RERA

My husband is recently diagnosed with sleep apnea. He is 80 years old, has no significant health issues other than high cholesterol for which he takes medication, and he has an enlarged aorta which has remained stable for several years and for which he also takes mediation.

Initial study:

Obstructive total events: 7 supine, 9 side sleeping
Central total events: 69 supine, 0 side sleeping
Mixed: 0
Hypopnea: 1 side sleeping
RERA: 0
Total limb movements: 351


Titration study:

Obstructive total events: 2 supine, 0 side sleeping
Central total events: 0
Mixed apneas: 1 supine
Hypopneas: 3 supine, 10 side sleeping
RERA: 0
Total limb movements: 322


He has been using a CPAP machine, System One RemStar Auto with A-Flex (560P) for about a month. He uses a full face mask and the pressure is set at 8. He is in bed for about 9 hours each night and his CPAP usage average is 7 hours. (He tends to wake at 5:00 or so to visit the bathroom and decides he has had it on long enough.)

According to sleepyhead software, after 30 days his AHI (index) is 6.43, and his RERA (index) is 14.55, with his most recent reading of RERA at 20.50 (178 events).

Two questions:

We visited our sleep doctor for the first time this past week and when I asked him about the RERA events he was quite adamant that my husband did not have any RERA events and that any software that showed them was false.

Is it possible that Sleepyhead shows false positives for RERAs?

And

Is the limb movement something that needs to be addressed or is this acceptable? We did not discuss this as we had not seen the sleep reports prior to our meeting with the doctor.

SleepyHead is only reporting what the PR S1 machine is flagging.
Encore from Respironics would report the same thing.
Respironics thinks they are able to isolate and flag potential RERA Respiratory Event Related Arousals. They must have put a lot of time, work and money in coming up with something that they are so sure about that they put it out there in their flagged events.
Now how important these flagged RERA events might be in the grand scheme of things is still up for discussion especially if everything else seems to be in good order.

This definition is from Respironics
RERA

Respiratory Event Related Arousal... a sequence of breaths characterized by increasing respiratory effort leading to an arousal from sleep, but which does not meet criteria for an apnea or hypopnea.”

RERA Detection in the Respironics System One data..Respiratory effort-related arousal..defined as an arousal from sleep that follows a 10 second or longer sequence of breaths that are characterized by increasing respiratory effort, but which does not meet criteria for an apenea or hypopnea. Snoring, though usually associated with this condition need not be present. The RERA algorithm monitors for a sequence of breaths that exhibit both a subtle reduction in airflow and progressive flow limitation. If this breath sequence is terminated by a sudden increase in airflow along with the absence of flow limitation, and the event does not meet the conditions for an apnea or hypopnea, a RERA is indicated.

Thank you, Pugsy. My concern is that his two sleep studies showed 0 RERAs. Not understanding his not having any to so many. One thing I did read indicated that sometimes having the pressure too strong could cause RERAs.

It’s just that after a month he still has so little energy. Perhaps I need to see a different sleep doc for another opinion. Or perhaps a month isn’t long enough to expect improvements.

In any case, I appreciate your response.

Dear elmtree2 (and husband),

I have not read that RERAs increase with pressure. I have read that increased pressure can bring on more CAs in some people.

I'd advise you keep talking with the doctor, and see if turning the conversation to AHI works better. While the doctor may not be worried about RERA scores from the machine, do have your husband say whether he is feeling any different on treatment. You said:

According to sleepyhead software, after 30 days his AHI (index) is 6.43

I would think the doctor would be concerned about that. Many of us have read (and been told) that the goal is to be below 5 AHI. Each body / person is different, but I used to feel a difference even when I got below an AHI of 2. If the doctor doesn't want to believe the machine is right about AHI either, then if it were me I'd be thinking maybe it is time to find a different doctor (there are studies which show that our machines are close enough to be right about AHI).

--SleepyCPAP

Elmtree, remember that the A in RERA means arousal. xPAP machines cannot detect arousals since this requires an EEG to determine whether the person is awake or asleep. As Pugsy so completely described, Respironics says that their evaluation of the breathing pattern can detect implied arousals, but this is not certain. I suspect that this is what the sleep doctor was talking about when he said that any software that showed them was false. The software does not have the EEG data, so ...

As for your question about limb movements, the question here is whether this is causing him to awaken or whether it is bothering your sleep. If the answer to either of these is yes, then you should talk with the sleep doctor about treatment. Periodic Limb Movement during Sleep (PLMS) could be a cause of a number of his arousals. Also, about 85% of people with PLMS also have Restless Leg Syndrome (or Willis Ekbom Disease). The treatments for PLMS and RLS are the same, can be very effective and can bring immediate relief from the symptoms. For more info about RLS and the treatments available, check out the WED Foundation webpage at http://www.RLS.org, their Facebook page or their bulletin board at bb.RLS.org.

elmtree2 wrote:after 30 days his AHI (index) is 6.43, and his RERA (index) is 14.55,

Can you post a typical detailed night's report?
His AHI is a bit too high to suit me...we need to evaluate the event categories for that AHI...particularly Clear Airway index.
viewtopic.php?f=1&t=81072&p=737779#p737779
This thread above talks about how to post screen shots and has some examples of what we like to see.

In the past, when we see elevated RERA and AHI it usually points to less than optimal sleep for some reason.
Less than optimal sleep usually means not feeling so great. Now it may be that just more time is needed but why not use that time to make sure therapy is at least optimal.

So we first evaluate the therapy itself and make sure there's nothing there that might need some improvement and the AHI is the first thing that I noticed...second is the RERA (and let's assume that Respironics at least comes close and the presence of RERA flags that are numerous means something even if not reinforced by EEG data).

Elevated AHI plus elevated RERA plus not feeling so great....points to less than optimal sleep or therapy.
Let's check out therapy first since we know that therapy has to be optimal before we have much chance at all of having good sleep and feeling better.

Have uploaded the info.

I included the overview to show the AHI history. Those numbers are trending down, especially the last couple of nights (although that is possibly impacted by fewer minutes on the CPAP). For that reason I haven’t been too concerned about the 6.5 as yet.

I have been concerned about the PLM and the RERA numbers.

Some nights he is extremely restless, moving limbs and rolling about. Other nights he either is not that restless, or I am tired enough to sleep through it.

Thank you for the link to the RLS organization, Rustsmith. We have been looking at caffeine and exercise as two areas where we can control some change which, other than meds, is about all I can find to impact the PLM.

Am wondering as well if the two are related, although I wouldn’t know which would cause the other.

As I mentioned, the RERA numbers in both the initial sleep study and the titration, his RERAs were 0. Across the board. That’s why I wondered if it could be a software issue.

I have also read some anecdotal evidence about a correlation between the simvastatin he takes and sleep apnea. Our internist has agreed to stop the simvastatin for a while to see if the lack of it impacts his sleep at all. I admit that with the meds controlling the cholesterol, I had not been watching our diet as I should. That has now changed.

The report the sleep doctor did reference was the one printed out by his office which mostly shows compliance, but also shows his average AHI at 6.0. So he is aware of that number.

But again, since the numbers are trending down, I think I’ll wait a bit more before getting nervous about that.

I do appreciate the input and the support. For now I think we’ll see what the next couple of weeks bring, and then come back with probably a whole boatload of new and different questions and concerns.

oh my. that picture is pretty miserable. I'll try again.

Elmtree, as I said, about an 85% crossover between PLMS and RLS has been shown. I am not aware of any research to shows whether the two are directly related, but the ways that they are treated are essentially the same.

The primary difference is that PLMS can be measured during a sleep study. There are no direct tests for RLS, only a questionnaire that is filled out and scored. You can find a copy of the International RLS Rating Scale at http://irlssg.org/. You will need to click on the Rating Scale tab at the top right and then "IRLS in English for the USA" at the bottom of the next page.

At this point, the question that you both need to ask yourselves is whether the PLMS (or maybe RLS) is causing either of you sufficient sleep disruption to justify treatment. The medications are very effective for many people, but you do not want to get started with them if his PLMS/RLS is not causing the two of you many issues.

I would focus more on the AHI which at above 6 is in itself enough to cause arousals which might get flagged as RERAs by the machine.
Reducing the AHI most likely would reduce the RERAs.
While we don't know for sure just how RERAs flagged by the machine are important...we do know that the AHI is very important.
How to reduce the AHI depends on what the reports show is going on.
Keep trying to post an image of the detailed report so we can see what you are seeing.
Often if it is just a matter of a few obstructive events a little more pressure will fix things.
But before we can offer concrete ideas we need to see what is going on.
Fix what obviously needs fixing first...then worry about what is left over that is causing problems.