REM-only Apnea?

For a number of years I've had people tell me I hold my breath while sleeping and make a strange, high pitched noise as I slowly exhale. I had one sleep study done where I did not sleep at all due to the conditions of the exam (straps, wires, technician fixing pads etc.) So the doc sees nothing and tells me I have no Apnea.

Last month I resolved to try again at a different Sleep Center. This time I took a sleeping pill (which I don't normally use) and was able to sleep in the lab. The results were I believe somewhat unusual: during the REM stage of sleep I had over 40 "events" per hr. My other sleep stages were largely unnaffected by apnea.

The doc suggested I try a CPAP and gave me a loaner which he set at 11. I am having the usual new-user compliance issues, but there have been several days where I woke up feeling great--enough so that I am determined to pursue xPAP as a continual treatment. A few nights I have skipped the machine and my in-house monitoring staff reported that I was "doing that holding your breath thing again...a lot". The symptoms of lack of REM sleep return (ie., dazed and confused)

I now have to get a machine of my own (out of pocket due to insurance $1k deductible) It seems unclear whether an APAP (or any xPAP) will be usefull in mitigating my REM breath-holding or whether one brand's artificial intelligence will respond better than another's. I'd like to get something with software capability so I can monitor my sleep performance. It also seems like I may need to take some anti-anxiety meds as part of my sleep treatment.

I'd appreciate any guidance or opinions on the issues I've mentioned. Thanks!

Anonymous wrote: I'd appreciate any guidance or opinions on the issues I've mentioned. Thanks!

Sleep apnea is almost always worse during the REM stage of sleep. Your not actually holding your breath, the most common type of sleep apnea is where your airway becomes blocked and you can't breath.

I'm confused as to weither you have had a titration to determine the pressure needed to eliminate your apneas? Did the doctor just guess at a value of 11cm?

Yes an AutoPAP will likely help a lot. It should be easier to tolerate than a strait CPAP. If your trying to determine the correct pressure yourself you'll need to get the software and a card reader. You really should have a titration study if you can afford it.

You shouldn't need to take sleeping pills. Infact taking them will typically make you have more apneas, you should try to avoid them if possible. There is an adjustment period but things like an AutoPAP and C-Flex can help. Posting any problem you have to this group can help you work though the issues.

did they see and note any CA or MA events on your 2nd PSG? Hopefully you got a copy of that report (if not I'd ask for it). If you have central apnea (can appear with and without cpap machine) that is what it mimics, you simply stop breathing vs. your airway being occluded from the tongue or other.

Thanks for your replies. I did also have a titration sleep study which established the 11cm setting. Unfortunately during my interactions with the Sleep Center staff I took the role of bewildered passive patient and it never occured to me that I should request a copy of my results, but I will do so now.

The doc seemed unsure whether CPAP would help me, though he suggested I try it. This leads me to wonder if any perceived benefit may in fact be a placebo effect. He also doubted that the insurance co. would recognize a need for CPAP based on my REM-only apnea. That is moot however as the cost will be out of pocket dut to their high deductible.

Many times I have awoken from a very stressfull dream and thought "whats that noise?", only to realize it is me making that high pitched groaning sound after having stopped breathing (whether from holding breath, collapsed throat or whatever). I had thought that some subconscious emotional stress was fueling these anxiety dreams that in turn made me "voluntarily" hold my breath. Now I see that the cause-effect relationship is likely the opposite. I stop breathing, due to a form of OSA, and my mind starts playing out an appropriate scenario for that condition.

Sorry to go on a bit here, but its very helpful for me to express this stuff.

I also have been diagnosed with GERD and take Nexium. From what I've read these conditions seem to go hand in hand. I am not overweight, but am a rather large fellow at 6'5" 220lbs. Perhaps there is some predisposition to apnea among people with my body type.

The doc had very little to say when I went for my follow up and, as per usual these days, seemed in a hurry to get me out of there. Even if I had known the right questions to ask, I doubt he'd have had an answer. I did ask about using an APAP machine but he dismissed that idea. It seems they have not been approved for use yet and are not available as of January 2007. Uhhhhh......ok doc....

The immediate question for me is whether to go with the auto "tank", M series or the 420E. Not to turn this into another which machine is better thread, but if anyone can identify a particular advantage to one over another based on anything I've said......

Many thanks.

Guest, it appears your doctor (what is his/her specialty?) needs to be educated in sleep apnea diagnosis and treatment. AHI of 40 is severe OSA. My AHI of 35 is severe OSA, but my AHI in REM was 79.1. It's pretty obvious most of the time I stop breathing is while in REM.

It sounds like you are ready to take control of your treatment, but you might want to make things easier for his/her other apnea patients. You might want to read the following thread to help educate the doc.

viewtopic.php?t=16751&postdays=0&postorder=asc&start=0

I agree with Alisha, and yes you will generally have more apnea events during REM, that is because that is where you are the most relaxed.

Sounds like your doctor is just playing the part and doesn't know very much about OSA and what the data means. Get a copy of your PSG that came from the sleep lab, call your doctors office and request it, if they don't have it, then tell them to call the sleep lab and send you a copy of the complete report. The report won't contain raw data but should include a 4 or more page report.

You paid for the study with your insurance, you are entitled to a copy of the results even if your doctor doesn't know what it means. Post the results of the report here, we'll tell you what it means and won't charge you $500 to find out.

Hi. Something you said caught my attention. I have a friend who makes a high pitched noise when sleeping and it is caused by vocal cord issues (stridor), although her sounds are on inspiration. GERD can in some affect the vocal cords. Wouldn't hurt to ask an ENT to take a look at them.

Glad the "bewildered passive patient" has now taken on the role of informed and involved patient.

Kathy

I didn't make it clear, but the Dr. mentioned in my post was the one at the sleep center (!?) I'm not going to suggest that he is incompetent. I think he normally sees patients who are elderly, very sick or were remanded to him by their employer or union (for falling asleep on the job) and thereby are less inclined towards much curiousity about their condition or treatment. Also, the fact that my sleep behavior is within normal parameters except for REM, where all the sudden I exhibit severe apnea, differs from the norm of obvious diagnosis that he is probably used to dealing with.

I can say that based on a few hours spent looking online, I had more knowledge about the state of the art in xPAP equipment than anyone in that office. As for the Dr's comment about APAP, I'm sure thats what he'd like to believe. While auto PAP technology is in its infancy today, eventually it will drastically curtail--if not eliminate--the very profitable sleep study business as it currently exists.

Overall I have come to accept that the medical/insurance world can not offer me much support in this area. This site has been very, very encouraging for me and made me feel that I can still find effective treatment despite the hurdles. It also has solidified the idea that I really do have a condition that needs aggressive treatment.

I did have an endoscopy which fortunately showed no damage to my vocal apparatus. There was some esophageal irritation but the Nexium and some reasonable "lifestyle" changes appear to have set that right.

I have been procrastinating picking out a machine (still using the loaner), partly due to waiting for some divine inspiration to help me choose the right one. But you gotta start somewhere so tomorrow I will call up and chat with the cpap.com folks and see what they say

Sounds like you've taken the bull by the horns, so surely your persistence will lead you to solutions. Interesting that your doc was able to diagnosis your vocal cords via the endoscopy. The doc who scheduled my endoscopy wanted me to see an ENT first, saying he could "take a look as he passed by" but wouldn't be able to visualize the cords completely.

I'm trying to remember reading about anyone's bed partner describing sounds other than snoring and snorting, but nothing is coming to mind. Wonder if that sound you describe is when an obstruction begins to let just a little bit of air through instead of a sudden wide open rush - like slowly letting the air out of a blown up balloon. And it causes me to wonder what an hyponea might sound like (if anything). Whatever it is, hopefully with xpap treatment the sound and the stressful dreams (which have been reported by others) will be a thing of the past.

Kathy

I think you are on the right path in general.

With the things you mention I would DEFINATELY go with the APAP and one with exhale relief. Also would limit future retitration costs. Check that sleep study for central apneas too before you decide though.

The software (you mention wanting it) for the ResMed is a bit harder to come by although some have posted you can get it from Australia. The exhale relief on the Resmed is not usable in Auto mode. This manufacturer recently raised internet prices so the machines are a bit more (not necessarily a better machuine though, all depends on the patient). Prices used to be similar not too very long ago.

The Respironics Tank (I have 2 of these) has both exhale relief and the software can be purchased from your host's web site as well as you can purchase a complete "bundle" machine, humidifier and software.

The M should be the same, but gives you some nightly data on the LED screen, and a ramp should you want one. The tank in Auto mode will reset to your minimum setting when you hit the ramp button, which many find quite sufficient.

The other one you mention doesn't have exhale relief I believe, but I don't own one of those so check the product description for that.

You can go to our host's website and use the compare feature and put them side by side.

Guest wrote:I can say that based on a few hours spent looking online, I had more knowledge about the state of the art in xPAP equipment than anyone in that office. As for the Dr's comment about APAP, I'm sure thats what he'd like to believe. While auto PAP technology is in its infancy today, eventually it will drastically curtail--if not eliminate--the very profitable sleep study business as it currently exists.

Good to hear that you've educated yourself. I will point out, however, that APAP technology is not in its infancy at all, merely resisted by the powers that be for the very reasons you mention, (except when they choose to use it, of course).

Regards,
Bill

Guest,

When I read your post, I had to ask myself if I wrote it. Your description sounds exactly like what I do regarding the high pitch whine during a long slow exhale. I've done this even as a kid -I'm now 43. BTW, I'm a 6-3, 200 lb man which is also similar.

For me, its as if taking in - and holding - a big breath of air is "delicious" for lack of a better term. It feels good to hold all this air in my lungs and I have no urge to exhale it. However, eventually I do exhale it at a slow rate while making the high pitch straining sound. When I awake or partially awake and catch myself doing this, I realize that holding this big breath of air and slowly exhaling it feels very "good" or comforting. I think thats why my body does it several times during sleep.

I have long struggled with morning headaches feeling like I've been blowing up balloons all night. Indeed I have been essentially doing just that while sleeping. I finally got refered to a sleep study and explained my symptoms to the doctor. When I described the high pitch straining and breath holding, it didn't seem to ring any bells with her. I thought that odd for a doctor who works at a sleep center. Anyway - long story short - I got my cpap yesterday.

I'm not convinced that I have trouble inhaling due to a blockage. I know that my mind won't let me exhale because lungs full of air feel so good.

I'm the "guest" who began this thread, now registered on the site.

The breath holding thing is difficult to understand. People who have heard me do it tend to describe it as voluntary, not like I'm choking or unable to breath because of an obstruction. It is hard to ignore the possibility of a psychological component of this behavior, especially given it's exclusive REM occurance. But as others have said, REM is the most apnea-prone stage and what looks like "holding" may in fact just be another form of collapsed airway due to over-relaxation of the relevant muscles.

Interestingly, I tend to hold my breath sometimes when I'm awake also, especially if I'm performing a difficult task or otherwise concentrating very hard.

The bottom line is that CPAP can potentially aleviate the problem, regardless of its cause and actual mechanism. I don't expect to get a lot of answers from the professional medical world on this. I do expect to get some answers (and some help) from the APAP I ordered (M-series Auto...woohoo!)

REMulac wrote: The breath holding thing is difficult to understand. People who have heard me do it tend to describe it as voluntary, not like I'm choking or unable to breath because of an obstruction. It is hard to ignore the possibility of a psychological component of this behavior, especially given it's exclusive REM occurance. But as others have said, REM is the most apnea-prone stage and what looks like "holding" may in fact just be another form of collapsed airway due to over-relaxation of the relevant muscles.

Honestly it really just sounds like sleep apnea to me rather than you holding your breath on purpose.