headboard or somewhere else, Padacheek makes nice ones.

[dae3dae3]

I already have a hose cover so I don't think that is causing the snores on the chart.

I think as long as things don't get worse I'm just going to stick to what I have going right now. I'm starting to feel a little better.

I kind of fell apart for the last two months. My BP was high again after being in good control for several years and now I am having GERD that isn't responding much to medications and the worst is that I am having anxiety problems which I haven't had for several years. I don't know if the apnea got worse and caused all these things to become uncontrolled again or what.

Edit: If the apnea did get worse it never showed up in the AHI numbers. That is why I was wondering if the VS could have been the problem.

[archangle]

It's a good question what counts as "one snore?" One good snort or 20 seconds of chainsaw noises? Might it count a cough, throat clearing, nose clearing snort, etc. as a "snore?"

[robysue]

It's a good question what counts as "one snore?" One good snort or 20 seconds of chainsaw noises? Might it count a cough, throat clearing, nose clearing snort, etc. as a "snore?"

'Tis a very good question indeed.

But, alas, none of the documentation that I can find in Encore Viewer, Encore Pro, or my clinician's guide to my System One BiPAP has any indication of what the definition of "one snore tick" actually means.

And unlike the OP, my VS scores seem to vary WILDLY from night to night on exactly the same settings: I've had nights with the VSI > 100 where the very NEXT night my VSI < 10 with NO change in setting---even back when I was running in FIXED pressure mode. And vice versa. And hubby reporting on both nights "he heard no snoring".

And unless I'm running in AUTO mode, there are NO VS ticks that show up in the wave form data in Encore Pro----just all the ticks in the Respiratory Events Table that's shown in both Viewer and Pro. But WHEN I'm running in AUTO and there are VS ticks in the wave form data, the number of VS ticks in the wave form pages is often a fraction of the total number of ticks in the Respiratory Events table and SIGNIFICANTLY LESS than the expected number of ticks given by #VS events = VSI * (time machine was running).

[Goofproof]

What are you going to do to stop them, they are what they are. As long as they don't disturb your sleep, no problem. With a APAP, they can drive the machine to a higher than needed pressure, but it you set the APAP correctly (3cm spread low to high) that will be ok.

Sometimes, it the hose rubbing, sometimes it our airway flapping in the wind. Unless it messes with your sleep it's not something I worry about. As long as my AHI is good and leaks controlled, I'm happy. Jim

[robysue]

What are you going to do to stop them, they are what they are. As long as they don't disturb your sleep, no problem. With a APAP, they can drive the machine to a higher than needed pressure, but it you set the APAP correctly (3cm spread low to high) that will be ok.

Well, that is in essence my problem in spite of having my BiPAP Auto set to a tight range: My Min EPAP = 4 and my Max IPAP = 8. This effectively means that my EPAP range is 4 to 6 and my IPAP range is 6 to 8. But on bad "snoring" nights, the "snores" unnecessarily drive up my EPAP (and because of the tight range, usually my IPAP), and that results in aerophagia problems.

I've been titrated in NPSG's at both 8/6 (Nov. '10) and 7/4 (Feb. '11). At 8/6 the pressure triggers aeropagia problems but keeps the AHI nice and low; while 7/4 controls the aerophagia and usually, but not always, keeps the AHI below 2.5ish---which is where I seem to start feeling the AHI numbers in part because I start to have nasty event clusters when my AHI gets above 2.5. So about a month ago, the PA suggested I switch from fixed 7/4 to Auto BiPAP with the current settings as a way of splitting the difference: If there aren't any apneas to take care of on a particular night or during a particular chunk of the night, the pressure stays pretty close to 6/4 or 7/4 (or 8/4 when there are flow limitations) and the aerophagia is not a big issue the next morning. When the apneas do occur, the EPAP can go up to 6, where my AHI is consistently reduced to something less than 2.0, but the pressure stays this high only for as long as necessary, and that should prevent the aerophagia from becoming too uncomfortable. At least that's how it's supposed to work in theory.

But the wildly variable "snoring" messes with the EPAP pressure by raising it and keeping it at 6 for large periods of time on the nights the System One thinks I'm snoring. And when EPAP has risen to 6 (regardless of the reason), that forces the IPAP = 8. So "snoring" all by itself seems to be increasing my pressure to the very top of my tolerance level for significant amounts of time on a rather significant fraction of my nights, which has in turn, caused a return of the aerophagia problems.

Unless it messes with your sleep it's not something I worry about. As long as my AHI is good and leaks controlled, I'm happy. Jim

And if aerophagia weren't raising its ugly head, I'd be happy too. But aerophagia does mess with both my sleep (indirectly) and my daytime functioning the next day.

[roster]

How important is it to keep down VS (Vibratory Snore)?

I will take the minority position on this one.

Some leading edge sleep doctors do indeed believe that snoring alone (without apnea) may have serious effects on one's health. For instance,

We know that in drivers, snoring alone without having formal obstructive sleep apnea significantly increases your risk of car accidents. Vibrations that come from snoring is thought to alter the sensory nerve endings of the soft palate, somehow damaging the protective reflexes that help to keep the upper airway open. Vibrations from snoring are also found to cause carotid artery wall thickening in rabbits.
Full article with one reference: http://doctorstevenpark.com/snoring-not-so-benign

There is also the issue that snoring may cause many arousals (arousals that the patient is not aware of) and the arousals are definitely destructive to one's health.

If I am going to all the trouble to use CPAP, I am sure as heck going to treat my snoring in addition to apneas, hypopneas, and flow limitations.

But you are getting good advice to check whether the VS on your data are actually snores or some other problem. There are apps available cheap that you can use to do an audio recording of your night and check for snores.

[DoriC]

How important is it to keep down VS (Vibratory Snore)?

I will take the minority position on this one.

There is also the issue that snoring may cause many arousals (arousals that the patient is not aware of) and the arousals are definitely destructive to one's health.

If I am going to all the trouble to use CPAP, I am sure as heck going to treat my snoring in addition to apneas, hypopneas, and flow limitations.

I actually observed my husband having semi-arousals while snoring. The snores definitely seemed to disturb him although he didn't appear to be aware of them.

[archangle]

I found that when my base pressure was slightly low, I would get clusters of VS indications just before I tended to wake up feeling apneaish. A slight increase in base pressure would make a big difference.

As far as "what is a VS," I'll just have to put the machine on, see if I can fake some VS and see what it takes to trigger an event in the log.

[robysue]

A sincere question for Rooster:

First: I won't argue that real vibratory snoring can be a problem in and of itself. It can be. And by real snoring I mean that kind of snoring that others can hear and that is frequently recorded as part of the data on PSGs and often mentioned in the summary notes of the sleep study. Getting that real snoring under control is indeed one of the (side) benefits of being on xPAP for many of us.

But the question here is whether the PR System One's VS algorithm is recording too many FALSE snores: Things that it thinks are snores, but are not. And how often that happens. And whether there is any reliable way to determine when the VS data bears some strong resemblance to reality and when it doesn't.

Use my own data as an example: On my four full PSGs, "some soft intermittent snoring" (and no arousals due to snoring) were noted on the diagnostic study and ONLY the diagnostic study. All three titration studies---including two on PR titration machines set to titrate the PR System One that I now use---specifically note: "no snoring" was heard.

So: Do I believe the techs who ran my studies and my husband who says I'm not snoring (almost all of the time) when I use my BiPAP? Or do I believe the BiPAP when there is no written documentation on what it decides to register as a snore? And since the way the BiPAP's data is reported in the Respiratory Event Chart is quantitatively different than what shows up in the wave form data, which data representation do I believe? The Respiratory Event Chart with its large number of tick marks and even higher VSI that indicate on "bad" nights "snores" are a significant problem? Or do I believe the wave form data from the exact same nights with its rather low number of tick marks that would back up my husband's report of "no snoring" and the PSGs saying that my titrated levels should adequately control my snoring since they are also controlling the apneas and hypopneas?

To complicate matters: On those few occasions my husband tells me I am snoring, Encore does show some snoring---both in the Respiratory Events Chart and in the wave form data. But on many occasions my husband has confirmed that I am NOT snoring between 7:00 am and 7:35 am when he's awake and I am not, but Encore Viewer's Respiratory Event table shows tick mark after tick mark after tick mark during this time and Encore Pro's Wave Form data does not. So the problem is largely one of significant numbers of False Positives---reporting lots of "snores" that do not seem to actually exist when other (reliable) sources of snore data are taken into consideration. And that tends to render the PR's VSI data more or less useless in my humble opinion.

I still believe that if these companies are going to have their machines record labeled things as "events", then it's only reasonable to provide some documentation about what constitutes an "event." And with PR, there's mightly little documentation on what constitutes a "snore" or "flow limitation" as a discrete "event". The S9's continuous graphs for the loudness of the snores and the severity of the flow limitations makes more sense to this mathematician.

[roster]

A sincere question for Rooster:

So what is the question for Rooster?