UARS Questions--Want to Feel Better!

Snoredog wrote:UARS is daytime fatigue and we don't know the cause of it, is what it should say. It is a kin to asking a lab tech what are those spontaneous arousals caused from? you get those deer in the headlights look and they shake their head.

LOL! Undoubtedly because they realize the inadequacy of the phrase "spontaneous arousal" and know that it's existence is on borrowed time!

I used to snigger at the people who used the phrase "cortical arousal", thinking, "Oh, you think you're so smart!" But indeed, in the next phase of monitoring, additional arousal types will appear, and differentiation will have to be made. On the forefront will be autonomic arousals, where the response of other body processes will be examined. High on the list will be Heart Rate Variation (HRV), which has been heavily pushed by the BI Deaconess group since the birth of CSDB. It is fascinating to watch HRV during the course of respiratory events. This is from my pal Snoozehunter (HRV is represented by "ECG R-R" interval, measuring the distance between heartbeats, or QRS complexes). See the undulating pattern



In the case of respiratory events, HRVs have their own characteristics (usually frequency, as in cycles per second), or "fingerprint" that will allow identification of the event that caused it. This was one of the components of the hallmark paper by Thomas and Gilmartin on CSBD (they weren't really introducing CSBD, that had been done earlier). For example, if you knew that say, CSR had a very precise variation (as do most central events)(OK, maybe not sleep-onset)(anyway..), and the frequency was about 0.01 Hz, if the HRV analysis showed a pattern like the one in the UR, you would say, AHA! CSR!



Then comes analysis using Cyclic Alternating Pattern (CAP) also originally out of Boston (Thomas, Terzano, et al).

This approach looks grossly at sleep, taking in several minutes at a time, and takes into consideration that sleep is bi-stable (like either it is, or it isn't).

What's interesting about these approaches is that rather than looking closer at sleep, we're backing up a bit. Quite a bit, actually, getting a much broader overview. This is infinitely more effective than looking at one arousal and asking, "Gee, I wonder what that was from?"
SAG

Hey, SAG—

Yes, he did write “RERA.” There was a category on the form typed “MH Index” that he crossed out and put, “ReRa.” I guess UARS is the “syndrome” and ReRa is the event?

On my sleep study, RDI (Respiratory Distress Index) was 19. Of that 19 RDI, he said the actual AHI was 4.7. (98 total RDI, 0 apneas, 24 OH and 74 ReRa). So a big portion of respiratory arousals were classified as what he called ReRa’s. Did have desats down to 85% and one obstruction lasted 93 seconds. CPAP titration left me with an RDI index of 2.6 (12 total), that were all ReRa’s. Thing is, now I can’t tell how many times this is happing, which is why I was trying to possibly hook it to snoring, because I can follow the snoring on the software!

Medications. Take Synthroid (thyroid replacement) in the morning. Toprol XL-beta blocker- (25 mg) in the morning. Used to take this at night, but read where it can mess with sleep, so I now take it in the a.m. Hydroclorothiazide in the morning (water pill). Singulair for allergies, which I was told I’m supposed to take at night. Also take magnesium at night.

Snoring. I’m just going by the Encore Pro graphs that show Vibratory Snores and used the numbers that shows.

By “raw data” are you talking about the 5 page report with all the tables of the entire night? Where the electrodes where placed, time in each stage of sleep, positions, latencies, arousal summary, heart rate analysis , oximetry breakdown, etc. (Side note: Thought the heart rates were too high, but he said they were okay. Several months later, my heart rate went out of control and I found out I had Graves’ Disease, which attacks your thyroid (causing hyperthyroid) and, among a lot of other symptoms, increases your heart rate, thus, the Toprol XL I mentioned above. That could have easily been creeping in there when I had the sleep studies done.)

Had a lot of those spontaneous arousals, too. I’m working on some things there such as getting out of the “severely obese” BMI category, stopping caffeine, and starting exercise. I believe that being extremely overweight can be a hindrance to sleep, even when OSA is addressed. And caffeine, even early in the day, can disrupt sleep cycles (just found this out recently). (Lost 10 pounds so far—much more to go.)

Hey there, snoredog. You know, I don’t believe that just because one can’t 100% identify something and neatly put it into a definite classification that it doesn’t exist. There’s something there, whatever one chooses to call it, that is not severe enough to be hypopnea or apnea, but is still enough of a SDB event to cause some sort of an arousal that disrupts sleep. Heck, even snoring on it’s own can disrupt the sleep of the person doing the snoring (not to mention anyone listening)!

Pam

According to William Dement's books the term UARS was coined by Christian Guilleminault at Stanford.

"The term 'upper airway resistance syndrome' denotes an entity characterized by the presence of daytime fatigue or sleepiness in the presence of a normal respiratory disturbance index and oxygen saturation. Despite some similarities, certain specific clinical and diagnostic features distinguish it from the obstructive sleep apnea syndrome. The essence of diagnosis lies in the documentation of increasing esophageal pressures during sleep with associated transient EEG arousals. Furthermore, the evidence suggests an abnormal blood pressure response to the changes in esophageal pressures and arousals. The exact pathophysiology is currently unclear. "

http://content.karger.com/ProdukteDB/pr ... ?Doi=27961

More info at

http://www.medscape.com/viewarticle/494651

If the above link does not work for you then google 'Upper Airway Resistance Syndrome-One Decade Later' and click on the link

WearyOne wrote:By “raw data” are you talking about the 5 page report with all the tables of the entire night? Where the electrodes where placed, time in each stage of sleep, positions, latencies, arousal summary, heart rate analysis , oximetry breakdown, etc.

By "raw data" I think he's talking about the entire sleep study, burned onto a DVD. Not just a report, no matter how long.

The raw data would be all the recordings for the whole night...epoch by epoch. Minute by minute. Second by second. The whole enchilada.

The Big Burrito.

Can you post that graph that shows the snoring? But overall, your respiratory numbers "shouldn't" account for that level of sleepiness. I remember/reread all the old posts and graphs, and sleep efficiency, of course, was a big issue. Except 1998, that looked pretty good.

You got off the SSRIs? I thought that would have made a good dent in the sleepiness.

What's your resting heart rate (first thing in morning, still in bed)?

Might be time for another sleep study to take another look at that architecture.

Gad, 30 million mixed apneas in that first (actually second) study. Hey, it might be, there's a 15% shot.

SAG

StillAnotherGuest wrote: Gad, 30 million mixed apneas in that first (actually second) study. Hey, it might be, there's a 15% shot. SAG

And they seem to be gone from on the cpap study.

Thanks, Laura. I thought it probably wasn't as easy as what I said! I can give that a shot, but I don't know how easy it will be getting it.

No SSRI's anymore.

Resting heart rate in the morning can be as low as 65. I've taken a few times, too, waking up in the middle of the night, and it's between 69 and 79. I have one of those finger oximeter things that also shows the heart rate, and I use that--can't see the clock without my glasses!!

Haven't felt that bad today and last night's graph was like this:



The little jump in mask leak was when I woke up from a bad dream, trying to act part of it out. (Nothing like bolting up in bed, trying to bite someone through your mask---don't ask...LOL)

But then there's also this:



Another sleep study is not possible at this point. I'm self-employed and COBRA from my husband's job ran out. I'M working on individual insurance, but with the high deductible I'm going to have to have, a new sleep study would be out of pocket and I just can't afford it right now. (My original one was 1/07 and the titration was 2/07.)

WearyOne wrote:
Hey there, snoredog. You know, I don’t believe that just because one can’t 100% identify something and neatly put it into a definite classification that it doesn’t exist. There’s something there, whatever one chooses to call it, that is not severe enough to be hypopnea or apnea, but is still enough of a SDB event to cause some sort of an arousal that disrupts sleep. Heck, even snoring on it’s own can disrupt the sleep of the person doing the snoring (not to mention anyone listening)!

I wasn't saying the syndrome doesn't exist, I was saying they don't know what the events ARE that make up the syndrome other than to include those that already known that make up what we know as OSA.

Those arousals you speak of and I mentioned are residual after the events that typically make up AHI. You can't really say it is snoring either because they show that you can have the syndrome without snoring and/or if snoring was eliminated with palatal surgery. The may coexist with each other.

The question is, are the events that supposedly make up UARS those arousals we refer to as spontaneous (or arousals without a known cause). They say UARS leads to daytime somnolence, so does obstructive sleep disordered events, but with CPAP you eliminate those events and the arousals we are referring to remain.

I also gave examples of patients that have come here had a PSG and their diagnostic AHI was below what insurance deems appropriate for OSA. So for those patients obtaining therapy is difficult or out of their own pocket. Many times it is their doctor that want them to have CPAP therapy.

When you go back to the term describing UARS, it is Upper Airway Resistance Syndrome, CPAP overcomes the "resistance" in the upper airway, but as we see many times CPAP does not eliminate those arousals (what ever you want to call them). Those arousals are the only logical feature left behind to destroy your sleep architecture.

In a way I'm glad they told me what they were (in my case) but like you frustrated there are no answers for them. Again, we know we cannot see them once you leave the lab, look at your own reports, you don't have enough "obstructive" events on that EncorePro daily report to justify your daytime fatigue.

I'll take it a bit further, I personally had 3 separate Hematological studies done prior to my first stroke, they were looking for causes of fatigue and reason I was having a TIA every few weeks (this was before my first stroke), they thought I had some kind of blood or clotting disorder. My platelet counts used to be 850,000 when they should have been under 399,000. I used to donate platelets just to lower my counts. I've also had malignant melanoma cut off me twice (confirmed malignant) and a BCC several times.

But the point is, you can rule out OSA as the cause if the machine eliminates the obstructive events that contribute to EDS, if you have blood work done to eliminate other possible causes (anemia, lupus etc., or other disorder), you are getting enough sleep (i.e. rule out other known causes) only thing left are those residual arousals left on your PSG they call spontaneous.

Now they tell you, you have UARS, when you try to decipher out what that is, you find EDS without AHI (in a nut shell) and you are back to square one.

Your VS:=10 indice, personally I don't think your snores indice is high enough to contribute to anything (when you consider how sensitive that machine is to scoring those tics found on the report). RERA's can be related to LOUD snoring (but if you stop snoring and the PSG still shows those arousals....).

RESPIRATORY EFFORT RELATED AROUSALS (RERAs)=Sleep Arousals due to respiratory events characterized by pressure flow limitations in the airflow indicator channel without significant O2 desaturations.

StillAnotherGuest wrote:Hey, it might be, there's a 15% shot.

OMG, you're about to open up a whole other can of ... definitions.

rested gal wrote:

StillAnotherGuest wrote:Hey, it might be, there's a 15% shot.

OMG, you're about to open up a whole other can of ... definitions.

WearyOne wrote:

StillAnotherGuest wrote: Gad, 30 million mixed apneas in that first (actually second) study. Hey, it might be, there's a 15% shot.

And they seem to be gone from on the cpap study.

Right. So whadz this mean? Everybody else with CSDB needs a $4000 machine plus additional adjuncts, and yours (if it really is CSDB) basically disappears with low-level CPAP. So were they really mixed? Mr. Skeptical would like to see for himself. But if CSDB is a concern (and it could be, if those events are scored correctly), then it must be kept in mind that overly aggressive pressures might create a problem. Sure wish there was REM in that first study.

Speaking of which, I had thought that, based on the prior sleep studies, most of the issues were based on sleep fragmentation, "spontaneous" arousals, and poor sleep efficiency. Your HAS score was up there at 51. And while HAS was designed to aid in the evaluation of Primary Insomnia, keep in mind this SAG sig:

One could easily debate the position that there is no such thing as Primary Insomnia (insomnia without a "known" cause). Not having a cause and not finding a cause are 2 entirely different things.

Can you retake the HAS? Because

WearyOne wrote:No SSRI's anymore.

The little jump in mask leak was when I woke up from a bad dream...

OK, that's new. REM, at just about where it should be.

The titration never looked at supine REM, and the VS are approximately where the early REM periods should be. Is supine REM being under-addressed? A thought.

But there's very early VS. Can we stretch that logic to say that those early snores are suggestive of a sleep-onset REM period? Without PSG, you're really blindfolded. But...

Overwhelming EDS when everything else is OK (let's say the sleep maintenance is better without the SSRI) sends us down other roads.

How'd you score on the Narcolepsy questions...

Oh No, Now What?

...like cataplexy, sleep paralysis and hallucinations at sleep-onset and upon awakening. I guess we got the EDS one down pat. Your only REM period in the titration is fragmented but that could be from anything. (But if all your events did have a "central flavor" to them, REM might have been a a little more stable from a respiratory standpoint, so the fragmentation could be due to something else).

Did we ever cover head trauma, especially one that produced coma, forever how long?

WearyOne wrote:Resting heart rate in the morning can be as low as 65. I've taken a few times, too, waking up in the middle of the night, and it's between 69 and 79.

The question there would be is Synthroid creating sleep maintenance issues in spite of "normal" labwork. Given everything, that HR's no help.

Doing all the other sleep hygiene things? Sure, lose the caffeine. Small dinners, 3 hours before taking sleep? I think the effect of GERD is over-rated. If people are eating the aforementioned "Big Burrito" 10 minutes before bedtime, that's not GERD, that's poor nutritional hygiene.

Also assuming that all of this is a "sleepiness" problem, and not a "fatigue" type of thing.

Magnesium, huh? For the RLS? Would like to look for PLMs in the titration, perhaps they're hidden in all that fragmentation. I like Mirapex. Some people say it gives people the urge to gamble, but I take it myself, and I'll give you 8 to 5 they're wrong.

How much time do you think you're actually sleeping now? We need a sleep log.

If insomnia is still an issue and you've tried self-CBT and not gotten anywhere, maybe a professional consult there would help.

SAG

Lifestyle may sometimes be a contributing factor on days I just can't stay awake mid-afternoon--I sit and type for a living, at home, by myself. Come to think of it--and this may not even be relevant--last week on a couple days when I had to go out early in the morning to pick up work from clients, I was much more awake the rest of day than usual.

The magnesium is, uh, for IBS. Helps things, uh, move right along.

Don't have any of the symptoms listed for narcalepsy, except sleepy and fatigued. Some days, I get to a point where I cannot say awake and have to take a nap. Other days, it's just being tired all day long, with no exceptionally sleepy periods. I don't fall asleep driving, while watching TV, talking with people on the phone or otherwise, typing, etc.

Those centrals on the titration were more of a sleep-onset thing, I believe?

What did they mean by MH and CH? Mixed Hypopnea? Central Hypopnea? He crossed out "MH" and wrote in ReRa for the sleep study; crossed out CH and wrote ReRa for the titration. Is the answer as simple as their form is wrong and he was correcting it? He did this, by the way, when I was in his office asking about some things on the report. Or maybe they don't have a category on the form for what is determine as an ReRa and just put it that category. Or does this really not make any difference at all?

No head trauma at all.

Don't have a sleep log, but might be a good idea to start one.

Since thyroid is measure in a range rather than a set number, with the best tracking done on FT4 and FT3 (not TSH), you can play with the dosage a little and still stay in range. I've done that between two different dosages and don't see a difference in the sleep. (Man, I wish you could check thyroid levels at home like you can glucose, cholesterol, etc.)

I did talk with the sleep doc at my last appointment three months ago. We discussed my still waking up. He suggested that since my numbers were so good (I brought him printouts from Encore Pro), that we might want to try something else. We talked about melatonin (which really helps my son who has DSPS), or Rozerem, which sort of works the same way. He had Rozerem samples, so I tried that. Affected me weird, so I didn't try it again, but might tonight. Three milligrams of prolonged-release melatonin didn't really make a difference.

Add female hormone havoc at "this time of life," and you put another probable cause/contributing factor up on the dart board. (Just went to a seminar about this at a compounding pharmacy this week.)

Pam

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, Encore Pro, Hypopnea

Can you get yourself out into the sun for half an hour every morning - maybe even first thing in the morning?

O.

ozij wrote:Can you get yourself out into the sun for half an hour every morning - maybe even first thing in the morning?

O.

Definitely a good idea, ozij! And when that's not possible, I could use the bright-light box early in the morning (simulates daylight intensity and is used a lot for people with SAD or any circadian rhythm problem). It's from my son's earlier days--he doesn't need it now.

Thanks!

Pam

WearyOne wrote:Those centrals on the titration were more of a sleep-onset thing, I believe?

Probably, there's major sleep-wake trasition there.

WearyOne wrote:What did they mean by MH and CH? Mixed Hypopnea? Central Hypopnea? He crossed out "MH" and wrote in ReRa for the sleep study; crossed out CH and wrote ReRa for the titration. Is the answer as simple as their form is wrong and he was correcting it? He did this, by the way, when I was in his office asking about some things on the report. Or maybe they don't have a category on the form for what is determine as an ReRa and just put it that category. Or does this really not make any difference at all?

Roger on the acronyms.

While a hypopnea is a reduction in airflow, say from 30 to 90%, you need one other thing before you can call it a hypopnea. Most often, that is a desat. An alternative definition to that would be simply an arousal. If you're using the desat-only rule to score hypopneas, then all the hypopneas with only arousals would be classified as RERAs. There doesn't appear to be desats (significant ones, anyway) with the events on the titration, so perhaps he was taking all the hypopneas without desats and tossing them into the RERA bucket.

WearyOne wrote:

ozij wrote:Can you get yourself out into the sun for half an hour every morning - maybe even first thing in the morning?

O.

Definitely a good idea, ozij! And when that's not possible, I could use the bright-light box early in the morning (simulates daylight intensity and is used a lot for people with SAD or any circadian rhythm problem). It's from my son's earlier days--he doesn't need it now.

And on the other end, don't be doing BLT when you shouldn't:

Turn That Thing Off!

SAG

StillAnotherGuest wrote:

WearyOne wrote:

ozij wrote:Can you get yourself out into the sun for half an hour every morning - maybe even first thing in the morning?

O.

Definitely a good idea, ozij! And when that's not possible, I could use the bright-light box early in the morning (simulates daylight intensity and is used a lot for people with SAD or any circadian rhythm problem). It's from my son's earlier days--he doesn't need it now.

And on the other end, don't be doing BLT when you shouldn't:

SAG

After my son had to use BLT for a while years back (including all the research I did into his circadian rhythm sleep problem), I really know the harm it can do if used at the wrong time, for too long, too close to it. etc. I will definitely be going outside when possible each morning, early. And save the BLT for those days I can't.

As always, you're a wonderful wealth of knowledge, SAG!

Pam

"I like Mirapex. Some people say it gives people the urge to gamble, but I take it myself, and I'll give you 8 to 5 they're wrong."

SAG,

I didn't think there was still any debate over the potential for dopamine agonists to in some people cause gambling, shopping, eating or sexual addictions. When I was having my sleep study last week, the tech was telling me about a patient of theirs on Requip who lost his life savings, his home, and his family before someone realized Requip could be the cause. Upon stopping the medicine, his compulsion for gambling ceased.

I experienced some of the compulsive behavior side effect when on Mirapex last year. I had gotten bad enough that friends had begun to recognize I had a problem, and ask me what was going on. One of them just bluntly said "Something's not right - what's going on with you? You're out of control and you've never been like this before."

Most will not have the extreme side effects that are possible, but to those who do, it can be life disrupting. Sadly, many have no idea why they are doing some things they do.

Just one more perspective, based on personal experience.

Kathy