One person’s journey - cpap FAIL (so far) [long post]

[SRSDDS]

Questions:

What is a trigeminal arousal and how do I know if I'm having them?
Trigeminal arousal only refers to the hyperfunction of the trigeminal nerve and it's associated musculature, as occurs in clenching and bruxism. Clenching is forcefully keeping the teeth closed together, bruxism is forcefully moving the lower jaw while the teeth are in occlusion

Does an NTI cause bite changes? What are the risks with using an NTI? Can one close their mouth with it and use CPAP?
A poorly adjusted NTI can certainly cause bite changes, and even worse, condyle position. There really are no risks to properly using a properly adjusted NTI appliance. Whether you can close you mouth with it on depends on how it's designed.
Is there any evidence to support that the NTI can improve SDB?
Relief of trigeminal arousal can certainly provide relief of SDB. see http://www.ncbi.nlm.nih.gov/pubmed/17520795
Can my horseshoe shaped mouthguard be making my SDB worse by preventing a compensatory mechanism for the collapsing airway (do you believe that theory?)?
Depends on how it is designed, what the increase in vertical dimension is. But, yes, I do think that can happen.

Thanks!!

You're Welcome!!
Stephen

[SleepingUgly]

Relief of trigeminal arousal can certainly provide relief of SDB. see http://www.ncbi.nlm.nih.gov/pubmed/17520795

I don't see how that abstract supports the notion that it can improve SDB.

[jnk]

http://journalgateway.com/index.php/ijp ... 011.4/html

I would pay good money to read -SWS's take on the above.

On the link you posted here or on the contents of this thread?

Both.

And more.

Heck, I'd pay good money (if I had any) just to read ANYTHING he wrote.

But I'm sure he would have good insight on the devices and their relationship to, and effect on, for example, facial/jaw nerve pain and all that stuff, right off the top of his head.

And his balanced vision on how other approaches compare to, relate to, and interact with PAP therapy is always beyond price, in my book.

Hey, can I help it if I'm one of his biggest fans?

[SRSDDS]

Relief of trigeminal arousal can certainly provide relief of SDB. see http://www.ncbi.nlm.nih.gov/pubmed/17520795

I don't see how that abstract supports the notion that it can improve SDB.

It states that trigeminal stimulation leads to arousals during nocturnal sleep, unlike olfactory stimulus, which does not lead to arousals. The logical conclusion is that if you can reduce the incidence of trigeminal stimulation, you will reduce nocturnal arousals.

"CONCLUSIONS:

With the present results we were able to demonstrate that, in contrast to trigeminal stimulation, the presentation of a strong but selective olfactory stimulus does not lead to arousals during nocturnal sleep in humans."

Stephen

[jnk]

Relief of trigeminal arousal can certainly provide relief of SDB. see http://www.ncbi.nlm.nih.gov/pubmed/17520795

I don't see how that abstract supports the notion that it can improve SDB.

Anything that ruins sleep by causing arousals can affect everything about sleep, including breathing, as I understand it.

And not all labs excel at linking specific arousals to specific changes in breathing.

My opinion remains that when it comes to sleep, the question of 'do I have blah, blah, blah' is rarely as useful as the question of 'is it possible that doing/using/taking/adjusting blah, blah, blah may improve my sleep.' Tests accomplish little more than qualifying for treatments and proving improvement. Other than that, names of disorders are merely names.

[rested gal]

I think I understand the distinction you're making, SU, when you said you didn't see how that abstract supports the idea that relief of trigeminal arousal can improve SDB (Sleep Disordered Breathing.) I don't quite see that either.

The abstract supports (in my mind) the idea that relief of trigeminal arousals could improve sleep in general, but I doubt that even if those particular arousals were eliminated completely, there'd be much improvement (if any) to anatomical features that are allowing the airway to collapse (apneas), partially collapse (hypopneas) or "start to collapse" (UARS.)

That said, Jeff's point is a good one, and could change my mind ...

Anything that ruins sleep by causing arousals can affect everything about sleep, including breathing, as I understand it.

In fact, Jeff's point is about to change my mind... thinking off the top of my head about one thing in particular pain might cause during sleep. Perhaps cause a person to hold their breath frequently during the pain. Or...clench the throat muscles tighter. hmmm.

[SleepingUgly]

Pain typically manifests in sleep as alpha intrusions or arousals. Even if we eliminate obstructive apneas from the equation, which would be even harder to explain, I don't see why pain would manifest as hypopneas (the AASM Recommended criteria for a hypopnea is ≥ 30% airflow reduction and ≥ 4% desaturation and the AASM Alternative criteria is ≥ 50% airflow reduction and ≥ 3% desaturation or arousal). If someone were breath holding during sleep, I'm guessing that would look like central apneas on an APAP, and would be obvious on a PSG for what it is (they have belts around the waist, etc.). The OP had on average a hypopnea a minute! That's a lot of explaining to do. I have about an average of one per minute in REM only... I am not sure how atonia of REM would jive with breath holding... I just don't know that much about REM.

In short, maybe I don't have a well-reasoned argument for why pain doesn't likely manifest as SDB, but I certainly don't find that abstract compelling evidence that it does. It's a shame, too, because I would have liked a simple solution!

On the other hand, I very much believe that SDB can lead to increased pain. And I believe that pain can cause arousals. And of course SDB can cause arousals. I just don't think that pain causes SDB.

[jnk]

. . . Jeff's point . . . .

I do believe that changes in breathing can affect the state of the airway, much as the state of the airway can cause changes in breathing. Pain and discomfort can change breathing.

But I was actually thinking a bit more along the lines of a hypopnea being scored because of changes in breathing occurring around the same time as an arousal and then a liberal scorer trying to make sure a person qualifies to try a machine. If someone is having so-called "spontaneous" arousals (whatever the heck they are) all night long, for whatever reason, I think some breathing changes are more likely to get scored that might not otherwise be scored, depending on who does the scoring. Maybe not when a SAGish highly-trained expert at a center does the scoring, but maybe in Bob's Sleep Lab down by the pool hall.

Even in respected labs/centers,I think creative sleep docs are likely to make sure techs err on the side of qualifying someone for trying a PAP machine, even when the person may be more UARSish than OSAish. I have no proof whatsoever of that accusation, mind you; it is just an impression I have.

Mostly, though, I think that if bruxism or discomfort is corrected, someone is likely to sleep better, and that may include breathing better with fewer of the kinds of pauses that would make it more likely that the airway might narrow in a way that could lead to actual obstructive hypopneas too. Others however might argue that if bruxism and discomfort are arousing, they should have more of a firming effect on the airway than a narrowing effect, so maybe I'm all wet. I don't think all the experts would agree, since they don't agree on much even when it comes to something as basic as the model of UARS vs OSA, as in whether points on a continuum or polar opposites, for example. Reaction to discomfort during sleep is highly individual, I'm sure.

Either way, all of the above is based more on DSMish thought-experiment than any experience or firsthand knowledge on my part, so please don't let it change your mind on ANYTHING, Rested Gal.

[SleepingUgly]

DSMish?

[rested gal]

Ok, Jeff. How about "open" my mind to possibilities? Like some of the ones you mentioned?

DSMish?

Long story, that. I'll tell you sometime.

[rested gal]

The OP had on average a hypopnea a minute!

I don't know if we're sure about that. If it really was an "AHI" that was being reported, yes. But if the report was giving an RDI, her saying "showed hypopneas only" could have simply been to stress that there were no apneas. If it was actually an "RDI", there could have been some hypopneas and perhaps a lot of respiratory effort related arousals...RERAs. RERAs would get counted in if the result was really an RDI rather than an AHI.

Or, perhaps the "60 or 70-something" was talking about the actual number of hypopneas that happened throughout the whole night...not the "average per hour" which is how an AHI is figured.

For enough events to be scored as actual "hypopneas" -- which, in PSG scoring, I thought would have to have a certain amount of oxygen drop (3% drop ? ) -- and for her to mention there were "Minimal oxygen desats" ... it's hard to know what was going on without seeing the full PSG report. An "AHI" as severe as 60 or 70, even if made up of hypopneas entirely -- gosh, I'd think there'd be some pretty significant O2 drops. But I dunno.

[SleepingUgly]

If they are using the AASM Alternative scoring, all the hypopneas could be associated with arousals, and not desaturations (like mine). There is a big controversy among the big wigs in sleep, with some rebelling against the notion that there have to be any desaturations. Thin people may not desaturate the way heavier people do (and of course some do), so any scoring criteria that requires desaturations misses a great deal of SDB in that population.

[jnk]

. . . perhaps a lot of respiratory effort related arousals...RERAs. RERAs would get counted in if the result was really an RDI . . .

Which can, I believe, in turn, be difficult to differentiate from spontaneous arousals, or at least that was the case for these folks back in 2009:

"Spontaneous arousals during sleep increase when organs are stimulated or [other] disorders exist. As we know, in the absence of apnea or hypopnea, respiratory effort-related arousals are increased in the sleep of subjects with sleepdisordered breathing as a reaction of the sleeping brain to a repetitive breathing disturbance. . . . We were unable to differentiate true spontaneous arousals from respiratory effort-related arousals."

http://homepage.vghtpe.gov.tw/~jcma/74/2/81.pdf


So to my way of thinking (admittedly nonstandard), if the spontaneous can mistakenly be considered breathing-related and counted in RDI, AND there are some other conditions that can cause both arousals and changes in breathing, then those of us with a mild-to-moderate diagnosis who have tried a machine and find the machine (even at the best pressure with the perfect mask) makes things worse, not better, may not want to latch on too tightly to the diagnostic-study results and assume that ALL our sleep problems are related to our upper airway.

[SleepingUgly]

I would be very surprised if the OT (who appears to have taken leave of us) got her hypopneas and RERAs mixed up, but I suppose it is possible. If hers was 15, I would buy that there could be a mistake. I don't think an AHI (or RDI) of 60-70 is all a mistake (even if she slept only 5 hours and we take an AHI or 60, that's 300 episodes to mis-score). And where mistakes are made, I think they tend to be in the direction of missing SDB, not finding it AND finding it so severe.

(Someone has to play the devil's advocate ).

[jnk]

I would be very surprised if the OT (who appears to have taken leave of us) got her hypopneas and RERAs mixed up, but I suppose it is possible. If hers was 15, I would buy that there could be a mistake. I don't think an AHI (or RDI) of 60-70 is all a mistake (even if she slept only 5 hours and we take an AHI or 60, that's 300 episodes to mis-score). And where mistakes are made, I think they tend to be in the direction of missing SDB, not finding it AND finding it so severe.

(Someone has to play the devil's advocate ).

I agree completely that any AHI, or even RDI, over 5 should qualify a sleepy/tired person to try using PAP therapy and that should always be the first choice for a treatment to try to help the person feel better and be healthier.

But when someone with no apneas and no significant desats has lousy sleep and feels worse at a good pressure with a good mask after months of patience with it, I think sometimes that person needs assurance that he or she is still welcome to post his or her experiences here, even if he or she chooses to try other approaches to getting good sleep.