.

Where did you get that sleep hygiene list? You correctly question the Bright Light Therapy in the late afternoon thing. BLT should have a target:

http://www.sleepeducation.com/Treatment.aspx?id=4

but since this is "hygiene" and not "treatment", the cheapest and best BLT (or maybe BLH) is get outside first thing in the morning for 30 minutes. Even a cloudy day provides plenty of lux.

And don't be staring at the computer screen before bedtime. That'll burn up melatonin, too.

I think FL is now very important to the discussion (sorry I didn't see it sooner, but this ain't the pickup window at McSleepStudies).

I think you need to make sure that your upper airway is patent. RIgid obstruction will create fixed FL and be untreatable. Can you breathe through each nare freely? Then try putting lateral traction on the skin between the bridge of your nose and cheekbone. Does that make significant improvement (if so, maybe a Breathe-Right Strip may help).

I'd ask your physician what their approach to treating FL is, and then ask, "Upon opening the Collection File, it appeared that due to filter settings, the tech was viewing



when they should have been viewing



What's up with that?"

BTW, immediately after the above epoch, intervention to 10cmH2O gave improvement to the FL waveform:



Yet, this was temporary, and shortly thereafter the process repeated at 12 cmH2O.

A bilevel approach (a flow burst as opposed to an overall pressure increase) may provide a better and more stable solution.

.

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secret agent girl wrote: What would be really helpful to me at this point would be:
**More of you lurkers to jump in, even if “just” with encouragement

Good luck, secret agent girl! A few comments before I retreat into my own TN based physical pain today:

1) Flow Limitations: NotMuffy discovered that graph filters in your past NPSG masked your flow limitations. I'm under the impression that some clinics still ignore flow limitations and focus on apneas and hypopneas. I'd call your clinic before the upcoming NPSG and ask about their flow limitation DX and TX policy. If they ignore FL or play down the importance of FL, then I'd cancel the sleep study and find a clinic that focuses on FL based SDB as much as apnea and hypopnea based SDB

2) Pain: Where is your physical pain now compared to when you had the NPSG that NotMuffy is currently analyzing? There's a chance that pain-related alpha intrusions are now one of your sleep spoilers. I'd ask the sleep clinic to look for alpha intrusions as well---since that may be one of your sleep issues now versus before.

3) Sleep Aids During the NPSG: This is a tough call IMHO. The inherent dilemma in your case is that if you can't sleep during the NPSG, then your disordered sleep obviously cannot be measured. If there was easy advice about HOW to sleep well during an NPSG, then that same advice could be applied nightly at home as well. And you wouldn't need the sleep study.

If you think there's a GOOD chance you can sleep naturally during the NPSG, then pharmaceutical sleep aids won't risk masking/skewing the underlying central breathing, wake/arousal, and perhaps even alpha-intrusion characteristics you endeavor to measure. Conversely, if you know there's a poor chance of sleeping during the NPSG without a sleep aid, then IMHO you're better off taking the sleep aid. You won't perfectly recreate your home-based sleep problems that way, but there will hopefully be characteristic sleep problems for them to study----there usually are. Sleep deprivation is one alternative to a sleeping pill. I intentionally reported in to my second of two sleep studies very sleep deprived. That way I was able to sleep during my second NPSG. I still presented more than my share of spontaneous arousals considering how sleep deprived I was. But at least I slept.



Call for lurkers and other semi-lurkers to offer secret agent girl practical advice or just wish her luck! Again, good luck. SAgirl! And thanks again for doing this, NotMuffy!

I'll pipe in here and offer some encouragement. I know it's frustrating, but I think you're getting exceptional input here and eventually, you all will get this all figured out.

Keep on plugging, keep on asking questions. The experts here are very, very good.

Secret Agent Girl, I'm rooting for you!

secret agent girl wrote:PS: It is a Beautiful Day--or were you just reminding me of one of my favorite bands from the sixties?
http://www.itsaboutmusic.com/beautifulday.html

Well, the self-entitled First Album was great, but actually my Mind Collage is going Warm Sun > Gorgeous Blue Sky (at the time of the original post, anyway) > U2 > Bono > Edge > IABD > LaFlamme.

Since we're talking about flow waves, bilevel, therapy tolerance, and filter settings, now is a great time to go back (if everyone hasn't done that already) and review one of the "Best of" threads, "BiLevel Therapy P****s" (sorry, that word is out of context).

Anyway, we're in the middle here:

Titrating To What?

Basically, one poster is saying that there should be zero tolerance for flow limitations, and a key component of that is a phenomenon termed "Expiratory Intolerance", while another poster is saying that there's NSFT called "Expiratory Intolerance", and it's simply (1) a misinterpretation of the waveform, and (2) even if there were such a thing, the treatment choice (lowering EPAP) would be totally inappropriate.

The Proposed "Normal" Waveform:



The Proposed "Abnormal" Waveform:



Now interestingly, you have this same "expiratory intolerance" waveform (enhanced through adjustment (removal) of filters):



Here are the proposed "Bumps of Expiratory Intolerance (BEI)":



However, superimposing the EKG waveform:



we can now clearly see that the "bumps" are simply artifact created by the pounding of the heartbeat that is picked up in the flow channel. Titrating to that would make no sense.

BTW, the Groundhog is frozen hard as a rock.

I think that's a bad sign.

In the Good News, Bad News Category:

I found the morning newspaper.

Unfortunately, I found it with the snow blower.

Looks like it's gonna be one of those days.

Secret Agent Girl, I'm one of the lurkers on this thread. I have nothing to add to this thread, but thank you for sharing this with us, so we can learn, and cheer for you.

OK, given your other thread re: weight loss, I'm kinda gettin' the feeling you're taking a slightly different direction in treatment approach, and maybe deferring PSG for a bit might not be a bad idea.

I mean, if you end up with a 30% weight loss, trying to microanalyze these FLs might be a little like Yossarian with the band-aid on the airplane.

In what may be a couple final thoughts, an interesting study showing the

Relationship Between Functional Residual Capacity And Obstructive Sleep Apnea

This study confirms prior observations that a low FRC is a risk factor for developing sleep disordered breathing.

but that

lack of association between FRC and AHI during REM sleep indicates that factors other than lung volume

which is kinda telling me that this phenomenon is a little CompSAS-y in nature (because it alters plant gain), and isn't strictly due to reducing tracheal traction (a la Split_City research).

Since weight loss will probably increase FRC, pre- and post-weight loss PFTs would lend discussion fodder.

secret agent girl wrote:The sleep doctor is not sleep medicine board certified, though she works in a practice with with some partners who are. It's actually one of these partners that dictated the report at the beginning of my 1st study. Would I be better of seeing a doctor who is certified?

Your most recent sleep log upload shows some good sleep hygiene stuff, but those awakenings look pretty significant:



If you choose to see another physician, try to get one who is not only Board-Certified, but is sharp in sleep itself. A clue would be to see if they are sub-certified in CBT.

Although your sleep study was a split and you've got a lot of wake in the titration portion such that there's not a great deal of data to analyze, this is an area that I believe may offer some good insights:



This is at about 0500 on 12 cmH2O PAP while on your left side (and usually OSA is less severe in lateral sleep than supine because of the way the airway collapses, so overall information is incomplete).

OSA severity can also change within NREM. "Light" NREM (stages 1 and 2) is more susceptible to OSA than "deep" NREM (stage 3)-- or, put another way, if you can get to NREM 3, breathing becomes stable regardless of virtually everything else.

This may offer credibility to the CompSAS argument. While breathing stability appears in NREM3 (expected), it is maintained in REM ("Sparkly")(although this is on 12cmH2O and a relative ton of pressure, but one would think that if you're FL-y on 12 in light NREM, you would have been FL-y on 12 in REM).

Gotta run. cya.

NotMuffy wrote: OSA severity can also change within NREM. "Light" NREM (stages 1 and 2) is more susceptible to OSA than "deep" NREM (stage 3)-- or, put another way, if you can get to NREM 3, breathing becomes stable regardless of virtually everything else.

[/quote]
NotMuffy,

This caught my eye for several reasons. Can you explain a bit more about deep NREM (stage 3) vs. light NREM?

Also can you explain the difference between stable and unstable NREM? How do they tell during the sleep test when NREM is unstable?

.