Need opinions about breathing waveforms - REM sleep? awake? don't know?

[green wings]

After looking at RobySue's recent post of some of her sleep/wake junk waveforms, I thought I'd ask people to take a look at my waveforms during periods of what I've been assuming was REM sleep, but I don't really know what's going on. Is it possible that I'm awake during these periods and don't remember it? The breath waveforms get really erratic.

The first two charts are the overview for one night's data. The ones after that are zoomed in on different portions of the sections where the clusters of obstructive apnea events start to be scored in rapid succession.

Thanks.

1. Overview pt. 1


2. Overview pt. 2


3.


4.


5.


6.

[Sleeprider]

On your charts, go to File/Preferences/Appearance and turn off the pie chart on the right side. Also in Events, enable the pressure pulse. That might explain some of the spikes during those apneas. You can disable UF1 and UF2 on the events and waveforms.

These appear to be obstructive apnea, and we usually associate SWJ with hypopnea and CA. The periods of diminished volume and apnea are interspersed with higher amplitude recovery breathing. There is no flow limitations, which is probably because you're not on an auto machine. There are also no snores. FL and S are normally precursors to obstructive events, so an auto machine might not increase pressure ahead of these clusters and head them off. Most of the night you are well treated at your CPAP pressure of 13, but it looks like you could benefit from auto CPAP during those periods where you have OA and H events.

I'd guess this is either sleep stage or physical sleep position, rather than SWJ.

[robysue]

Since there's no evidence that you turned the machine off and back on shortly before that cluster around 2:15 starts and since you say you don't remember any wakes, I'd say that it's more likely to be REM related or positional related (i.e. you turned onto your back) rather than sleep-wake-junk.

The timing for the cluster that starts around 1:45 is better for a REM-related cluster. But it's quite possible that the 2:15 cluster might be the first REM cycle. It's really impossible to figure that out with any certainty from just the CPAP data. It could also be that after the first (short) REM cycle around 1:45, you flipped onto your back, and the 2:15 cluster might just be a supine sleep cluster.

The timing of the events between 4:30 and 5:30 strongly suggest that some (maybe all) of those events might be REM related.

One thing about REM breathing is that normal REM breathing can look a lot more ragged than other sleep breathing: It can have a higher RR rate and the depths of the inhalations can have more variability than normal sleep breathing.

[robysue]

There is no flow limitations, which is probably because you're not on an auto machine.

The OP is using a PR System One Pro. Those machines do NOT flag FL the way the PR System One Autos do. (And the PR Autos only record FL if they're in Auto mode).

[green wings]

Thanks for your comments, Sleeprider.

Oops, sorry about the pie chart. I used to keep that off but turned it on again some time recently.

My diagnostic sleep study did show that I have REM-related apnea. Approximate numbers:

non-REM, non-supine AHI<5
non-REM, supine AHI~30
REM, supine AHI~75
REM, non-supine sleep - none observed

overall AHI for study ~35, RDI~55
also, no REM sleep observed until 3-4 hours into study. I don't remember the exact number.

FL and S are normally precursors to obstructive events, so an auto machine might not increase pressure ahead of these clusters and head them off.

That fits with what I usually saw when I was running my machine in auto-trial mode. I would either start REM sleep (or shift sleep position) and a cluster of OAs would start. The auto algorithm would increase pressure by about 3 cm, but the OAs would keep happening, and the algorithm would stop responding to them.

On your charts, go to File/Preferences/Appearance and turn off the pie chart on the right side. Also in Events, enable the pressure pulse. That might explain some of the spikes during those apneas. You can disable UF1 and UF2 on the events and waveforms.

These appear to be obstructive apnea, and we usually associate SWJ with hypopnea and CA. The periods of diminished volume and apnea are interspersed with higher amplitude recovery breathing. There is no flow limitations, which is probably because you're not on an auto machine. There are also no snores. FL and S are normally precursors to obstructive events, so an auto machine might not increase pressure ahead of these clusters and head them off. Most of the night you are well treated at your CPAP pressure of 13, but it looks like you could benefit from auto CPAP during those periods where you have OA and H events.

I'd guess this is either sleep stage or physical sleep position, rather than SWJ.

[robysue]

FL and S are normally precursors to obstructive events, so an auto machine might not increase pressure ahead of these clusters and head them off.

That fits with what I usually saw when I was running my machine in auto-trial mode. I would either start REM sleep (or shift sleep position) and a cluster of OAs would start. The auto algorithm would increase pressure by about 3 cm, but the OAs would keep happening, and the algorithm would stop responding to them.

Sounds like the min pressure was set too low in Auto mode. What was the pressure range you were using?

[green wings]

Thanks, robysue. I take Cymbalta for fibromyalgia pain. It's an SNRI antidepressant, and I think it's one of those medications that's known to "suppress" REM sleep (not sure exactly what "suppress" means in this case.)

Either because of the screwy sleep that comes with fibromyalgia or because of the Cymbalta, I rarely remember anything that happens during the night after I first fall asleep. So that's one reason I was asking opinions about the possible REM sleep. I don't really know what goes on once I fall asleep.

Another reason that I'm asking about this stuff is that I'm trying to decide how hard to push to switch to an auto machine. The model of machine I have is fixed pressure CPAP, but it has the ability to run in auto-trial mode for up to 180 total days. I have used 120 of those days and much prefer the auto mode.

I did a trial for my doctor about four months ago to determine a new fixed pressure, and the 90% pressure was 15.0. If I use a fixed pressure that high all night, night after night, I swallow air, so the 13.0 is a compromise. My long-term average AHI is around 5.0, though, so my sleep doctor thinks that's just fine.

Since there's no evidence that you turned the machine off and back on shortly before that cluster around 2:15 starts and since you say you don't remember any wakes, I'd say that it's more likely to be REM related or positional related (i.e. you turned onto your back) rather than sleep-wake-junk.

The timing for the cluster that starts around 1:45 is better for a REM-related cluster. But it's quite possible that the 2:15 cluster might be the first REM cycle. It's really impossible to figure that out with any certainty from just the CPAP data. It could also be that after the first (short) REM cycle around 1:45, you flipped onto your back, and the 2:15 cluster might just be a supine sleep cluster.

The timing of the events between 4:30 and 5:30 strongly suggest that some (maybe all) of those events might be REM related.

One thing about REM breathing is that normal REM breathing can look a lot more ragged than other sleep breathing: It can have a higher RR rate and the depths of the inhalations can have more variability than normal sleep breathing.

[green wings]

Sleeprider: Overview pics with pressure pulse & without pie chart for 1) Nov. 3, the night I used in the previous pics and 2) Nov.4, following night with more PPs.

Nov. 3:


Nov. 4:

[green wings]

Pressure range for the auto-trial for the doctor was 10.0-20.0. Some example nights.

1.


2.


3.


4.

FL and S are normally precursors to obstructive events, so an auto machine might not increase pressure ahead of these clusters and head them off.

That fits with what I usually saw when I was running my machine in auto-trial mode. I would either start REM sleep (or shift sleep position) and a cluster of OAs would start. The auto algorithm would increase pressure by about 3 cm, but the OAs would keep happening, and the algorithm would stop responding to them.

Sounds like the min pressure was set too low in Auto mode. What was the pressure range you were using?

[Sleeprider]

Going back to whether to push for an auto machine. I think that may be the ticket. First the complication of fibromialgia makes constant high pressure painful. So there is a definite advantage to having a machine that only goes higher for the episodes of OSA that happen during the night. Now in your case, if an auto machine was selected, I'd want one that responded faster like the Resmed Airsense 10 Autoset (not for her). The second advantage to that machine is the true EPR which lowers EPAP by 3 cm, making higher pressures tolerable. Your own data shows APAP works better, in fact you seem to have less than half the AHI with an auto algorithm working. In no instance was hypopnea or CA a problem.

Yeah, I definitely think so.