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Thank you Pugsy for the interesting information. I have learned so much on this forum and learn more every day. Thanks to the OP for starting this interesting thread.

I think I contributed to a misperception here about my sleep doc, AHI levels and oxygen levels.

As she explained it (and I'm taking this from the Mayo Clinic site because I don't have her words):

Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) is greater than if you don't. The more severe your sleep apnea, the greater the risk of high blood pressure. [O]bstructive sleep apnea increases the risk of stroke, regardless of whether or not you have high blood pressure. If there's underlying heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event. Studies also show that obstructive sleep apnea is associated with increased risk of atrial fibrillation, congestive heart failure and other vascular diseases.

So it seemed important to insure that my oxygen levels did not drop below 90%. According to the one-night test I participated in, my CPAP was meeting that goal.

Then she decided that a change in sleep hygiene would be more beneficial to reducing AHI than playing with pressure. For some reason she felt that the CPAP AHI numbers were incorrect. She apparently is ignoring the RERA numbers and clusters.

In any case, I'm shopping for a new sleep doc.

pikov22 wrote:Then she decided that a change in sleep hygiene would be more beneficial to reducing AHI than playing with pressure. For some reason she felt that the CPAP AHI numbers were incorrect. She apparently is ignoring the RERA numbers and clusters.

She may be thinking that the elevated AHI is from awake/semi awake events being flagged (and that's sure possible) and wanted to work on making sure you were asleep first before worrying about the AHI.

Improving sleep hygiene is hard work and takes a lot of time to get an answer.

Changing the pressure would give an answer pretty quickly...don't know why she didn't want to try it. It's not like you were at hugely high pressures already. Sometimes the docs think that "well this is what we came up with at the titration study so it just has to be spot on"... in real life sometimes it is and sometimes it isn't. We just don't sleep the same every night and that for sure includes the titration study.
To be clear...I am not talking a huge pressure increase. Maybe just 1 or 2 cm...

Thanks Pugsy for trying to help pikov22, I always learn something from you while you're reaching out to others. You're a "mensch", look it up!

Some random thoughts and my 2 cents:

. . . Changing the pressure . . . pressure increase . . . maybe just 1 or 2 cm...

Maybe the doc tried that? (Though I don't know for how long.) Pikov22 said:

pikov22 wrote: . . . She increased the pressure from 11 to 12 and decided that it did not make any difference. . . .

But, yeah, I agree 100% that pressure and modality may not be optimized yet.

And depending on other details and history, such as . . .

pikov22 from the sleep doc thread wrote: . . . my cervical stenosis, my COPD and . . .

. . . it may be that AHI will never be where others are able to get theirs--though it is always worth fighting to get it as low as possible, of course, if the fellow patient is willing to put in that work. That work is best done by an educated patient, not the doc, in my opinion, so changing docs wouldn't necessarily help that, from where I sit.

I wonder if the COPD is such that "overlap syndrome" is why the doc is focusing so much on O2. ( http://pats.atsjournals.org/content/5/2/237.full)

Centrals could be complicating things in ways difficult to decipher from home-machine data, too, I would assume.

The Medline Plus dudes wrote:Conditions that can cause or lead to central sleep apnea include: Arthritis and degenerative changes in the cervical spine or the base of the skull.--http://www.nlm.nih.gov/medlineplus/ency ... 003997.htm

In other words, I got nothing helpful to say.

Wow! That's great and I do appreciate your taking the time to write. I see from other posts that others have profited, too.

I previously said "RERA is defined as 'respiratory-event/effort-related apnea'. To my way of thinking, that means 'every apnea that is not CA, OA or Hypopnea' or 'we have no idea what causes these'."

I found this that I think supports my thinking to some extent. "An RERA is an event characterized by increasing respiratory effort for 10 seconds or longer leading to an arousal from sleep but one that does not fulfill the criteria for a hypopnea or apnea." So it's an apnea that is not CA, OA or Hypopnea. Sort of a catch-all or "none of the above" occurrence.

My doc's concern with desatting was related to the fact that my levels of desatting during the sleep study were cause for concern regarding strokes, heart attacks, etc., and not related to my actual sleep apnea.

She wants to deal with my SA by changing my sleep patterns. (My d-i-l rolled her eyes when I told her that because they tried to change her patterns over a period of years and it had no effect. She has a sleep order that, in layman's term's, delays her day by 2-3 hours. She's had to make special arrangements with her employers over the year to accommodate that.)

To get back to your questions, I don't think I was awake at all except when I turned the machine off and got up. And I'm not aware of any tossing and turning. I did a lapsed-time photo series of me one night and I look like I'm dead (for the most part!).

What's periodic breathing, by the way, and what does it signify (I can find definitions but no interpretations of its meaning)?

I found the link to the instructions for increasing the pressure. I think I will go up 1 cm/H2O and see what effect it has over the period of a few days.

Again, thanks so much for your input.

jnk wrote:

pikov22 wrote: . . . and OSA makes me grumpier!

Until you get your AHI down, if you can.

One can hope!

pikov22 wrote: ". . . that does not fulfill the criteria for a hypopnea or apnea." So it's an apnea . . .

If it isn't an apnea, then, uh, it isn't an apnea.

pikov22 wrote: My doc's concern with desatting was . . . not related to my actual sleep apnea. . . .

Desats during sleep relate to something about breathing during sleep one way or the other if there are no desats during the day.

pikov22 wrote: . . . I don't think I was awake . . . I'm not aware of . . .

It takes a lab PSG to differentiate wake from sleep definitively, in my opinion. For all I know, I'm asleep right now.

Google Scholar can be helpful for finding out more about periodic breathing.

pikov22 wrote:I don't think I was awake at all except when I turned the machine off and got up. And I'm not aware of any tossing and turning.

Then it is unlikely that the events we see flagged can all be blamed on sleep/wake/junk...some maybe but not all and that leaves less than optimal pressure allowing the events to occur as the most likely suspect. We don't always remember awakenings but I am pretty sure if you were awake during all that ugliness on your report you would be able to remember at least part of it.

Periodic Breathing is just a term for a breathing pattern where the airflow waxes and wanes...up and down sort of thing. It has to last for 2 minutes before Respironics machines will even bother to flag it.
Periodic breathing is not normally much of a concern unless we see a lot of it (seeing some is normal) and it seems to be associated with apnea events. Particularly important if we see it associated with centrals consistently because it might be Cheyenne Stokes Respiration (you can google it) and maybe an indication of other problems (also maybe not).

It seems to me that the Respironics machines are real conservative and will flag PB when there really isn't much going on to be exited about. PB breathing time will be highlighted in green on your reports. To see it up close so you can really get an idea what is going on you have to zoom in on the flow in SleepyHead or look at the wave form graphs in Encore.

I have never been able to find a nice tutorial about Periodic Breathing. Sorry. I have looked.

RERAs...I have never had many of them so I haven't dwelt a long time studying them. Normally when they show up looking like your report does. And Usually when we see the obstructive apneas and hyponeas like you have...the thing to do is try to reduce them with more pressure. A by product of the increase in pressure usually reduces any RERAs at the same time.

To my mind..they all go hand in hand and are unwanted when we see them in these numbers. Doesn't really matter if it is some sort of unknown event or an apnea that didn't grow up or whatever...I would want them gone no matter what causes them because there's a real good chance they are messing with sleep quality and anything that messes with sleep quality is unwanted.
I rarely ever have even one RERA.

Here's an example of Cheyenne Stokes Respiration that would be classified as PB on a Respironics report.



Here below is a PB flagged breathing pattern that isn't real exciting at all. Just notice the ebb and flow. No events happened and the time spent with this pattern wasn't very long. I just shrugged my shoulders and moved on. Not worth worrying over.



And here is an example with Obstructive apneas. Now it does have a Cheyenne Stokes Respiration appearance...sort of. I don't think it was real CSR but even if it was...it was rare, short lived and I might have even been awake. Awake breathing is often flagged as PB for some reason and of course it isn't. I also shrugged my shoulders and moved on with this one. I might go a month without seeing one of these.



And here would be pretty much normal flow happening...so you can see what normal looks like when we are asleep. Also in this image is a little snore that got flagged and an obstructive apnea. Notice the flat line...airway blocked off. The other airflow pattern is normal. The snore has a minor reduction in flow..easily seen. Airway tissue collapsed just a little and I had a little vibration..not much

Getting a bit long in the tooth, but still a decent brief overview of CSA in general, I think:

http://yoursleep.aasmnet.org/Disorder.aspx?id=50

And my understanding as a patient is that once someone's brain has flipped over fully to OSA, then his brain is less likely to be touchy enough to cause arousals from those less-than-hypopnea events. It is more often the people whose brains have not yet become desensitized to the state of their airway (to the point of allowing it to be fully closed for many seconds before reacting) who lean more toward the UARS condition that makes them more likely to suffer sleep distubances from small changes in their airway that would be considered a true RERA. Most people either have an overly-sensitive brain with that or a brain that has become dulled to it--but not many, I believe, have a brain that is both overly-sensitized and dulled simultaneously to the state of the airway and the state of their breathing during sleep in general.

But hey, I may have that wrong. That working theory some researchers had may already be disproved, for all I know. So I'm not sure why I even bring it up.

pikov22 wrote:RERA is defined as "respiratory-event-related apnea". To my way of thinking, that means "every apnea that is not CA, OA or Hypopnea" or "we have no idea what causes these". Is that close?

Respiratory Effort Related Arousal.

RERAs are more complicated and less well understood than apnea. Definitively measuring them requires a pressure sensor in your throat and an EEG to detect the arousal (abrupt change from one sleep stage to another.)

"For the measurement criteria to be classified as a RERA, there must be a pattern of progressively increased negative esophageal pressure that is terminated by a sudden change in the pressure to a less-negative level and a sleep arousal. Furthermore, the event must last 10 seconds or longer." http://www.clevelandclinicmeded.com/med ... breathing/

RERA measurements via CPAP machine from airflow and/or pressure measurements are iffy, so don't get too concerned about CPAP reported RERA.

Treatment is not very well understood either.

Insurance may act as if RERA and UARS doesn't exist. Some doctors don't seem to be familiar with it either.

archangle wrote: RERA measurements via CPAP machine from airflow and/or pressure measurements are iffy, so don't get too concerned about CPAP reported RERA.

Someone here was concerned about what showed in the reports I posted.

pikov22 wrote:

archangle wrote: RERA measurements via CPAP machine from airflow and/or pressure measurements are iffy, so don't get too concerned about CPAP reported RERA.

Someone here was concerned about what showed in the reports I posted.

I didn't mean to ignore them. Just don't put TOO much faith in the reading if everything else seems right.

RERAs are one of the things where the doctor MIGHT be right and the machine sees things that aren't necessarily harmful to your body. However, the machine reported RERAs may indicate some real problems too.

And once again, RERAs are arousals, not apneas, and may not respond to CPAP the way apneas do. The cause, effects and cure may be different.

pikov22 wrote:

archangle wrote: RERA measurements via CPAP machine from airflow and/or pressure measurements are iffy, so don't get too concerned about CPAP reported RERA.

Someone here was concerned about what showed in the reports I posted.

Forget the RERA for now. Your AHI is too high in the reports. You are not getting good therapy for the breathing problem.

I see your profile says you're retired so you obviously have a lot of time on your hands. The polite thing would have been to say something like this: "Just wanted to let you know that the link for the Swift FX slide show has changed and it's now X"

Make your own blog if you don't like mine. You obviously have plenty of time for it.