Persistent micro arousals? first few days on ResMed after switch from Philips.

[manders513]

Hi folks! I had been using a PR DS1 for a few months prior to taking a WatchPAT study which came back with a mild apnea result (based on RDI). I was able to use that Rx to rent an Autoset 11, which I have been using for 2 nights now. My flow rate is much improved! I used to have a lot of flow limitations, but now my waves are much smoother. However, I'm still noting a persistent pattern of what appear to be microarousals every 5-12 minutes, pretty much all night long (depending on sleep stage). 

Below are 2 photos of last night's deep breath arousals. I don't remember waking up or noticing these deep breaths, but I see them recur throughout each night at regular intervals (on average, probably every 7-8 mins, which happens to correspond with my RDI).
   
   

These also happen often when I'm starting to drift off to sleep, and they wake me up...I'll suddenly be awake and conscious mid-way through the deep exhale. Here is an example of a time that happened when I noticed it (green line marks the deep breath around 2:10. The jagged breathing a few breaths later was me "marking" the event so I could find it easily in OSCAR later). This was a while ago, when I was using the Dreamstation. But I have noticed this happening prior to treatment and it has continued during. 
   

I have an in-lab PSG scheduled for July, so I'll get some EEG data at that point. But does anyone have any ideas or experience with this? I'm assuming it's screwing with my sleep quality. I have never felt full relief of symptoms since starting CPAP in late January of this year.

Thank you!!

[gainerfull]

Could this come down to a difference in EPR / comfort algorithms between the phillips machine and the resmed? Also, why is your pressure max so high?

[manders513]

Could this come down to a difference in EPR / comfort algorithms between the phillips machine and the resmed? 

I doubt it--this was happening every night with the dreamstation as well. It was also happening before I started CPAP treatment, though I obviously didn't have proof. But the gasp/big exhale was waking me up when I'd try to fall asleep. 

Regarding my pressure--I just started using the Autoset 2 nights ago, so the first night I left it pretty wide open (5-20) to see what the machine would do, then dialed it in closer to the 95% last night for my min. I just left max at 20 to not handicap the machine and let it do what it wants to do. That said, tonight I intend to maybe increase my minimum to 9.4 or 10 to get it closer to last night's 95%. Does leaving the max high matter much?

Thanks!

[OpalRose]

Does leaving the max high matter much?

Usually no. But if you experience higher than normal Flow Limitations, the FL could cause your pressure to rise to whatever max you might have set. This can cause arousals and be disruptive to sleep.

Just watch your FL. The 95% FL should be under .10, preferably lower.

Personally, I prefer narrower pressure ranges. That takes awhile to figure out by studying your graphs.

[manders513]

Thanks, OpalRose! I'll keep assessing my data and trying to tweak my pressure range. Any thoughts on the microarousals? I'm not seeing anything in the data to explain them...have you ever seen these before? Again, they've been constant regardless of the machine I use or the settings. I'll probably get a definite answer at my sleep study with EEG in July, but until then I'd like to see if I can resolve them if possible.

[Apnea23]

You are clearly experiencing flow limitated breaths and narrowing of your flow rate also.

This is significant respiratory effort, and the deep breaths are your system correcting the lack of consistent unimpeded breathing. To do that requires an arousal of sorts, even if you don't know about it.

The problem is, APAPs just aren't programmed to deal with this - they're programmed to jump in to stop more severe limited flow events that will desaturate us. If it's sleep that's disturbing and causing arousals, APAP couldn't care less. APAP will happily sit and watch hazardous disordered breathing unfortunately until medicine moves on.

Regarding your Dreamstation variable breathing %, same thing in my opinion.

Personally I would turn off EPR or increase pressure by 2cm (or both if you're game) for more contrastable data to look at tomorrow, and perhaps consider forgetting about APAP and titrate yourself to a fixed pressure where none of this is happening over the next week or so.

If you have had these settings for a while you may be surprised how much better your night goes.

Oh by the way, really nice tip on marking on the flow rate graph. I shall be stealing that!

[manders513]

You are clearly experiencing flow limitated breaths and narrowing of your flow rate also.

This is significant respiratory effort, and the deep breaths are your system correcting the lack of consistent unimpeded breathing. To do that requires an arousal of sorts, even if you don't know about it.

The problem is, APAPs just aren't programmed to deal with this - they're programmed to jump in to stop more severe limited flow events that will desaturate us. If it's sleep that's disturbing and causing arousals, APAP couldn't care less. APAP will happily sit and watch hazardous disordered breathing unfortunately until medicine moves on.

Regarding your Dreamstation variable breathing %, same thing in my opinion.

Personally I would turn off EPR or increase pressure by 2cm (or both if you're game) for more contrastable data to look at tomorrow, and perhaps consider forgetting about APAP and titrate yourself to a fixed pressure where none of this is happening over the next week or so.

If you have had these settings for a while you may be surprised how much better your night goes.

Oh by the way, really nice tip on marking on the flow rate graph. I shall be stealing that!

Oh wow, OK well I'm almost glad to hear there's likely a good reason (flow limitation) for the arousals. If you don't mind, could you share with me how you can tell ("flow limited breaths and narrowing of the flow rate")? It's more obvious to me in my Dreamstation screenshot, but I'm not able to detect it as well in the AutoSet shots. Especially since it's not flagging any flow limitation leading up to the arousals. My flow rate looks pretty smooth to me, but I have only been able to teach myself so much in the last few months! 

Regarding APAPs not being designed for this: So I'm gathering the only answer for folks like me is to be vigilant about checking the data and...increase the pressure until they go away? Or are there other solutions too?

Good eye catching my variable breathing on the dreamstation! I would get that so much every night. I was reading into that recently and I think I saw that variable breathing was often just cycles of flow-limited breathing and then increased effort to breathe. Is that what you mean?

I'll probably change one setting at a time so I can tell which variable is affecting my data--thank you!

HA! You're very welcome to use my little huffing/marking trick! Glad to be of service.  

[Apnea23]

Yes to all of the above questions, sorry for the delay.

How did you sleep last night and what did you change?

[WakeUpTime]

I'm not sure if this applies to you, but I wonder if you may wish to also consider looking at pressure relief settings in addition.  I too found different results between Philips and ResMed systems, upon similar settings.  Philips "may" handle pressure relief differently from ResMed in its algorithms.  

https://www.apneaboard.com/forums/Thread...-Pressures

I'm also thinking that you should consider the impact of "pressure relief" handling by the two different manufacturers, like gainerfull suggested earlier.

Could this come down to a difference in EPR / comfort algorithms between the phillips machine and the resmed? 

[manders513]

Yes to all of the above questions, sorry for the delay.

How did you sleep last night and what did you change?

Thanks for asking! I slept pretty much the same - waking randomly and not feeling rested. I bumped my min pressure up to 10.4 but left EPR the same (3). I'm still seeing the gasps every few minutes, same as always. The machine is reporting as if everything looks pretty good--low AHI and such. But I think it missed a few events (see photos below). Can you share with me how you can tell I'm flow-limited in the second picture (attached) before the gasp?

Also, for the record, I am taping my mouth but I don't have a chin strap at the moment. I'll have one Sunday...I tend to get a bit of aerophagia even with my mouth taped because I think my jaw is dropping and I'm chugging air down my throat. I'd like to strap my chin before I crank up the pressure and drop down the EPR, in case I blow up like a balloon.

I'm not sure if this applies to you, but I wonder if you may wish to also consider looking at pressure relief settings in addition.  I too found different results between Philips and ResMed systems, upon similar settings.  Philips "may" handle pressure relief differently from ResMed in its algorithms.  

https://www.apneaboard.com/forums/Thread...-Pressures

I'm also thinking that you should consider the impact of "pressure relief" handling by the two different manufacturers, like gainerfull suggested earlier.

Thank you! I'm not sure I made it too clear in my original post, but this recurrent micro-arousal thing has been happening for a long time. I noticed it nightly when I was using the Dreamstation from late January through mid-May (C-Flex was at 3, then I dropped it to 2 I think). I'm fairly certain it was happening before I even started using a PAP device, as I would gasp awake often. Given that it's been consistently happening regardless of which machine, I'm assuming the pressure relief wouldn't matter? But I can try to lower EPR on the ResMed next week.

I was under the impression that if someone thinks they have UARS, that a higher EPR would be better though. No?