runs vs. centrals

echo · Post by **echo** » Sun Jul 27, 2008 8:17 am

I've been looking at my AHI averages over the past half year. If I take just the pure AHI numbers, I'm less than 1.0 on nearly every night, with an average of 0.7 AHI. (including apneas, hypopneas, and central apnea's).

If I add acoustical vibrations and runs, the average index goes to 4.0, and on some nights is as high as 30 or so -- I have lots of runs.

I've been wondering if UARS is a problem. I have the same that some others have reported - I started out at CPAP 7, was good for a while, then it didn't seem to be enough - so I increase it, seems to be OK for a while, then isn't enough... now even 10 doesn't seem to be enough (subjective feeling = I feel "hungover" when I wake up. AHI=0.8 ; AHI+AcVib+FlowLimRuns=2.7 ; after 17 days with 10cm).

At my titration, they weren't sure whether to give me a pressure of 7 or 10... 7 wasn't enough to stop all the apnea's but 10 was too high and was causing central's. The titration was done with an Auto Remstar (i think) - not a CPAP. The sleep doc said to start at 7 and increase it up to 10 if I was still tired .... that was the treatement!

My question is - how to handle the flow limitation runs without inducing central apneas?

At the beginning of the year I had APAP set to 7-10 (maximum=initial=7cm) and included IFL1 and IFL2, but I don't sleep well - and I think that's because I woke up every time it responds to an IFL1. So I turned off the IFL1 and it has stayed off. I'm now sleeping better on APAP but still feel soooo tired.. and am still getting tons of runs. I have no idea if I'm one of those "shallow breathers" that should turn off IFL1.
My partners says that in the mornings I'm breathing really fast, double his breathing rate. I don't notice than during the day or when I'm going to sleep at night.

Lately I've been using 8-12, with initial pressure set to 10, IFL1 off.. and haven't noticed much difference (though it's only been 3 nights). I've been spending more than 93% of the time at 8cm. I still feel so tired.

Same with CPAP set to straight 7.. then 8... then 8.5.. then 9... then 10. (Yes, I've tried each one for at least a week, normally more). AHI stays < 1.0 and AHI+AcousticVib+FLRuns is around 4-5 on the higher pressures and 2-3 on the lower pressures.

Actually it's more than feeling tired in the mornings - the thing is that I feel that "hungover over apnea" feeling in the mornings.

I'm still getting central's at 8cm (though the index is around 1.0).

So how do I find the right pressure to stop the flow limitation runs without causing more central's? I think the bulk of the central's are starting before 10cm.

I've tried everything else (I can think of, so maybe it's time to try to address the flow limitations?)

Does it make sense to turn on IFL1, lower the "Max pressure for command on apnea" , and keep 8-12 with initial = 10 ?

Thanks, and sorry for the long boring post!

[Disclaimer Sleep doc isn't much help as she told me to go by "how I felt" and try anything in between 7-10cm ]

ozij · Post by **ozij** » Sun Jul 27, 2008 8:44 am

Echo,
It would help very much if you would post some screen shots of your detailed results.

Here are some very general commnents:

All the number's you're reporting look fine.
Are you getting enough sleep?
Tunring IFL1 off stops the machine's response to flow limitations and to . That should be done only if the pressure rises uncontrolably when IFL1 is on.
I don't think one should add the "Runs (Fl) Index" to the AHI. Those "Runs" are a specific, PB calculated parameter, and people who have tons of PB "Flow Limitation runs" have parctically no "Flow Limitations" on a Respironics.
For what its worth, my "Runs (FL) Index) for last 2 months was 28.2 - and yes, that's the index, and no, no typo. The PB considers many of my breaths flow limited, and if I leave IFL1 = on , it will jus raise pressure more and more.

By the way, do you wake up naturally, or do you need an alarm clock to wake you up?

Edit: and the of course, there are mouth leaks to consider....
_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, AHI

echo · Post by **echo** » Sun Jul 27, 2008 9:51 am

Hi Ozij, attached are 4 example graphs, thanks to your great tip on google!

APAP set 7-10, with initial pressure at 8, IFL1 and IFL2 turned on. One day is with the FFM and the other day with the Activa (durn congestion).
1. http://sleepecho.googlepages.com/june7_ ... on_ffm.jpg
2. http://sleepecho.googlepages.com/may22_ ... activa.jpg

APAP set 7-10, with initial pressure at 8, IFL1 off and IFL2 turned on, using Activa.
3. http://sleepecho.googlepages.com/july6_ ... activa.jpg

Last night's data from 8-12 with initial pressure set to 10, IFL1 off and IFL2 on, using Activa.
4. http://sleepecho.googlepages.com/july27 ... activa.jpg

Are you getting enough sleep?

Plenty... at least 8 or 9 hours... up to 10. I find that sometimes I awake easily after 5 hours, then I sleep a few more hours and feel hungover.

Tunring IFL1 off stops the machine's response to flow limitations and to . That should be done only if the pressure rises uncontrolably when IFL1 is on.

That seems to happen sometimes - see for example june 7 (#1).

By the way, do you wake up naturally, or do you need an alarm clock to wake you up?

I definintely need an alarm clock... 2 or 3 is better... best is to have someone kick me out of bed. It was worse in the pre-CPAP days, but I find myself sliding back into that "really deep sleep" in the morning thing, and cannot wake up easily even to the alarm clock. First month on CPAP was GREAT and then downhill since then. I also had a few good weeks in January. Lemme see if I can find those graphs (But I dont remember the actual dates , damn. And I don't have the data from the first month of therapy - they had me on the 420G. I ordered the 420E when it started going downhill).

Edit: and the of course, there are mouth leaks to consider....

Yes defininte mouth leaks. My partner noticed it, thank god. Not mouth breathing, but really just a tiny leak from the corner of my mouth. I've been using the micropore tape since last year. It helps immensely. When I wake up in the morning the tape's still in place solidly, and I don't notice any leaks in the tape on the sides. I make sure it fully covers both lips and the edges of the lips.
I sleep better with the FFM than the nasal mask but it leaks like a sieve when I start moving around at night, so I still sleep better with the Activa. On the PSG they did not note any significant movement, and my partner has not mentioned it either (he wakes up a good few hours before me and usually studies me in the morning to see how I'm sleeping ).

Thanks for your help!!

echo · Post by **echo** » Sun Jul 27, 2008 10:00 am

I should add - I've had numerous tests over the last 4-5 years for thyroid and diabetes and numerous other blood parameters. Everything looks "normal".

In a last desperate attempt I got a blood glucose monitor.. tested myself for a few days and went to my (new) doc with the results. She said I might be hypoglycemic so now I shall go see a nutritionist... but no diabetes (probably??). There are still a couple of tests I want to get to rule out diabetes for sure.

Hypoglycemia can also cause tiredness... but what I'm getting in the mornings is really the old pre-CPAP hungover feeling back again, which makes me think it's cpap related and not something else.

I've also gained weight (a few kg each year) and it's just getting higher and higher, even with the CPAP therapy. And I wasn't slim to begin with!

Who knows?? As you say the "numbers" are all OK!! This thing is driving me crazy, to say the least. I'll have a few good days and think it's getting better, and then I'll have a week of feeling horrible. It's getting to be really depressing, and I am getting really discouraged. Not with the therapy, mind you, but just with myself. I love my CPAP and will continue to sleep with it every day, cause otherwise I wake up even more horrible than now!

ozij · Post by **ozij** » Sun Jul 27, 2008 10:27 am

I can't see a thing there to explain the way you feel....

June 7 is an example of pressure being drive up be snores - the response to flow limitation runs is fine - no viciuos cycle there, and no inidication you should have IFL1 off.

The only thing I can think of - cpap realted - is that your sleep may be effected by the pressure changes - though there are few of those all in all..

7.5 constant?

O.

echo · Post by **echo** » Sun Jul 27, 2008 11:01 am

Hmmmmm if _you're_ stumped....

Yeah, I think it's time to call the sleep doc, again. They've just been SO hands off that I'm wondering what they will do with this info.

When I mouth breathed, they said turn the pressure to 4.
When I said I was congested and wanted a FFM (they were my DME at the time), they said "No FFM for you.. it's ok not to use the CPAP until the congestion clears because its effects last a few days."
When I said I wanted an Auto, they "they respond so slowly it won't do you any good."
When I asked about a data capable machine they said "the data's not reliable."
When I said how do I know which pressure is best between 7 and 10 they said "just go by how you feel."
In Jan when they asked if was congested, I said yes. In my report (which I got last week) they said that I said "No problems with congestion."

GRRR... and this sleep doc is on the board of this local professional association for sleep research/medicine... though the 4cm and FFM comments were from another doc in the lab.

Well I'm really stumped. It seems the therapy is OK. The GP seems to think that the blood work is OK. So what the heck is wrong with me? A few on the boards have suggested fibromyalgia and other things like that, but .. well, I dunno.

The only thing I can think of - cpap realted - is that your sleep may be effected by the pressure changes - though there are few of those all in all..

I thought that too... I have run in constant mode for many many week without any major differences...

7.5 constant?

Yes.. that's one pressure I haven't tried .
I'm actually thinking of bumping it up to 10.5 or 11 for a week. Since the doc seemed to think that 10 was ideal, if it wasn't for the central's, I might try just above 10 (I've gained some weight since the titration last year), and see whether any central's are caught.

Oh, and here's something else interesting I noticed.
As pressure goes up, from 8 to 8.5 to 9, on straight CPAP, my Centrals' go DOWN (from 1.86 to 1.0) while the Hypopneas go UP (from 1.7 to 4.0). At 10cm I still have 3.6 Hypopnea's and 2.5 central's.
Maybe the differences are not statistically significant, but it's kinda funny cause I would have expected the reverse situation! Also the number of sample points / nights for each pressure is different.

echo · Post by **echo** » Sun Jul 27, 2008 11:04 am

And Ozij, thank you so much for reading through my looooong posts and for your suggestions. I really really appreciate it!!

And at least I see that I'm analyzing the graphs correctly..

Snoredog · Post by **Snoredog** » Sun Jul 27, 2008 11:57 am

What is UARS?

and HOW does it differ from plain jane obstructive sleep apnea?
What is the difference between it and simple flow limited breathing and snoring?

It is my understanding that it does NOT contribute to desaturations, but somehow contributes to microarousals once unclassified as spontaneous arousals known to destroy sleep architecture.

Believe there is only one medical school that subscribes to the theory of UARS that is Stanford with Guilleminault leading that band and has written many papers on to topic.

Cutting to the chase, CPAP more specifically Bilevel therapy is suggested. You find the EPAP pressure that eliminates all obstructive events then bump up IPAP from there by 8 to 10 cm. You have to use a bilevel machine that allows a PS of greater than 8, reason a PB425 is suggested.

That means if your current cpap pressure is 8 cm, you will most likely need a 18/8 to address UARS.

I'd hate to see you waste $800 on a machine only to find it didn't work. You can only have it done in certain labs that use a probe to measure esophageal pressure to confirm the condition exists.

If it is a true disorder, why do they still call it a syndrome? I'm still optimistic but skeptical, show me a before and after and improvement to sleep architecture and before and after microarousals and where once thought spontaneous arousals disappear. How hard can that be? I got it from my first 2 studies, here is your sleep architecture before CPAP and after.

Ask for that simple information with UARS and you get all kinds of excuses or it is explained in some book somewhere. If I wanted vague answers out of a book, I'd go buy Kevin Trudeau's book Stuff they don't want you to know about.

http://en.wikipedia.org/wiki/Upper_Airw ... e_Syndrome

dsm:
I know dsm had a PB425 and probably still does, he has done all kinds of experimentation, while I'm sure he is not able to measure his esophageal pressure differentials I wonder if he ever experimented with 8-10 positive pressure over his EPAP?

echo · Post by **echo** » Mon Jul 28, 2008 2:24 am

Snoredog wrote:It is my understanding that it does NOT contribute to desaturations, but somehow contributes to microarousals once unclassified as spontaneous arousals known to destroy sleep architecture.

Interesting! During my PSG, my desats never went below 90%, the lowest was 93%, even with AHI=35. (My RSI was more like 40 on the other hand.) The sleep doc explained this by saying that I aroused from the obstructive events quickly therefore I never went into desat. I still have yet to find out if I had more Apnea's or Hypopnea's. (there were also a few central's thrown in there for good measure).

[quote"Snoredog"]Cutting to the chase, CPAP more specifically Bilevel therapy is suggested.[/quote]
I still have yet to understand how a low expiration pressure solves the "collapsing straw" theory, but I just need to spend more time reading up on this.

Update from last night:
I changed IFL1 to on and left the 8-12 (initial 10) settings from the nights before. While I was falling asleep I kept feeling my throat collapsing - and I was starting to snore before I was even out.

I changed the pressure to 10.5 and the collapsing was a bit less. I could still feel the "collapsing straw" phenomenon somewhat but I guess you can't really make a diagnosis based on a feeling .

Anyhoo, this morning I felt really good! I didn't have any problem waking up to the alarm, and I feel RESTED and CLEAR HEADED for the first time in MONTHS.

For the entire night, I had 1 central, 3 hypopnea's, 2 runs, and no apneas/snores/flow limitations. The AHI is like any other night, only the runs are less.

Go figure!

Do you know if the : Normal cycle, Flow Limited cycle, Intermediate cycle, and Invalid cycle % can be used to calculate "time in apnea" ?

Thanks a bunch Snoredog and Ozij!

ozij · Post by **ozij** » Mon Jul 28, 2008 3:29 am

Waking up before you desat is one of the descriptions of UARS.

Havning no runs when IFL1 is on - in your case -is just as it should be.

Good to hear you're feeling rested!

O.

echo · Post by **echo** » Mon Jul 28, 2008 3:32 am

Thanks

Actually I was running on 10.5 cm straight CPAP the whole night!

Waking up before you desat is one of the descriptions of UARS.

This I had completely missed! I'll have to re-read some of those sources again...

ozij · Post by **ozij** » Mon Jul 28, 2008 3:46 am

The IFL1 setting is of course meaningless when the pressure is constant.
O.

echo · Post by **echo** » Mon Jul 28, 2008 4:06 am

I have been able to find a lot of info on UARS (both pro + con), especially from Guilleminault, but I have not been able to find info on the treatment of UARS - where/who says that a BiPap is better for UARS than cPAP/aPAP?

Edit: rather, the treatment info always mentions CPAP. To be honest I haven't read beyond the abstracts of the articles.

echo · Post by **echo** » Mon Jul 28, 2008 5:53 am

Nevermind, I found the links:
cpaptalk-articles/flow-limitation-UARS-BiPAP.html
and
viewtopic.php?p=17152&sid=fc142a9674507 ... 16a14de2b3
and others...

I had JUST read the one from Barry Krakow a few days ago.... I must be sleep deprived

Well, at least now it's all starting to make sense.. including the flow limitations story as well.

Assuming that the flow limitations picked up by the 420E are possible UARS related events, I'd like to see what the best pressure for those are (10.5 seemed to work for last night).

I'd also like to discuss this with the sleep doc but I don't think they subscribe to the UARS theory We'll see...

jnk · Post by **jnk** » Mon Jul 28, 2008 6:57 am

echo,

You probably use them already, but I find I feel more rested when I use earplugs.

I think a mouse whispering next door can arouse my brain outa levels 3 and 4!

jnk