Oscar Data. No events flagged but weird flow rate pattern during REM

[Dormeo]

Ynot, when you use high pressure support, you get more central apneas. When your PS is lower, you have hardly any. When you PS is higher, you get slightly fewer flow limitations; when it's higher, you get slightly more.

You are worried about your breathing during REM. I'm not sure how you know when you're in REM sleep or what exactly it is that you think the problem is. Do you fear your REM breathing is kicking you out of REM sleep prematurely? Or is it something else? I will say that REM breathing is naturally more irregular than non-REM sleep breathing.

I worry that you have unrealistic goals. You will never consistently have no CAs and no FLs. Having some of each is completely normal. You'll also always see some natural variation in both from one night to the next.

You don't seem to me to be a good candidate for ASV. You seem to do well with PS of 4 or 5; why not stick with that for a while?

If your sleep isn't restful, I'd urge you to make time for a good 7.5 hours of actual sleep per night, and I'd urge you to go to bed at the same time each night and get up at the same time each morning. It's not so easy to change these habits, but I think it'd be beneficial to you and well worth the effort.

[Ynot]

Ynot, when you use high pressure support, you get more central apneas.  When your PS is lower, you have hardly any.  When you PS is higher, you get slightly fewer flow limitations; when it's higher, you get slightly more.

Hi Dormeo,


yes, when I use high ps, I get more central apneas. Yes, when ps is lower, I hardly get any CA, but even though I do not get apneas, I do often get the cheyne-strokes like waxing and waning central pattern, which probably hurts my sleep and health. I refer to them as TEC events instead of TECSA. 

Also, the higher the ps, the fewer the flow limitations. 


You are worried about your breathing during REM. I'm not sure how you know when you're in REM sleep or what exactly it is that you think the problem is. Do you fear your REM breathing is kicking you out of REM sleep prematurely? Or is it something else? I will say that REM breathing is naturally more irregular than non-REM sleep breathing.

I think I have a pretty good idea of when I'm in rem sleep. Every relevant chart becomes erratic (attachment) every time I'm in rem sleep (Which could be normal to some extent). The breathing was so bad with cpap, that I could tell just as well just by looking at the flow rate chart. 

I also have a pretty good idea of what my problem is. I mentioned it in my first post:

"I had a sleep study, and was diagnosed with mild sleep apnea and moderate to severe UARS: (Only 6.2 AHI but an RDI of 23.3/hr (44.5 in the supine position), AHI in rem of 21.8/hr (4.1 outside of rem) (No apneas, only hypopneas). (Only about 3h of sleep).

These results lead me to believe that my sleep apnea is unusually “rem specific” compared to other people with the condition. And this is consistent with my insomnia prior to treatment which consisted of waking up after only about 5h of sleep and not being able to go back to sleep (more arousals during rem which become more common during the morning.)"

Of course my worry is that my breathing is not healthy during rem sleep. This could lead to a variety of problems - most likely excessive arousals during rem sleep leading to poor sleep quality. 

I understand that breathing is naturally more irregular during rem sleep, but how irregular? For instance, if you look at my cpap data, I do not think anyone will claim that rem sleep is naturally that irregular and flow limited. 

I worry that you have unrealistic goals.  You will never consistently have no CAs and no FLs.  Having some of each is completely normal.  You'll also always see some natural variation in both from one night to the next."

Maybe, but it seems like a large coincidence that my breathing was undeniably terrible exclusively during rem without treatment, and with cpap, and that now, although improved, the breathing imperfections exclusively during rem are "completely normal".

That is why I asked the "how is rem supposed to look like?" question.

Users like phelaronic, claim that their breathing is not as unstable during rem as mine, which makes me believe that my FLs and TEC events are not normal and problematic. 


You don't seem to me to be a good candidate for ASV.  You seem to do well with PS of 4 or 5; why not stick with that for a while?

Probably right. I will stick with that for a while regardless. 


If your sleep isn't restful, I'd urge you to make time for a good 7.5 hours of actual sleep per night, and I'd urge you to go to bed at the same time each night and get up at the same time each morning.  It's not so easy to change these habits, but I think it'd be beneficial to you and well worth the effort.

I will. I do struggle with insomnia. [b]Without treatment and with cpap, fixing my insomnia was impossible, obviously due to UARS. Now, getting 7-8h is very straightforward with the advise you mentioned.  Improving my breathing has not been that straightforward. [/b]

Thank you for the advise and attention.

[SarcasticDave94]

The last chart I saw prior to this was a zoomed in one, with about 7 hours sleep duration, 11 CA flags over that time, 0.0 FL.

You don't like variable pressure now, you'll hate ASV. That's what it does to do its job. The only ASV machine mode that doesn't vary is static CPAP.

Yes, I've used ASV for 2 years in the past, and I was fine with variable EPAP, PS, and IPAP. Besides that, I see no real big CA trouble to indicate even thinking about ASV.

I do honestly believe your higher PS to be the culprit to any CA flags, but it's your therapy. Meaning I can suggest something, but it's on you whether you'll accept and apply.

[Dormeo]

A couple of things. There is no one way that REM respiration looks like. In your sleep study, you had only three hours of sleep, probably just one REM period. I wouldn't generalize too much from data that are so limited.

You do sometimes have some waxing and waning breath, but it isn't at all like Cheyes-Stokes breathing. So please don't worry about CS breathing. By itself, waxing and waning isn't a problem either.

I'm glad you plan to stick with your machine, and I hope you'll stick with your settings. If you get concerned about CAs, bring you PS down a little.

Again, I hope you'll concentrate much more on aspects of sleep other than your settings so that you can feel rested and fresh during the day.

[Ynot]

It's not that I do not like variable pressure, it is just that I do not think or see in my data that variable epap helps me. I do see, however, how variable ps could help me.

I assume you could customize the settings to include a fixed epap with asv.

When I use high ps, it does lead to TESCA, but lower ps aggravates flow limitations so it is hard to choose between them.

I'm not sure which graph you saw, but now, with mouth tape, collar, high sensitivity, and 5.4-6ps, I do not get legit CAs. I do however get waxing and waning central hypoapnea-like events, similar to cheyne strokes respiration, occasionally during rem sleep.

I'm trying to find the optimal balance.

Thanks

[Ynot]

A couple of things.  There is no one way that REM respiration looks like.  In your sleep study, you had only three hours of sleep, probably just one REM period.  I wouldn't generalize too much from data that are so limited.

You do sometimes have some waxing and waning breath, but it isn't at all like Cheyes-Stokes breathing.  So please don't worry about CS breathing.  By itself, waxing and waning isn't a problem either.

I'm glad you plan to stick with your machine, and I hope you'll stick with your settings.  If you get concerned about CAs, bring you PS down a little.

Again, I hope you'll concentrate much more on aspects of sleep other than your settings so that you can feel rested and fresh during the day.

The data in the sleep study fits perfectly with my symptoms, and it is clear in my cpap data, that my breathing was terrible during rem sleep (attachment). 

I know I do not have CS, it is just a comparison to express the pattern without attachment. 

I'll try to optimize my settings. 

If you or someone could offer a healthy model of a good night with good breathing, so I can have an idea of how volatile rem is normally, it would be appreciated.

Thanks

[Ynot]

Hello

Increasing trigger sensitivity helped with TECSA. Are there any other settings changes like Ti max, min, cycle etc that might help so that I can tolerate higher ps, or that's about it with vauto.

Thanks

[Dormeo]

It's a good question, but I don't know the answer. I hope someone else can help with it.

[donsburg]

I've read this whole thread with interest. I may have missed this but I don't think I saw much discussion of whether a "ragged" or "jagged" flow pattern is normal??

I'm not allowed to post images yet, but post #19 on page 2 has some example images. Particularly the second image. 

Any thoughts or information about whether the "shaky" line between expiration and inspiration is normal / ok?

[Dormeo]

Those oscillations around the zero line are called cardioballistic artifacts. The heart telegraphs its beat to the airway. A fair number of people have this, and it's nothing to worry about.