First Sleep Dr. visit after starting CPAP

[Pugsy]

I notice the number of RERA's, it reminds me of my wife's SH data. I was, perhaps mistakenly, thinking that CPAP therapy had no effect on RERA's. I thought RERA's were a result of a COPD condition. Is this incorrect?

The official definition of RERAs by Respironics doesn't mention COPD as being a part of things.
Now maybe someone with COPD might tend to be in a situation where RERAs are more frequent but I don't think that it necessarily means that anyone with RERAs flagged are having potential COPD issues.

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.

[hpm08161947]

Are RERA's included in the AHI calculation? IE... more RERA's.... higher AHI.

[klm49]

That works. As you can easily see there are some FLs going on. Not a huge number but when looked at in conjunction with the RERAs...might point to possibility of some low level arousals going on that you may or may not remember. It's not screaming out "fix me" though...but it points to maybe something that could be improved upon and maybe help if someone is having a lot of wake ups or not sleeping well.
The fix is easy...usually just a little more pressure during the times where you see the RERAs and FLs either with a little more minimum if using apap mode or a little higher overall pressure if using cpap mode.
Something to think about...not anything that is standing out as urgent though.

If it is solely related to supine sleeping then maybe doing something to help stay on your side would be enough. I haven't been too keen on adding something to cause me to wake up (like the tennis ball trick) due to discomfort because I see no sense in adding something to cause more wake ups when my sleep is already fragile enough. I prefer to just let the machine do its job no matter what sleeping position I am in or if my pressure needs change because of REM sleep (which we can't control anyway).

Pugsy, Thanks.So do you think 12.5 and 13.5 max. would be a place to start or maybe higher?
I haven't mentioned it, but sometimes my hip starts aching when I am on one side for to long, this could be some of the arousals. Sometimes it does wake me up.

I posted the above earlier and am having second thoughts. Does it make sense to raise minimum without knowing I need it? I am about to go to bed so I think I will leave it as is with low 12 high 12 till we discuss.

[Pugsy]

Are RERA's included in the AHI calculation? IE... more RERA's.... higher AHI.

No...RERAs are not part of the AHI. When they are included with the OAs, hyponeas and Centrals then it is called RDI Respiratory Disturbance Index...everything gets counted.

But AHI is just the OAs, hyponeas and Centrals/Clear Airway events.
RERAs, Flow limitations and snores are NOT part of the AHI at all.

[Pugsy]

So do you think 12.5 and 13.5 max. would be a place to start or maybe higher?

Yeah...I don't think that much more will be needed but actually what I would do is leave the minimum at 12 and let the max be 13.5. See what happens. You don't appear to need more than 12 for the bulk of the night so I would try apap mode with a tiny range and see if it will go up just a little only when it thinks it needs to.

[klm49]

So do you think 12.5 and 13.5 max. would be a place to start or maybe higher?

Yeah...I don't think that much more will be needed but actually what I would do is leave the minimum at 12 and let the max be 13.5. See what happens. You don't appear to need more than 12 for the bulk of the night so I would try apap mode with a tiny range and see if it will go up just a little only when it thinks it needs to.

Pugsy, Thanks so much! Will make changes tonight and see what happens over a few days.

[klm49]

So do you think 12.5 and 13.5 max. would be a place to start or maybe higher?

Yeah...I don't think that much more will be needed but actually what I would do is leave the minimum at 12 and let the max be 13.5. See what happens. You don't appear to need more than 12 for the bulk of the night so I would try apap mode with a tiny range and see if it will go up just a little only when it thinks it needs to.

Pugsy, Here are my last 3 nights after changing pressure:
Fri., I zoomed it in as I had taken an hour nap earlier and it was totally uneventful.


Sat.:
Don't know what happened with the Flow Rate data. Thinking it might be a bug I tried closing/reopening Sleepyhead but always the same.




Sun:
I know I woke up several times with some minor leaks and sometime around 3 a.m. I woke up with a leak, dry lips and mouth from mouth breathing.


Why are there 2 lines on the pressure and the leak rate graph?
Thanks in advance for your help.

[Pugsy]

First...the absent flow rate where all you see is the event flags...I think that you may have left the SD card either in the computer or if you did put it in machine it didn't stick like it should and maybe bounced back a little..
If the SD card isn't inserted so that the machine can write the flow rate directly to the card then the flow rate is lost. The other stuff the machine stores in its internal memory so when the SD card gets put back in the machine that stored data will get put on the SD card.

The 2 leak lines...the top one is total leak....mask vent rate plus any excess leak.
The bottom leak line is sort of an attempt at excess only leak report similar to what the ResMed machines do. I don't know if Mark resolved the extra problems that comes with attempting this calculation since the machine itself doesn't offer it as a clear data point and a lot is involved when attempting to calculate excess leak only with the variability of vent rates in auto mode. So I just sort of take that bottom leak line with a grain of salt. We don't have a line in the sand when it comes to excess leak only where large leak territory begins unless we just happen to have a leak line showing no LL flag and a LL flag at the right next to it so we can see clearly and we can reproduce it for verification. When using auto mode the line in the sand moves with the pressure and makes it difficult to know for sure...so I decided a long time ago that as long as the machine itself doesn't give me a LL flag then things were good.

The 2 pressure lines....Are you using the Flex exhale relief at all? I think what you are seeing might be inhale and exhale...and the exhale relief isn't dropping all that much.

[klm49]

Pugsy, No CFLEX is off although the Cflex setting is 2. I changed none of this when I went to APAP. You are correct about SD card, I did have a problem.
So should I just continue with the settings for a time? I don't see that much of a change if any comparing to old charts.

[Pugsy]

We see the machine respond to the stuff at around 1:AM mark on the June 10 report...that cluster of snores, RERAs, along with the OA cluster and hyponeas...the machine went to 13.5 and pretty much stayed there that entire time....a little before 1 and ending around maybe just a little past 1:30.

My main thought with trying the tiny range was to see what the pressure did and what type of events might be happening or getting flagged. If it was just the RERAs having a little more pressure might fix the RERAs or FLs.

That time frame...30 minutes and when it happened...My first suspect is REM stage sleep.
Looks like you need more than 13.5 at least during REM (assuming that was REM related)

On the June 12 report...again you maxed out the pressure for 15 to 30 minutes at various times during the night but with no clustering of OAs or hyponeas like there was on the other report.
So maybe the June 10 was REM on your back and these on June 12 are REM on your side. It's hard to know for sure..I suppose it could be totally side vs on your back sleeping but the amount of time at the higher pressures really is close to the amount of time someone would spend in REM sleep.
Google "sleep stages" and look at the hypnograms and how they start out in the sleep cycle and how they progress to where in the wee hours of the morning they come on faster and last a little longer.

I mention this as a potential explanation for the periods of time that you appear to need more pressure. It's quite common. Now how much more...don't know at this point...and do you really, really need to allow it to go higher if it wants to...don't know that either. It's not something that is blatantly obvious and happening every night and we only have 3 nights so far to see how much of a pattern might show up..
If I saw clusters like on the June 10 report very often...then I would probably want to try to stop the clusters but if those type of clusters were rare...maybe let them slide.

I would also have to evaluate whether going after those clusters with more pressure (make more maximum available) is likely to create a problem worse than the presence of the little cluster creates or not.
Not everyone has a problem with the machine going up in pressure to address situations like this whether it is REM related or just supine related. When I was using apap I saw 18 often (minimum of 10) for my REM worse OSA and slept right through it and never knew where I went until I saw the report. So pressure changes never bothered me. Slept quite well and felt decent.

You are at a stage where you are sort of fine tuning things. This is where you also have to take into account your sleep quality along with what you see on the software reports.
And you have to decide if you want to pursue killing those RERAs, OAs and hyponeas with more pressure...and if you want to do that...at this point I would look at the max pressure setting before resorting to minimum pressure increases just for 30 minute segments. In other words...we know that 13.5 didn't get the job done...so even if you set the minimum to 13.5...it's unlikely that would get the job done either...so I see no sense in messing with the minimum until we know where the pressure really wants to go.

Up to you how you wish to proceed. Several options available...so slow or go fast or go in between or even do nothing.

Oh...if we can't blame the 2 pressure lines on Flex...don't know what to blame it on...and that's where we blame the aliens.. they get the blame for all unexplained stuff. It's as good as any.
It probably does relate to inhale/exhale some how but I don't know how...and I wouldn't spend any time worrying about it since we can't explain it for sure and it doesn't mean anything bad is going on and if you were using Encore...it wouldn't show up anyway. It's not really all that important that we see inhale or exhale.

If you are wondering what I would do if I was in this situation...I already have been down this road with my REM worse OSA and needing higher pressure some parts of the night and not other parts...I just opened the max to 20 and let the machine decide what to do and slept right through it all. Some nights I might see 18 for part of the night...some nights it never went over 14 (I had a minimum of 10) and slept right through it all.

[klm49]

Pugsy, Thanks for all the info! I sleep on my left side so Sat. night I added a pillow laying same direction as my back to see if it would eliminate some of the snores from laying on my back. Not sure it works as I can still somewhat lie on my back, maybe need something else. I think I'll leave pressure alone for a few more days, then possibly try upping the max. a cm or 2 just to see what happens. It seems like last night I had more small leaks wake me up than normal. I don't think it was the higher pressure doing this but we will see. I've been looking at my Titration study results and on the back is a chart showing the pressure setting and statistics at that setting. I don't see where they even tried any pressure above 12, do you know why that would be? All I see that stands out at the final 12cm setting is there is one CA.
Forgot to mention I still haven't gotten a new cushion from my DME. I called Fri. and the lady at their "store" here who I have been dealing with had a guy that I assume is the Therapist call me. He told me he had ordered these but they didn't come in Fri. like they were supposed to. Its been 10 days since I started asking for these. He assured me that as soon as they came in he would mail them. I'm gonna give them till Wed. then I may have to escalate this with the Dr. or someone else. He did tell me that they normally use some other type of FFM and they didn't stock parts for this one.

[Pugsy]

As to why they didn't try more than 12...maybe they ran out of time...maybe they didn't see a need if everything was within "acceptable" numbers already...maybe you didn't happen to have one of these "episodes be it REM or supine or a combination" times for them to even see what might be needed.
Here's the thing...we don't sleep the exact same way every night so it's very possible that whatever is causing the pressure need during these time periods didn't happen during the titation for any number of reasons.

Titration sleep studies don't always get it spot on...they can get us close but sometimes not all situations are even present during the sleep study so they don't even see it to address it.
In my case despite having a full entire night devoted to the titration study I didn't sleep particularly well and just barely hit REM so really spent no time where I sometimes need higher pressures and sometimes I don't.
So I came out of the titration study with RX pressure of 8 but with no real REM time we were never faced with where my OSA is much worse.
I come home and use 8 cm and sleep well and hit REM and I have some really nasty clusters of OAs show up. It really wasn't a big surprise and it really wasn't the fault of the lab tech I had during the titration (even though he was an asshole in other areas).

Now I did wonder how much supine sleeping might have been involved with the REM pressure needs so early on in my therapy I decided to fix a way to make sure I never got on my back. It took some doing but I figured out a way to build a wall so that I slept against the wall and couldn't ever sneak over onto my back. I slept that way for about a month. I still would see the dramatic pressure increases during probable REM even when I knew for sure I was always on my side. So in my case supine sleeping didn't make it worse...so that left me with simply needing a lot more pressure in REM and since we can't control REM...I opted for apap mode with 10 min and 20 max. Let the machine sort it out. and I sleep in any position that I want because it isn't going to make it better or worse. One less thing to worry about.

Now I was fortunate in that the pressure changes caused no problems. No aerophagia, no problems with leaks, no feeling like the changes in pressure affected sleep quality. Should I have had any of those issues then I would have re evaluated things.

Oh...the one central you see....don't worry about a few centrals here and there.
It's normal to have centrals during sleep stage transition...so it could have just been that happening.
It could have been an awake/semi awake central getting flagged or maybe you turned over in bed and held your breath briefly.
I know people see centrals and think higher pressures in same thought and tend to start the worry mode but while higher pressures can cause centrals in some people...it isn't all that common and doesn't have to be all that high (I have seen it happen to people using 5 cm)...and even if it was related to the pressure unless someone is having a truckload of them they aren't anything to worry about.
So and occasional central...real or not is nothing to be alarmed about.

[klm49]

As to why they didn't try more than 12...maybe they ran out of time...maybe they didn't see a need if everything was within "acceptable" numbers already...maybe you didn't happen to have one of these "episodes be it REM or supine or a combination" times for them to even see what might be needed.
Here's the thing...we don't sleep the exact same way every night so it's very possible that whatever is causing the pressure need during these time periods didn't happen during the titation for any number of reasons.

Titration sleep studies don't always get it spot on...they can get us close but sometimes not all situations are even present during the sleep study so they don't even see it to address it.
In my case despite having a full entire night devoted to the titration study I didn't sleep particularly well and just barely hit REM so really spent no time where I sometimes need higher pressures and sometimes I don't.
So I came out of the titration study with RX pressure of 8 but with no real REM time we were never faced with where my OSA is much worse.
I come home and use 8 cm and sleep well and hit REM and I have some really nasty clusters of OAs show up. It really wasn't a big surprise and it really wasn't the fault of the lab tech I had during the titration (even though he was an asshole in other areas).

Now I did wonder how much supine sleeping might have been involved with the REM pressure needs so early on in my therapy I decided to fix a way to make sure I never got on my back. It took some doing but I figured out a way to build a wall so that I slept against the wall and couldn't ever sneak over onto my back. I slept that way for about a month. I still would see the dramatic pressure increases during probable REM even when I knew for sure I was always on my side. So in my case supine sleeping didn't make it worse...so that left me with simply needing a lot more pressure in REM and since we can't control REM...I opted for apap mode with 10 min and 20 max. Let the machine sort it out. and I sleep in any position that I want because it isn't going to make it better or worse. One less thing to worry about.

Now I was fortunate in that the pressure changes caused no problems. No aerophagia, no problems with leaks, no feeling like the changes in pressure affected sleep quality. Should I have had any of those issues then I would have re evaluated things.

Oh...the one central you see....don't worry about a few centrals here and there.
It's normal to have centrals during sleep stage transition...so it could have just been that happening.
It could have been an awake/semi awake central getting flagged or maybe you turned over in bed and held your breath briefly.
I know people see centrals and think higher pressures in same thought and tend to start the worry mode but while higher pressures can cause centrals in some people...it isn't all that common and doesn't have to be all that high (I have seen it happen to people using 5 cm)...and even if it was related to the pressure unless someone is having a truckload of them they aren't anything to worry about.
So and occasional central...real or not is nothing to be alarmed about.

Pugsy, I haven't gone away. I went Dial-A-Wingin and eventually ended up at min 12cm max 15cm. I realized along the way that adding pillows to stop supine sleeping and my latest trick was to tape my mouth to stop my drooling and mouth breathing all have an effect on my Sleepyhead data, so I decided just to leave the settings alone for a while.Some nights it maxes out at 5 at times and some it never gets to 15. I am thinking I may need to up mAX. even more, but I am going to wait for that. I'm not suire if I mentioned that duriong my Sleep Study and my titration the Sleep Dr. said he noticed some unusual activity on the EEG. He said it was probably nothing but I should let my PCP know and see if he wanted to refer me to a Neurologist. Well he did and I went in for a full EEG. Now he says that yes they see what the sleep Dr. saw and I need a 3 day hospital EEG in their "EMU". I am not conscience of any seizures, but I got to thinking that if I was having some kind of seizures that it probably would have an effect on my sleep data. I'm [posting 2 S/H data, one where 15 gets maxed and one not. Any comments appreciated. I am feeling better on CPAP but I still am taking 1-2 hr. naps every day.






I finally got the new cushion from the DME and it sounds like he is on "my" schedule now. I should be getting my first call soon for my regular resupply. Since I only recently discovered that my machine has a modem in it I am curious if I will be chastised for changing my settings!

[Pugsy]

Do you have more nights with ugly clusters like the night where the pressure just barely kissed 15 or more nights like the other night where it didn't go up at all really?

We go back to the basics...the 2 most common causes of those little clusters you see when the pressure went to barely 15 are supine sleeping or REM stage sleep or a combination of both.
Your reports are very similar to what mine were when I was using apap...some nights I would hit 18 cm and some nights I never got above 12 (had a 10 cm minimum). I never could figure out why the difference. I did a month long experiment where I built a wall and stayed on my side all night and I still saw the same big differences so I assumed that supine for me wasn't the issue.
Since my OSA is 5 times worse in REM...I always just blamed it on REM but that wouldn't/shouldn't account for the nights where it didn't change much because I would assume I had some REM.
Anyway...I never really got an answer to that weird little question.

Raising the pressure past 15 is unlikely to address that ugly little cluster because the machine really didn't get up there very good and certainly didn't stay there very long like we would expect it to.
I have no idea at all if any of this is related to what may be going on with the EEG thing. That's far beyond my scope of knowledge.

If you see a lot of those ugly cluster nights then maybe a little more minimum would prevent them better because I don't think that more maximum is doing a good job unless you see other reports where you hit the max and stay there for a while. If the other reports are like this one where you just kiss 15 briefly...increasing the max won't likely help much. The apneas are happening while the pressure is going up and giving the finger to the machine when they leave while the machine is still increasing. The machine simply can't increase to where it needs to be quickly enough to prevent the collapse.
If you don't see very many of these ugly clusters...I don't know that I would worry about overly much about them.
It's a judgement call on your part.
We go back to do we want to use even more pressure all night just for an occasional short lived ugly cluster...and if these nights are rare I don't know that I would do anything about them myself.

If your DME even notices the pressure tweaking..the worst thing they will do is reset the settings via the modem controls and maybe slap your hands verbally.
You can always go back in and set them again...they won't be bothered to do it daily.

In regards to the need to nap...that's a tough one because on these reports we just don't really see anything that screams out fix me and you won't need to nap. If you have ruled out medication side effects and the usual sleep quality issues (lots of wake ups for some unknown reason or pain or whatever5) then maybe something else is going on that is a contributing factor. I firmly believe that often when people have the excessive sleepiness during the day when the reports say they probably shouldn't that it's probably a combination of other unknown factors going on that haven't been identified yet.

[klm49]

Do you have more nights with ugly clusters like the night where the pressure just barely kissed 15 or more nights like the other night where it didn't go up at all really?

We go back to the basics...the 2 most common causes of those little clusters you see when the pressure went to barely 15 are supine sleeping or REM stage sleep or a combination of both.
Your reports are very similar to what mine were when I was using apap...some nights I would hit 18 cm and some nights I never got above 12 (had a 10 cm minimum). I never could figure out why the difference. I did a month long experiment where I built a wall and stayed on my side all night and I still saw the same big differences so I assumed that supine for me wasn't the issue.
Since my OSA is 5 times worse in REM...I always just blamed it on REM but that wouldn't/shouldn't account for the nights where it didn't change much because I would assume I had some REM.
Anyway...I never really got an answer to that weird little question.

Raising the pressure past 15 is unlikely to address that ugly little cluster because the machine really didn't get up there very good and certainly didn't stay there very long like we would expect it to.
I have no idea at all if any of this is related to what may be going on with the EEG thing. That's far beyond my scope of knowledge.

If you see a lot of those ugly cluster nights then maybe a little more minimum would prevent them better because I don't think that more maximum is doing a good job unless you see other reports where you hit the max and stay there for a while. If the other reports are like this one where you just kiss 15 briefly...increasing the max won't likely help much. The apneas are happening while the pressure is going up and giving the finger to the machine when they leave while the machine is still increasing. The machine simply can't increase to where it needs to be quickly enough to prevent the collapse.
If you don't see very many of these ugly clusters...I don't know that I would worry about overly much about them.
It's a judgement call on your part.
We go back to do we want to use even more pressure all night just for an occasional short lived ugly cluster...and if these nights are rare I don't know that I would do anything about them myself.

If your DME even notices the pressure tweaking..the worst thing they will do is reset the settings via the modem controls and maybe slap your hands verbally.
You can always go back in and set them again...they won't be bothered to do it daily.

In regards to the need to nap...that's a tough one because on these reports we just don't really see anything that screams out fix me and you won't need to nap. If you have ruled out medication side effects and the usual sleep quality issues (lots of wake ups for some unknown reason or pain or whatever) then maybe something else is going on that is a contributing factor. I firmly believe that often when people have the excessive sleepiness during the day when the reports say they probably shouldn't that it's probably a combination of other unknown factors going on that haven't been identified yet.

Pugsy,I did have one really ugly night (AHI 4.62) , but I knew it when I woke up as I woke up quite a few times. Don't know what the problem was, seemed to be having problems getting my mask how I wanted it. Out of a week excluding that night there have been a couple of times where pressure maxed out briefly, but usually it has not. With all that is going on with the abnormal EEG I think I am just going to leave all as is until I get whatever is going on with my head resolved. Now that I know something is positively wrong with my EEG it will probably effect how good I sleep just thinking about it anyway. My AHI's are normally under 2 and frequently under 1 and from the start all that really concerned me was the volume of RERA's. I do appreciate all your help and knowledge and hopefully in the not too distant future we can dial my CPAP in.