What Is RERA?

[jweeks]

Hi,

In my first sleep study 3-1/2 years ago, I had an AHI of over 100. This was well treated for 2 years using BiPAP at 13/20. I was consistently able to get an AHI under 2, and usually felt pretty good.

Due to another medical issue (paralyzed diaphragm), I entered a medical weight loss program and lost 125 lbs so far, with another 25 to go. As I started to lose weight, I started having a nasty problem with swallowing air when using my BiPAP. I found that any pressure level above 15 caused issues with aerophagia. But I also found that I didn't sleep well if I set the pressure less than 18.

To try to sort this out, my sleep doctor ordered a new sleep study. In that study, they found an AHI of 0. I didn't have a single apnea or hypo all night. This is consistent with a near zero AHI on my CPAP machine in recent months. But, they found that I had a RERA event strong enough to wake me up once about every 45 seconds on average.

I understand that a CPAP machine cannot detect an RERA, so a machine on auto will not ramp up and suppress them. But at the same time, my RT set my machine on auto at a starting pressure of 10. That didn't seem to work at all, so I went back to 18. To compound the issue, my insurance company saw the AHI of 0, and now they think I am cured and are resistant to spending any more money on this. I'd like to learn more before I start dipping into my own funds on any further tests or follow-up visits. I don't mind running the CPAP on that high of pressure, but the aerophagia sometimes wakes me up, and I really don't like the 2 to 3 hours of passing gas after I wake up as the air exits my system.

I am wondering what RERA is and how it is treated?

-john-

[CarpeNoctum]

I applaud you for losing weight. Your sleep study is a mystery to me. An AHI of zero??? Yet you're having reras? My only reasonable response is that your sleep lab is totally incompetent and you should go else where for care.
CN

[rested gal]

Your sleep study is a mystery to me. An AHI of zero??? Yet you're having reras?

That may be a mystery to you, but it's not a mystery at all to the scoring sleep techs or the sleep doctors who look at the reports.

My only reasonable response is that your sleep lab is totally incompetent and you should go else where for care.
CN

Well, you told John to "just look at the definition for reras." You're right about RERA standing for Respiratory Effort Related Arousals. You're also right about "you are trying to breath[e]." You start getting off the mark, though, when you conclude, "but your airway is closed." Your "only reasonable response" doesn't sound very reasonable to me.

The airway might be "closed" during the effort to breathe that finally results in an arousal. Or the airway could be just partially closed.

There are requirements that must be met during a PSG sleep study before an event can be scored as an obstructive apnea (fully or almost fully closed airway) or as an obstructive hypopnea (partially closed airway.) For example: duration of the event, percentage of reduction in SpO2, amount of reduction of airflow, arousal occuring ... things like that are taken into consideration before an event can be scored as an obstructive apnea or obstructive hypopnea. If requirements to score an event as an official apnea or hypopnea aren't met, the event should not, and cannot, be scored as an apnea or a hypopnea. However, if the "effort to breathe" (that doesn't meet apnea/hypopnea criteria) results in an arousal.... the event can be scored as a RERA.

RERAs (as I understand them, and I could be just as wrong as you are, CN) are arousals that occur BEFORE enough time has passed and/or before enough drop in SpO2 has happened. It's a RERA when the reduced air flow the sleeping person is dealing with (the belts showing physical effort to try to get more air) simply doesn't meet the official criteria for being scored as an obstructive apnea or an obstructive hypopnea.

The effort is respiratory related, yes. And the effort does result in an arousal to breathe better. But in a RERA, the duration of the event and/or the SpO2 measurement doesn't allow it to be scored as an apnea or hypopnea. Or, to put it another way, the arousal to breathe better happens more quickly than would be the case with an "apnea" or a "hypopnea."

So, it could be perfectly possible for a person to have tons of "RERAs" and not a single "apnea" or "hypopnea" during a sleep study. There could very well be an AHI (apnea/hypopnea index) of 0 during a PSG sleep study, even though the person's sleep was being severely fragmented by tons of arousals following those respiratory efforts to simply breathe better. That would be indicative (to me, anyway, but I'm not anything in the sleep medicine field) of possible UARS (Upper Airway Resistance Syndrome.)

CarpeNoctum, it sounds like you didn't study the definition of RERA very well yourself, before firing from the hip and slamming the sleep lab John went to.

Oh, but one other thing you got right -- applauding John for losing weight. I agree there.

You've done a very good job on weight loss, John!

To compound the issue, my insurance company saw the AHI of 0, and now they think I am cured and are resistant to spending any more money on this.

You'll probably need to enlist the assistance of your doctor to write a letter of medical necessity if your insurance company balks at continuing to pay for your therapy. There's no guarantee such a letter will get the job done, but if it comes to an appeal, the doctor might be able to help you.

I am wondering what RERA is and how it is treated?

If a person has a lot of RERAs disrupting their sleep architecture, xpap ("x" standing for any kind of cpap, autopap or bilevel machine) is usually the treatment, same as if they had received an "official" OSA diagnosis. If you think of hypopneas as "baby apneas", then RERAs might be thought of as "baby hypopneas." Pressure to help hold the airway open during sleep is the treatment for obstructed breathing during sleep....anywhere along the continuum.

[Mr Bill]

Thanks Rested Gal, I learned something there. I recall that at one of our monthly DME sponsored talks, a sleep doctor commented that UARS (Upper Airway Resistance Syndrome) was something that was currently off the radar of many insurance companies but was potentially as serious as obstructive apnea and that they had ways of working around the data to make it possible for patients to get treatment one way or another.

[DoriC]

My thanks too, RG. Mike has several RERAs recorded during the night, but by my observation these occur when he is turning from side to side, which is somewhat difficult for him, or making other positional adjustments in his sleep. During these times I observe him holding his breath a bit until he's resettled. He doesn't wake up. The more restless he is the more RERAs. I know somewhere along the way you've told me not to worry!

[napstress]

Congratulations, jweeks, first, for reducing your AHI so dramatically, and second, for losing the weight.

I had an AHI of 0.2 on the night of my sleep study. I had 0 obstructive apneas, 0 centrals, and 1 hypopnea. But because of RERAs, my RDI (Respiratory Disturbance Index) was 45, which means that I woke up 45 times per hour on average. I didn't have significant drops in oxygen saturation, either.

I was confused for months b/c on my report the doctor wrote, "No significant sleep breathing disorder was observed. Significant obstructive sleep apnea and hypopnea was seen in all positions of sleep." As it turns out, she couldn't use the term UARS b/c insurance companies will not pay for therapy for that. (The term is outdated, too). But if you wake up every 45 seconds on average, you definitely have SDB (Sleep-Disordered Breathing), an umbrella term for both apnea and UARS/RERAs. The treatment for both is CPAP.

The key is to have the doctor word a document in such a way that insurance will pay for the CPAP machine. In the summary section of my PSG report, the doctor wrote, "Based on the above findings and questionnaire responses, the patient has: 1. Mild-moderate Obstructive Sleep Apnea Hypopnea (....), 2. Significant sleep disruption secondary to respiratory events which are not associated with a 4% fall in oxygen saturation. 3. Excessive daytime sleepiness. 4. EEG findings during sleep can be associated with un-refreshing sleep."

It occurs to me that it's a miracle insurance paid for my machine, thanks, I believe, to my doctor's ability to fog the facts. Also, there are two ways of slicing and dicing the numbers: the Recommended Standard and the Alternative Standard, which I believe is what Rested Gal was talking about. After months of being puzzled, I asked the doctor by which standard she had measured my numbers. It was the Alternative Standard. Yours may have been scored on the Recommended Standard. Maybe your sleep lab can reconfigure the numbers so you can avoid doing another PSG, which it sounds like you'd have to pay for yourself.

I wish you the best of luck in getting insurance coverage for your CPAP treatment, and finding the right titration and overcoming the aerophagia.

[jweeks]

I had an AHI of 0.2 on the night of my sleep study. I had 0 obstructive apneas, 0 centrals, and 1 hypopnea. But because of RERAs, my RDI (Respiratory Disturbance Index) was 45, which means that I woke up 45 times per hour on average. I didn't have significant drops in oxygen saturation, either.

Napstress,

That is almost exactly what I had...0 AHI, 47 RDI, Oxygen averaged 96% and never dropped below 93%. That was consistent on pressures as low as 7 and as high as 15.

The key is to have the doctor word a document in such a way that insurance will pay for the CPAP machine.

I own my own machines, and my doctor will continue to write prescriptions for supplies, so I am good there. My key issue is that if I can get the pressure down below 18 to somewhere between 12 and 15, my life would be better (due to not swallowing air). My sleep doctor has suggested several things, all of which cost money:

- get a work-up from an ENT
- visit a doctor who specializes in the spine to look at a possible contributing issue of a curve in my upper spine
- a neurological exam to see if my brain is the issue causing low respiratory effort
- try a dental device

For now, I am trying to learn everything I can before picking any of these paths to follow up on.

-john-

[napstress]

I own my own machines, and my doctor will continue to write prescriptions for supplies, so I am good there. My key issue is that if I can get the pressure down below 18 to somewhere between 12 and 15, my life would be better (due to not swallowing air). My sleep doctor has suggested several things, all of which cost money:

- get a work-up from an ENT
- visit a doctor who specializes in the spine to look at a possible contributing issue of a curve in my upper spine
- a neurological exam to see if my brain is the issue causing low respiratory effort
- try a dental device

For now, I am trying to learn everything I can before picking any of these paths to follow up on.

Oh, I see what you're saying. Yes, I, too, have been wondering why I have such respiratory efforting. My doctor says it's b/c I have a long, narrow nose with a deviated septum, which causes me to breathe through my mouth. Air coming in through the mouth affects the throat differently than when it comes in through the nose: it causes the throat to collapse a bit (but not enough for an OA or H). Along with CPAP, I do a Saline Rinse, take a Claritin before bed, and put a nasal strip on my nose—all in an effort to breathe through my nose as much as possible.

What did you mean when you said you don't sleep very well with a pressure below 18?

[jweeks]

What did you mean when you said you don't sleep very well with a pressure below 18?

Napstress,

I have all the apnea symptoms the next day...headache, sleepy, attention issues, ears ringing, slow reactions. At a pressure of 18, I feel marginally OK. I feel pretty good at 19 and 20, then at 21, the air ingestion causes enough bloating to be painful.

I never had an issue with ingesting air when I was over 300 lbs. As I lost weight, it started happening when I got down to 285. In fact, it would often wake me up. The air issue was reduced somewhat when I got down to about 255...still swallowing air, but it isn't waking me up. It does take about 2 hours for all the air to pass in the morning after I wake up. When I experimented with pressures, the air issue stopped happening someone where around 15 cm of pressure.

-john-