I'm baaaack!

[HalfAsleep]

Finally, I have a new sleep study. I'm now at a different sleep department, on a different campus, with a different team of medicals. This is the first sleep study I've had (after 3 others) that I feel more or less captures reality.

While there might be an element or two that we could disagree with in the recommendations, I'm satisfied that this new study is a good beginning. The data does seem to correspond to my sense of what actually was happening during the night, as well as my Sleepyhead history. At least now I can be on the same page as the sleep team as far as data, which was never the case before.

[To summarize my 3 prior sleep studies: #1 was on 2 beds; #2 was a tech no show, and everyone had to be sent home, in a blizzard; #3 titration was done almost entirely while I was awake.]

Here are some captured observations from my new, March 2024, sleep study.

The tech (IMO he was really on the ball and very diligent):
Patient met criteria for split. Estimated AHI 12, CMS AHI 5. Patient was very sensitive to inspiratory pressure not being high enough, and expiratory pressure of 4 being too strong. Severe CA presented on CPAP. Titration achieved on BPAP at pressure of 13/7 cm H2O, with transitional CA.

The doc:

In the baseline portion, the patient slept for 122.0 min. and their sleep efficiency was reduced due to prolonged sleep latency and was just 61.8% .  They exhibited sleep stages N1 (8.0 min./6.6% of TST), N2 (70.0min/57.4% of TST), N3 (38.0min./31.1% of TST) and REM (6.0min/ 4.9% of TST) of the total sleep time.  They were supine for 99.6% and non-supine for 0.4% of the total sleep time.  In the titration portion, the patient slept for 93.0 minutes, exhibiting stages N1 (5.5 min./5.9%), N2 (83.0 min./89.2%), and N3 (4.5min./4.8%).  There was no REM during the titration portion.  They were supine for 99.5% and non supine for 0.5% of the total sleep time.

......

In the titration portion, pressure settings between 4-10 were used and the patient struggled with the perception that they were insufficient and she was not able to generate any sleep.  Then she was switched to bilevel mode and slept better.  Settings of 10/4-13/7 were used.  At 10/4 to 12/6, she exhibited both obstructive and central events while struggling to transition to consolidated sleep.  Once she was firmly into stage N2, the central apnea activity resolved but she still had occasional obstructive hypopneas.  At bilevel of 13/7, obstructive events were almost entirely prevented in non-REM supine sleep but as noted above, there was no documentation of an effective pressure when in rem because she did not exhibit REM.

The doc's recommendation is for biPAP. However, he is clear to explain that this is only an introductory recommendation. Since I didn't experience REM during the titration, there's no way to determine exactly what the outcome will be. I appreciate the flexibility in this remark, because he's not fixed on a therapy, except that CPAP has been eliminated as an option. I believe this will leave some room for discussion if I ultimately need an ASV.

*******

Note: the AHI was 20, not 12 as the tech guess-timated.

I had no REM while being titrated. That's an interesting development....

[Sleeprider]

I don't think it's any surprise your sleep architecture is disrupted, especially in a clinical setting. The presence of CA events at pressures that bracket the 13/7 result suggests to me, that you will use these titrated settings, but CA will continue to be consistently inconsistent until you get ASV. We will see.

[HalfAsleep]

That's what I think, too, @sleeprider, but at last I have a solid basis from which to move forward, and I don't feel like I'm on the deck of a listing ship when trying to have a discussion with the docs.

I am actually quite shocked at the lack of REM, even though I realize lab conditions aren't normal.

[BoxcarPete]

Your total sleep time was only 93 minutes in the titration portion, which is almost exactly the expected REM sleep delay. Maybe the latency should have been less since you had some sleep in the baseline portion already, but if you did enough fiddling around in between it might qualify as new sleep to some extent. Slightly more surprising that you only clocked 6 minutes in the initial two hours, but sometimes REM 1 is short like that, especially under atypical conditions.

[HalfAsleep]

Great input @boxcarpete!

I had been noticing lately that my dog seems to get more REM than I do (i.e. chasing squirrels while asleep), so, yep, I might in fact have to pay more attention to REM length.

Is there a way to locate REM on an OSCAR image? Or would I have to have a separate instrument, like an O2 ring or my Applewatch (which will give me heart rate)?

[BoxcarPete]

If things are going fairly well, the REM cycles will be patent in your advanced respiratory stats (i.e. tidal volume, respiration rate), as the breathing patterns are more chaotic. This is especially true for the first half of the night, as a normal sleep architecture is N1 for a handful of minutes, N2 for twenty or so, and N3 (deep sleep) for about an hour before our first REM cycle, which typically lasts for 20 minutes or so. Then another hour of N3, then another REM. The difference is especially stark between N3 and REM because your breathing should never be more steady than deep sleep, and REM sleep breathing is often as chaotic as waking breaths, if not more so. After that a robust sleep architecture will bounce back and forth between REM and N2, with timing of each stage more dependent on the body's needs rather than on a schedule.

Applewatch and other wearables will make their own guesses as to sleep stage, but they are depending on data from heartrate and body movement which isn't as accurate as a good OSCAR chart in my opinion.

[HalfAsleep]

Could someone remind me how to bring up the number of “hours used” on a Resmed Aircurve BiPAP? I am picking one up at the (new) DME, and don’t want to be sent home with a used one. The last DME did exactly that: placed a used Airsense on the table for pick up. They were shocked when I reached over, pressed a coupla buttons, and revealed the usage meter. But I forgot that nifty little trick!

[HalfAsleep]

Well, this is very entertaining....

New biPAP. Hella mess at the DME.

Night One: I slept almost the whole night with mask on, no leaks, unit off (seems to have turned itself off). Great AHI, but not close to enough oxygen for survival.

Night Two: Yeah! My AHI went UP.... Those purple slashes are like the red marks on my boarding school Latin exam: oh, dear.

[A side note to the wise: I have an F40. Resmed specifically says the unit has to be set to "pillows" for this mask..]

[Side note #2: My doc told me the sleep study AHI is 20, but DME says he told them 60]

Chart momentarily..... man, I forgot how to do this.

[HalfAsleep]

Wooohooo! I'm gonna score an A+ for failing treatment...


Correction: A+ for managing mask leaks, A++ for sleeping more hours than I have for years, F for treatment.

Can any one figure out what's going on? Is there a way to tell where I'm engaged in REM sleep?

[BoxcarPete]

Normally, we can suss it out to some extent or another by reading the tea leaves in the wiggliness of your respiratory stats like tidal volume and respiration rate. In this case, we can't do that and besides, you have... bigger issues to work out than sleep architecture. Suffice it to say that your event clusters are not likely tied to REM because there are too many of them spread out throughout the night.

What did you change to make this happen? I thought things were going reasonably well for you before.