Obstructive Sleep Apnea without snoring

I've been conversing with a sleep Doctor in Detroit for the last few days. I mentioned that I have almost no snoring and was diagnosed with severe obstructive sleep apnea.

At that point he proclaimed 'Without snoring, you don't have significant OSA'

While snoring is normally present I don't believe it always has to be. I'm certain that some of my sleep apnea books even mention that snoring while normally there is not present in all cases of OSA.

Wouldn't the existence of snoring depend in part on the location of the obstruction, etc. Soft pallet obstructers being the obvious choice for big time snoring (My obstruction is tongue base)

Does anyone else in the group other than me have OSA without much snoring?

I guess it also depends on how quick the airway becomes "floppy." If the airway is becoming floppier during breaths that lead into an obstructive event, then IMO, your chances for snoring go up. Conversely, if your airway happens to collapse instantaneously, then snoring may not occur.

I am beginning to gather some really interesting data which I will be sure to post over the coming weeks. My current work is more or less an observational study where I attached several recording devices to some OSA patients and recorded several variables while the patients had apneas. It will hopefully give us a better idea about what may trigger an apnea.

Here is a figure showing ventilation leading into and out of an apnea. The dotted line on the left indicates apnea onset while the dotted line on the right indicates the end of the apnea. It clearly shows that ventilation is dissipating leading into an apnea. Now is this simply a consequence of the patients having a lower drive to breathe i.e. respiratory muscles not as active OR a consequence of the airway becoming floppy i.e. respiratory muscles still pumping away but airway becoming smaller and thus not allowing air to come in. I would think that this may relate back to the snoring question. I would predict that snoring would be likely leading into an apnea.

The slide also clearly shows the hyperventilation following an apnea. This hyperventilation may set up conditions which are ideal for the next apnoea.

NOTE: Time is in secs on the x-axis

well, do you have the sleep study information to prove it? I have read that snoring isn't required also and I believe I got it from books, not random internet pages. I will look more tomorrow for credible sources for you.

Split City - thanks for that. I am an information junkie. Well the nicer way to put it is that I love learning and would love to learn more about your study and how your conducting it. I assume your tech or a researcher or something? I can't wait for more information.

crossfit wrote:Split City - thanks for that. I am an information junkie. Well the nicer way to put it is that I love learning and would love to learn more about your study and how your conducting it. I assume your tech or a researcher or something? I can't wait for more information.

I'm in my final year of my PhD and have worked on a few studies which have increased our knowledge of how OSA works. I have mainly been looking at lung volume, diaphragm and upper airway muscle activity, intra-abdominal pressure (and how it might affect the upper airway) and respiratory drive (how hard the individual breathes during apneas and at sleep onset).

I will have loads to talk about with my current data. I did measure lung volume, genioglossus (tongue) muscle activity and diaphragm muscle activity in the current study. Basically, I will have a number of graphs which take the form of the one I just posted. I hope this data gives us a better understanding of how OSA operates. But like most scientific work, the more data we get, the more questions it poses

crossfit wrote:well, do you have the sleep study information to prove it?

Yes he was looking at it when he made that statement. Here is his exact quote:

'The polysom report notes no snoring! This is incredible. Without snoring, you don't have significant OSA. Most likely, the hypopneas were overscored.'

jskinner wrote:

crossfit wrote:well, do you have the sleep study information to prove it?

Yes he was looking at it when he made that statement. Here is his exact quote:

'The polysom report notes no snoring! This is incredible. Without snoring, you don't have significant OSA. Most likely, the hypopneas were overscored.'

Interesting but maybe not the case. If your airway remains open but you simply breathe shallower, thus lowering your flow profile, then I assume they could still be scored as hypopneas??

common sense says Vocal Cord Dysfunction would look like OSA without snore.


Split: I would expect to see the apnea slam shut much faster than your graph shows.

But we have seen here hundreds of Encore Pro reports with very little if any snoring.

James: That PSG report, was that diagnostic or titration? meaning was the snore absent with no CPAP in the circuit?

Do you still have that Encore report where AHI while on the machine was 32 or 64 or something very high?

Snoredog wrote:Split: I would expect to see the apnea slam shut much faster than your graph shows.

I don't quite understand what you mean there. Do you mean that you would have expected the fall in ventilation to be much steeper than what I have shown??

OR

Do you think that the first breath on the left hand side equals the first breath after sleep onset? If this was the case, then yeah it would seem quite a long time before the airway completely collapsed. However, I'm not referencing my breaths to sleep onset. An issue I had to deal with was patients tended to cycle through events. I wanted to make sure that I didn't overlap breaths during data analysis i.e. post apnea breaths could overlap with breaths leading into the next apnea. Therefore, for cycling events, the first breath on the graph is >2 breaths after the offset of the previous apnea. Thus, these breaths may still be part of the hyperventilation response to the previous apnea (as shown by the breaths on the right hand side of the graph).

split_city wrote:

Snoredog wrote:Split: I would expect to see the apnea slam shut much faster than your graph shows.

I don't quite understand what you mean there. Do you mean that you would have expected the fall in ventilation to be much steeper than what I have shown??

OR

Do you think that the first breath on the left hand side equals the first breath after sleep onset? If this was the case, then yeah it would seem quite a long time before the airway completely collapsed. However, I'm not referencing my breaths to sleep onset. An issue I had to deal with was patients tended to cycle through events. I wanted to make sure that I didn't overlap breaths during data analysis i.e. post apnea breaths could overlap with breaths leading into the next apnea. Therefore, for cycling events, the first breath on the graph is >2 breaths after the offset of the previous apnea. Thus, these breaths may still be part of the hyperventilation response to the previous apnea (as shown by the breaths on the right hand side of the graph).

No actually I'm looking at the drop in ventilation for the 4 breaths before the apnea, that is not what I was expecting to see.

To me that decreasing ventilation pattern sticks out like a zit if I know what is to follow (apnea in the center).


Is that typical?

(i.e. to see the decreased ventilation before the apnea) or is that flow limited breaths we are looking at on the left before the apnea?

Looks to me to be 4ea breaths in a 13-15 second time frame.

Snoredog wrote:

split_city wrote:

Snoredog wrote: Split: I would expect to see the apnea slam shut much faster than your graph shows.

I don't quite understand what you mean there. Do you mean that you would have expected the fall in ventilation to be much steeper than what I have shown??

OR

Do you think that the first breath on the left hand side equals the first breath after sleep onset? If this was the case, then yeah it would seem quite a long time before the airway completely collapsed. However, I'm not referencing my breaths to sleep onset. An issue I had to deal with was patients tended to cycle through events. I wanted to make sure that I didn't overlap breaths during data analysis i.e. post apnea breaths could overlap with breaths leading into the next apnea. Therefore, for cycling events, the first breath on the graph is >2 breaths after the offset of the previous apnea. Thus, these breaths may still be part of the hyperventilation response to the previous apnea (as shown by the breaths on the right hand side of the graph).

No actually I'm looking at the drop in ventilation for the 4 breaths before the apnea, that is not what I was expecting to see.

To me that decreasing ventilation pattern sticks out like a zit if I know what is to follow (apnea in the center).


Is that typical?

That is correct. The apnea is between the two dotted lines. While the number of breaths during the apnoea varies, I only looked at the first two post apnea breaths and the last two apnea breaths (shown between the two dotted lines).

I would say this type of fall in ventilation prior to obstruction is common when events are cycling. However, there were certainly some events where there might have been only 2-3 breaths between the previous apnea and the next apnea. Furthermore, there wasn't any real apparent fall in ventilation leading into the next event.

Snoredog wrote:(i.e. to see the decreased ventilation before the apnea) or is that flow limited breaths we are looking at on the left before the apnea?

The are a mixture of flow limited breaths and breaths during shallow breathing. Peak inspiratory flow and inspiratory tidal volume show a similar profile to ventilation

Sorry skinner for kind of hijacking this thread The graph sort of helped me answer your question though (for apnea events).

Hi James,

It seems as you have had many unrecorded Apnea instead of snores and hypopnea......(set the limit to less than 3 many record more of your real events of apnea in the PSG. I have long been suspected of this so call conventional parameters) your physical adjustment of sleep positions is a strong evident that suggested that you have many apneas events. Do you know what is your current mm in (left, right, supine positions) distance of pharyngeal? There is CT and MRI scan study of this off limits research in apnea.

Snoredog: Good observation.
Split_City: In what Uni you are?

Best Regards,
Mckooi

Snoredog wrote:James: That PSG report, was that diagnostic or titration? meaning was the snore absent with no CPAP in the circuit?

Diagnostic. You can view it at http://james.istop.com/apnea/reports/Sl ... ly2006.pdf

Snoredog wrote:Do you still have that Encore report where AHI while on the machine was 32 or 64 or something very high?

I'm sure its somewhere I will see if I can dig it up.

Shoot I snore when I'm AWAKE! If I breathe wrong it all goes floppy on me and I have to stop and think about my posture and what I was doing to get all floppy.

Sounds like the doc is a flop. Try again.

Good luck!
B.

ZERO apnea, ZERO Snoring ALL Hypopnea??

What is causing the Hypopnea? I guess this is all kind of mute if you cannot tolerate CPAP due to dry nose syndrome.

Too bad they didn't insert an optical camera to determine that and/or test you with the dental device.

Maybe you need to check out getting one of those didgeridoo, I'll look for you on the discovery channel

I'm told that the mother of all proofs is how the patient feels before and after, i.e., if he feels worse without the mask and better with it, then, sure enough, he has OSA, snoring or not, and the treatment works!