Morning clusters of obstructives over last three days

[cliffspab]

Hello all

Big fan of this forum and longtime lurker here.

I don't have enough posts for screenshots (and weirdly couldn't find the instructions about how to upload them either).

I've had an AHI under one for the last six months or so, but over the last few (three or four) days have noticed a big cluster of obstructives each morning at around the same time.

No idea what's causing them as I haven't done anything different routine-wise (except eat an ice cream after dinner on those nights!)

Here's a shared google photos folder for with this morning's example. the whole night, and the cluster zoomed in on. I use an Airsense 10 auto and dreamwear mask.

https://goo.gl/photos/cqLEJV3NcnZ1uUNR7

Normally my pressure doesn't go above 13/14, but these clusters have pushed it right up to 20.

Just wondering if anyone has any advice they can share or can see anything in the screenshots that might help?

Best wishes and keep up the good work (I've learned everything I know about succcesful self-titration from reading the information here!)

Sensei

[robysue]

cliffspab,

The timing of that cluster is appropriate for a cluster of REM-related events.

Yes, as xxyzx has pointed out, there is leaking going on during the cluster, but the pressure increase is not caused by the leaks---it's caused by the events. And as the pressure goes up in response to the OAs scored between 8:18 and 8:26, the leaks don't actually get any worse. The largest of the leaks (when you're in Large Leak territory) doesn't start until after 8:30.

Notably, you've got other periods during the night when your leak rate is high, but you don't have a significant number of events being scored and the pressure stays where you expect it stay. It could be that the machine missed some events during those other periods of Large Leaks, but it's also possible that the machine didn't miss enough events to worry about.

Of course, the follow up question is, "What to do about this kind of clustering?"

In my opinion you may need to bump that min pressure setting up a bit to try to prevent REM-clusters from getting started in the first place. Working on the leaks would also be a reasonable thing---it could be that you are losing enough pressure that the APAP is just not affective at preventing a really nasty cluster from getting started in a prolonged REM period.

[cliffspab]

Thanks robysue

Those leaks are relatively standard for my usage over the last year or so.

When I have a bit more money I plan to get some of the new nasal cushions for my dreamwear as they look as though they'd deal better with the leaks. I'm in Bangkok and though I have insurance, the apnea counted as a 'pre-existing condition', so they didn't pay for any of the gear (but they did pay for the initial study, I think.

I agree that it's probably an REM period

I've worked my min pressure slowly up from 9-11 (titrated at 10), and like i said have had an average AHI of 1ish for nearly a year now.

I wonder if i roll onto my back in the mornings or end up in a different position at that time. I recall this morning i went onto my front after the bathroom break (normally I sleep on my side).

If there's no improvement tonight I'll up the minimum again. There's not really much else one can do!

Thanks again for the input.

[ajack]

if you are awake at the time, they don't count.
work on your leaks
could be back sleeping or tucking your chin to your chest, soft foam cervical collar will fix that
normally the chart and pressur looks ok and doesn't need adjusting, much.

[Pugsy]

Usually when we see clusters like this where the pressure is obviously not getting the job done the reason is either REM Stage sleep or Sleeping on one's back. Like RobySue I tend to think the cluster is REM related but I also wonder if supine sleeping is also playing a part because you should have had other REM stages during the night long before this cluster. So something changed to make this particular cluster harder to deal with.

I suspect that you got the double whammy....your OSA is worse in REM sleep and when sleeping on your back. Either is quite common.
Some people might have one or both situations where their OSA is made worse by REM sleep or when sleeping on one's back and need more pressure during those times.

My OSA is worse in REM and I might need 6 to 8 cm more pressure during those times when compared to non REM sleep.
Sleeping on my back doesn't seem to make things worse though. Confirmed by a month long experiment where I built a wall and pretty much staying on my side all night.

Since we normally will have 3 or 4 REM stage sleep segments during a normal night I would suspect that you had some other REM stages where your pressure used was sufficient. So something changed during this one segment and the first suspect would be that you moved onto your back.

So what to do? Not much we can do about controlling REM but some people are successful with staying off their back if that is the way they elect to go. Otherise like RobySue says...a little more minimum pressure to hopefully better hold the airway open and prevent that cluster from ever happening.

The cluster is likely unrelated to the large leaks...your leaks weren't all that bad during the time of the cluster. Yes, you barely went over the 24 L/min line for a short time during the cluster but it was just barely over and was very brief. The ResMed machines are still fairly accurate up to the 35 L/min mark. Usually when leaks start affecting things the first sign is the machine will flag "unknown" apneas because it knows something is going on but can't quite figure out what to call it.
Besides...only the data during the time of the large leak is suspect and the bulk of the cluster was with the leak below large leak territory.
2 suspects for large leak....mouth breathing or mask movement. No way to know for sure without totally eliminating the mouth breathing suspect by taping one's mouth. Meaning if you tape your mouth and there are still times with large leak then you know it is mask movement. They look the same on the leak graph...been there myself with my new DreamWear Gel nasal pillows. Mask movement confirmed by my taping my mouth one night to make sure.

In your situation you spent less than 4% of the night in large leak territory. If it were me I probably wouldn't worry about it and would just shrug my shoulders and move on. I don't get concerned about brief times in large leak territory. ResMed won't even give you a Mr Frowny face for leak management until you hit at least 30% of the night in large leak territory.
Now if the leaks are waking you up then they need to be worked on because anything that disturbs our sleep is unwanted but if you are sleeping right through those leaks then I don't know that I would be going to extraordinary measures to fix 3% of the night in large leaks. Sometimes the fix/cure is worse for disturbing sleep than the leak itself.