got my data :)

[mollete]

I think at some point you need accurate documentation of what's happening.

However, since you now own the raw data, there's certainly no rush. And anyway, once Grave's is under control...

Anyway, another interesting thought:



Positional therapy shows promise. If events only occur supine, then don't be supine!

[mollete]

REM during titration. Flow still a little flat on top:

[pandatx]

You're very cute the way you think I have any idea of what you are trying to say....like the "interesting thought" with the Body Position Trend graph. I don't know what I'm looking at. But I have time, right? So for now, while waiting and trying to get Graves under control, keep using CPAP as well as I can and try not to be supine?

[mollete]

You're very cute..

U2.

Anyway, what we're working with is the diagnostic study- no CPAP. The above image suggests that position therapy alone might be an option as it corrects the hypopneas.

However, in rescoring their arousals and RERAs (hey this takes a while) 8 RERAs still remain in that segment:





Having finished respiratory event scoring, overall RDI is significantly reduced, REM dominance remains:



Arousals have been edited and viewed. Considerations include:

• There appears to be a reduction of arousals at the beginning of this night. Is that a medication effect (probably. Also, SWS is very stable, and tends to be resistant to arousal)?
• If Grave's is controlled, will arousals decrease, and with that, the RERAs (Flow Limitation w/o Arousal is "nothing")?
• A number of arousals have been edited because of scoring rules:
  • Spontaneous arousals - 67
  • Respiratory arousals - 54
  • Total arousals - 121

[mollete]

Arousals have been edited and viewed. Considerations include:

• There appears to be a reduction of arousals at the beginning of this night. Is that a medication effect (probably. Also, SWS is very stable, and tends to be resistant to arousal)?
• If Grave's is controlled, will arousals decrease, and with that, the RERAs (Flow Limitation w/o Arousal is "nothing")?
• A number of arousals have been edited because of scoring rules:
  • Spontaneous arousals - 67
  • Respiratory arousals - 54
  • Total arousals - 121

BTW, to the Arousal List must be added the Awakenings (more severe than arousals), of which there are 34.

Normal is like, 2.

[pandatx]

I honestly can't believe that you are doing all this for me. I am really so incredibly grateful.

[NotLazyJustTired]

Three cheers for Mollete! Wow. How nice is that?
I am not understanding quite everything either, but I only wish my sleep study was explained to me with even half this detail. I had to figure most of it out for myself and I expect there are still a few bits I am missing.

Panda, I am actually encouraged by what Mollete is presenting. I am certainly no doctor but I am fairly analytical. From the data I see here I could draw a similar conclusion that your hypersensitivity from Graves may be contributing to the arousals/awakenings. I am not saying you do not need CPAP, maybe you do, but I do think it makes sense to focus on the Graves first and see where you go from there.

I have followed your story from the beginning, and from the bottom of my heart I am hoping for a successful conclusion to all of this.

Going back to lurk mode now...

[Drowsy Dancer]

This is absolutely fascinating. Additional cheers are raised on behalf of mollette.

It sounds like positional therapy while (she is)(you are) working on the Graves might be a good idea, eh what? Understand that I can barely grasp conclusions that are obvious to mollette.

[Pugsy]

We can change positions and try to stay off our back which sometimes is easier said than done. We don't have much control over REM though. Lots of awakening would reduce REM chances but that's not good either. As sleep quality hopefully improves there's likely to be even more REM.
Since my OSA is also REM dominant that's why I don't worry about position (which really didn't make any difference anyway for me in REM sleep when I tried a month of using a wall to stay on my side).

[pandatx]

what kills me is that my husband and I sat in the doctors office before getting my CPAP machine and he pointed out all these places where I "stopped breathing" for 30-45 seconds at a time. Was he just putting on a show to sell a machine? They definitely said "apnea" and they said it was much worse during REM. Why don't they investigate arousals more in depth. Grrrr.

[mollete]

what kills me is that my husband and I sat in the doctors office before getting my CPAP machine and he pointed out all these places where I "stopped breathing" for 30-45 seconds at a time. Was he just putting on a show to sell a machine? They definitely said "apnea" and they said it was much worse during REM. Why don't they investigate arousals more in depth. Grrrr.

Grrr?

As noted there is REM supine dependency, and an unambiguous event was presented earlier. But let's take a look at that area (the first REM period) that bought you your CPAP:



You never "stopped breathing". There are no apneas in the study whatsoever. Further, apneas need to be scored in the thermistor channel, and that waveform had steady breathing throughout (OK, it's a little ratty looking).

Hypopneas need to be scored in the nasal pressure (PFlow) channel, and there's definitely stuff there. Event 1 is a classic hypopnea, with hefty reduction in amplitude, flattening, increasing effort in the abdominal and thoracic channel attempting to overcome obstruction, leading to arousal, and a subsequent desaturation. Event 2 is a little less severe, but valid. Event 3 even less so, and no qualifying (3%) desaturation. Event 4 has no desaturation, amplitude reduction is questionable, but there is an arousal, so OK, let's let it slip by.

However, I would question Events 5 and 6. Sure the flow looks terrible for a prolonged period of time (~73 and 89 seconds, respectively) but why is there not a concomitant desaturation? Given what happened in the Event 1 I would have predicted a substantial desaturation. Yet, nothing! Was it a signal problem? Maybe mouth opened at that time (perhaps they had a nasal-only pressure cannula). The abdominal and thoracic channel activity do not support that degree of obstruction either (look at the areas where valid hypopnea occurred).

[mollete]

However, I would question Events 5 and 6. Sure the flow looks terrible for a prolonged period of time (~73 and 89 seconds, respectively) but why is there not a concomitant desaturation? Given what happened in the Event 1 I would have predicted a substantial desaturation. Yet, nothing! Was it a signal problem? Maybe mouth opened at that time (perhaps they had a nasal-only pressure cannula). The abdominal and thoracic channel activity do not support that degree of obstruction either (look at the areas where valid hypopnea occurred).

And indeed, if we are to Zoom In (Alice talk for amplify signal) on those 2 events:



while it is clear that amplitude reduction has occurred, the events bear closer resemblance to Event 3 (the significant flow limitation occurring only in the center of the "scored" hypopnea).

[pandatx]

Okay, do you think my doctor lied to me? Just stupid? Did I spend a couple thousand dollars on a Titration study and machine that I didn't need? Do I keep trying every night with the CPAP when I don't even need it? And, BTW, even if I don't need it..you guys aren't getting rid of me. I <3 you.

I've always only slept on my stomach (only supine during the test b/c they wanted me to) and was still not sleeping well/feeling like I woke up gasping, etc. I'm really interested in seeing what happens when my Graves is stabilized, but regardless of that, this sleep center diagnosed me and had me buy this machine and I just really hope I didn't just basically throw that money out the window.

Molette, I will reread everything you've (tried to) explain to me so far. Thank you so much.

xo

PS "Grrrr" is me verbalizing my frustration/anger. I'm "growling", lol.

[mollete]

Okay, do you think my doctor lied to me? Just stupid? Did I spend a couple thousand dollars on a Titration study and machine that I didn't need? Do I keep trying every night with the CPAP when I don't even need it?

I've always only slept on my stomach (only supine during the test b/c they wanted me to) and was still not sleeping well/feeling like I woke up gasping, etc. I'm really interested in seeing what happens when my Graves is stabilized, but regardless of that, this sleep center diagnosed me and had me buy this machine and I just really hope I didn't just basically throw that money out the window.

Well, you could go back to my suggestion about having them rescore the study. I'm sure if you did that tactfully they might not get all defensive (OTOH, if they are a CPAP factory, they certainly will. But that's academic. We got the thing, and if necessary, it don't take all that long to post the improperly scored hypopneas).

One of the criteria to treat SDB is that you "feel better". This would be determined by improvement in EDS, and measured objectively by the Epworth Sleepiness Scale (ESS). Generally, the decision to treat is >10 (right, yours was 7). Additionally, mild sleep apnea (AHI 5 - 14) tends to fall in the "to treat or not to treat" category (there are other variables to consider, i.e., the presence of significant desats, etc.)

While "you stopped breathing for x seconds/minutes/hours" is frequently used in explanations to patients about SDB, "IMHO" it is somewhat between inappropriate to unprofessional (outright lie). One must consider the audience in these explanations, and since in the minds of laypeople the expression "you stopped breathing for x seconds/minutes/hours" brings images of a "Code Blue" with chest compressions, yelling, screaming, lights and sirens, etc., one is forced to wonder about the motivation behind using it.

[mollete]

Additionally, mild sleep apnea (AHI 5 - 14) tends to fall in the "to treat or not to treat" category (there are other variables to consider, i.e., the presence of significant desats, etc.).

Perhaps another sidebar discussion could include the criteria that AHI/RDI determination was based. Your guy appeared to use the current criteria for hypopnea (which is obviously appropriate). However, your insurer may differ. For instance, UnitedHealthcare uses a hybrid definition (the 4% desat rule):

5. An initial 12-week period of CPAP is covered in adult patients with OSA if either of the following criterion using the AHI or RDI are met:
a. AHI or RDI greater than or equal to 15 events per hour, or
b. AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
...
7. Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.

https://www.unitedhealthcareonline.com/ ... 022012.pdf

And you had one desaturation.

And interesting how your RDI was exactly 15.

mollete is such a troublemaker!