Rapid Breathing-Fractured Sleep-Out of Breath

[Fixit50]

I have a problem.  My sleep is fractured and I rarely sleep for more then 1.5 to 2 hours before waking up short of breath, or from OA’s or just high pressure.  I think there is a problem with my breathing.  For a large part of the typical night my breathing is more like panting at rates around 50bpm.  Flow limits creep up causing high pressures.  Let’s look at some example pictures.  The left picture below shows the rapid breathing on the left side.  If we assume this breathing is during REM, then I come out of REM at 3:06:30am.  While I’m still asleep here, note on coming out of REM, there is a large recovery because I’m short of breath (SOB).  Recovery Tidal Volumes are huge here.  This suggests I’m not getting the oxygen I need during REM even though there are no events. 
More often than the above example, it happens that during this rapid panting REM, I wake up before coming out of REM due to being SOB, or finding the high pressures uncomfortable.  On waking, I yank my tube off the mask even before being fully awake.  It can take multiple large breaths to regain my composure. 
Let’s take a look at what my breathing looks like during this (presumed) REM.  In the middle picture, I’ve zoomed in on a 1-minute portion of REM breathing.  Notice the resp-rate around 40-50bpm and the jagged irregular flow rate.  Doesn’t look much like normal breathing. 
The rightmost picture below shows a typical night’s sleep.  Notice the longest uninterrupted sleep session is less than two hours.
I should point out one more thing.  The examples shown all have max pressure set to 15cm.  For years I had max pressure set to 20cm.  This kept my AHI scores lower than presently with the max at 15cm.  I lowered it to 15cm from 20cm because of frequent wake-ups as described above.  In terms of lowering the number of wakes, going to 15cm didn’t help much.  At 15cm, sometimes I wake up due to a series of OAs where as at 20 I would instead wake up due to high pressure or as shown, due to SOB.  In the end there doesn’t seem to be a winner between 15cm and 20cm.
I’d like to find a way of getting to less fractured sleep, and solving what looks like rapid-strained breathing with not enough oxygen.  Comments, suggestions?

           

[BoxcarPete]

Your breaths may be multiply counted by the machine. Look at the first chart with your eyeballs, it doesn't look like triple the subsequent rate, certain flow limitation patterns can cause the system to double count breaths. The second chart looks a little more chaotic and hard to tell what's really going on. Maybe they both look the same and it's a difference in zoom level that's tricking me instead.

In any case, it's still something that's worth looking into, but unfortunately I can't help too much on that front.

[PeaceLoveAndPizza]

I did not go through your previous posts, so my comments are only to the posted information here...

You are hyperventilating in those latter sessions. Try turning off ramp as you may be physically reacting to the large jump in pressure when ramp ends. It may be a bit uncomfortable when you start the session, but as you relax it will feel more natural. 

Your range looks fine based on the chart, but we can look at some small tweaks depending on how it goes with ramp turned off.

We may also consider a fixed pressure to see if that helps with comfort.

Note that even at EPR 3 you are still having a lot of flow limitations. You may end up being a good candidate for a bilevel machine so you can have more pressure support.

[Sleeprider]

Welcome back. I'm sorry to see you're still having such difficulty with the therapy and a very erratic respiration rate from time to time. I think I last looked at your results in 2017 here: https://www.apneaboard.com/forums/Thread...#pid231923 At that time I confessed, "The analysis of why this respiratory pattern occurs in you or Hojo is beyond my expertise, and I can speculate whether this may respond to bilevel or if it might need something like ASV to stabilize. In theory, the pressure support of bilevel should stabilize the inspiration of those very flow-limited breaths, allowing a rapid complete and normal respiration. I don't pretend to understand this odd respiratory pattern, its causes or its cures, but you should probably find an interested and engaged medical team to help you resolve it."

I wish I could say I have gotten smarter since there. There have been several other members that presented with similar erratic breathing featuring stop and go inspiration and sharp expiration with what appears to be significant flow fluctuations and perhaps cardio ballistic artifacts. I don't think there is anything I can recommend to do with CPAP that has any chance of changing this. It's possible with bilevel (Aircurve 10 Vauto) we could manipulate inspiratory time, trigger sensitivity and of course pressure support to help you overcome this unusual respiration pattern, however I can't promise it will help. For one thing, we simply have no medical explanation of what causes this pattern with hesitations in inspiration and expiration. It may or may not be related to obstruction, and while I wish I had a great answer and solution to this, I just don't. My trial and error approach with others is probably a bit under 50% successful in resolving it. My preference would be that you consult a pulmonologist and/or ENT to diagnose a possible cause. It's essential you understand and make it clear to any consulting doctor that this is not just sleep disordered breathing that can be resolved with sleep studies and CPAP pressure. This may be physiological, neurological or other issue, but it is not caused by collapsing upper airway tissue or conventional sleep apnea factors. If you want to try to obtain a bilevel machine and work with the positive pressure manipulation, I can try to help, but I want to make it clear this is really out of my lane.

[Fixit50]

Thanks to all for the responses.  Let me add one more piece of information to see if it changes matters.  I think this erratic breathing waveform is related to flow limitation or obstruction, probably during REM only.  I did an experiment about 5-years ago when I wore a chin strap in an effort to control obstruction and see if it made a difference.  The result was a dramatic improvement as seen below (ignore the mode; the machine was in APAP with min pressure 11 and max 20).  You can see that the resp. rate is controlled.
   
If I zoom in on the worst part of the waveform, here below is what is found.  Compare this with the middle picture in my opening post.  Big improvement!  To my eye, this doesn’t look too abnormal.  Let me know if I’m wrong.  The issue is, I find the chin strap to be uncomfortable and therefore, not much of a solution. 
   
A few questions:
·       If you agree that the problem is obstruction or flow based, does this result shed any light on matters, or suggest a possible different approach to what was already suggested?
·       Do you have any suggestions as to how I might find the right Pulmonologist or ENT to diagnose this, if that is still needed?  Does any Pulmonologist or ENT doc deal with these matters?  From what I’ve seen of sleep doctors, I have little confidence they could or would help.
 
Thanks for helping with this.

[Sleeprider]

I think flow limitation is a very plausible explanation, and another reason why your solution lies with bilevel if anything. Again, we can't attack this with CPAP and EPR.

[Fixit50]

Thanks.  
So, The next question is how I convince what doctor that Bi-Level is what I need.  My concern is they won't do anything without a sleep study and its probably 50/50 as to what outcome that would have.  I can imagine since my AHI scores are always less than 5 and usually a lot less, that the sleep doc would declare I'm fine where I am and I don't need any help.  Where to go from there, I'm not sure.  I have very good insurance but the challenge as I see it, is finding a doc who would support the idea that I need a bi-level and how to find that doc.  Any ideas as to how to make that happen?  
Thanks again for any help.

[Sleeprider]

In your case it should not be hard if the doctor is listening. CPAP does not resolve this erratic breathing pattern because it has no pressure support, time of inspiration or trigger/cycle controls. These are the basic elements needed to overcome this wavering and variable respiratory effort. You can certainly show him the problem in graphics and explain that where weak or obstructed inspiration is preventing a full breath in a short time, pressure support helps the patient to acquire that breath by replacing part of the inspiratory effort with mechanical assist. That respiratory assist pressure and time can be manipulated in the machine settings of a device like the Aircurve 10 Vauto or even the ST. The objective of bilevel is to ensure a breath is accomplished in a normal amount of time, which means it is desirable to ensure inspiration time is less than expiration time. This inspiration/expiration ratio is critical to resolving the airway resistance that in your case causes a lot of respiratory effort, which is disruptive to sleep integrity (RERA). While your AHI is very low, you expend a lot of effort to get every breath, so bilevel is the only solution available that can help to normalize that.

If your doctor does not understand or comprehend why your breathing patter indicates a significant problem, then he may not possess the understanding of respiration needed to help you. One solution I recommend often is for you, the patient, to acquire a used machine on the gray market at a good price and simply demonstrate the efficacy of bilevel pressure in helping you to breathe normally at night and resolve your symptoms of fractured sleep, poor respiratory structure and resulting fatigue. There are many sources for these machines without a script such as Dotmed, FB Marketplace, Craigslist, or a new machine purchased out-of-pocket with a Rx. The first step is always going to be your doctor agreeing that your problem requires an effective resolution that may be helped with BiPAP. His judgement is all that is needed to provide the prescription to enable you to move forward with or without insurance. You must also argue that a sleep test or titration test is not designed to deal with this problem, so you need to work as a team to find a solution to improve your health and well-being. A sleep test is a very simplistic trial and error intended to reduce apnea and hypopnea events. Some clinics can target respiratory arousal using bilevel titration, but that is an advanced objective that few are familiar with. You might appreciate this thread with Deborah K https://www.apneaboard.com/forums/Thread...to-Bilevel

[Fixit50]

First, thank you for taking an interest in my case and for taking the time for your helpful response.  Next a little background/history.  The last time I saw a sleep doctor was probably about 5-7 years ago.  At that time a PA or NP took the place of the sleep doctor.  I showed him my waveforms and he claimed that Sleepyhead was lying to me and there was no way I was breathing that fast (1).  He dismissed the data as any valid indication of a problem.  Later, I emailed the waveform to my actual MD Sleep Doctor, who was also a pulmonologist and published sleep researcher at a well-known teaching institution.  He replied saying that it’s normal for breathing patterns to change and rates to increase during REM, and advised I not worry about it!  I doubt that he even noticed the actual rate was 40-50+ bpm! 

I’ve had a total of three formal sleep studies in a clinical setting. The last one I had, I requested full medical data afterwards.  There were no flow waveforms included, just stats mostly about pressures and event numbers.  I called to obtain the breathing waveforms and was told that I was given everything that exists! 

Moving on from the historical frustrations, … I like the idea of getting a low cost BiPAP, DIY method however, I’d first like to see if my insurance will fund it.  If that doesn’t happen, I’ll explore the DIY method.  If I can get a prescription, I don’t think there will be any issue with insurance.  Given the above history with docs and sleep studies, I see this as a probable up-hill battle but I’m willing to take my best shot. 

There are a few things you explained that I’d like to understand better in particular, so I am prepared to explain why a BiPAP will help me when I meet with my doctor:

·       You mentioned:  “CPAP does not resolve this erratic breathing pattern because it has no pressure support, time of inspiration or trigger/cycle controls. These are the basic elements needed to overcome this wavering and variable respiratory effort.”  I have not heard of “Time of inspiration or trigger/cycle controls.”  I thought a BiPAP simply provided more than 3cm of pressure support or difference between IPAP and EPAP.  What other controls does BiPAP offer other than the increased IPAP-EPAP difference?
·       One thing I need to be prepared for is that my doctor may require another sleep study before making any changes, especially since it’s been so long since my last study.  The only way I’d be interested in another sleep study is if I can be assured the study will look at my Flow Rate with the goal of improving this.  You mentioned:  “A sleep test is a very simplistic trial and error intended to reduce apnea and hypopnea events. Some clinics can target respiratory arousal using bilevel titration, but that is an advanced objective that few are familiar with.”  Is there a name for the study to which you refer?  Will it identify and define my breathing as something that needs to be resolved?   What should I ask for to be sure I’m getting the right type of study (IF it comes to that)?

As always thanks for your continued support.  I look forwards to getting some answers to my questions above. 

PS:  Yes I did see the Deborah K thread.  Very helpful for sure.  Having seen that thread, I only proceeded to post my thread due to the key difference in our situations being that she does not share the rapid, irregular breathing with large recovery and fractured sleep, all of which seems to be the source of my troubles.

(1) The sleepyhead/Oscar Flow Rate is true even for my irregular and rapid patterns.  I had doubts at first.  ResMed would not help at all and referred me to my sleep doctor.  I did an experiment to verify the accuracy of the Flow Rates shown, and they are accurate.  I’m happy to share what I did to draw that conclusion, though it would take a paragraph to explain.

[Sleeprider]

Fixit50, if you are able to persuade your doctor, any doctor, that your CPAP therapy is ineffective and that bilevel may be more helpful, you can be dispensed a bilevel machine. the links to the wiki articles, Dealing With A DME, and Insurance and Medicare Issues I linked in Deborah K's thread should help. I understand the difficulty in explaining your variable breathing rate and volume is disruptive and undermines CPAP therapy, and getting a doctor to understand the nexus to pressure support and timing is even more difficult. I cannot guarantee success with bilevel, but CPAP is a non-starter as you have already proven. Let me know how I can help.