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OSCAR and Watchpat Results - Need Help w Treatment
#11
RE: OSCAR and Watchpat Results - Need Help w Treatment
from the few videos I've seen, plm can be as little as you describe to huge and comparatively violent. here's a plm flow rate pic from last night for reference. obviously it's up to you to determine if you have plm and the extent it affects you. all I can say is that when present, plm seriously affects my sleep quantity and quality and handicaps my pap therapy.


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#12
RE: OSCAR and Watchpat Results - Need Help w Treatment
A whole lot of guessing going on in here. Watchpat is only as good as majority of other at home sleep tests. It can only guess what stage sleep you are in, apneas etc. Your PSG that you recently had done will have a lot more information and clearly outline sleep issues and be able to tell your if PLM is an issue etc. With PLM it is only really an issue if it is causing an arousal, only your PSG data will be able to tell you that.

Your purchasing of a bipap wasn't stupid but setting pressure and PS as high as you did was a poor place to start. You want to start low and work your way up. Your centrals were what are called treatment emergent centrals and they were occurring because of the high pressure support. This high pressure support was too efficiently evacuating the CO2 from your lungs/blood so your brain was taking a break from breathing (since CO2 levels is what controls respiratory drive). Lowering your PS as you did stopped this from happening which is why centrals went away and AHI dropped.

You actually dropped pressure support all the way to zero (Gideon's recommendations were leave on bipap with EPAP set at 8.5, IPAP at 0.5 for PS of 1) and it didn't show any obvious issues which is good and a sign that if you have obstructive sleep apnea it appears to be more obstructive apnea versus hypopnea.

I would try and see if you can get by on lower pressure and I would add some PS back in as it might be more comfortable. I would change back to BiPAP mode with EPAP of 4 cm, PS of 2 cm so IPAP of 6 cm. If your data shows apnea or hypopnea at these reduced settings slowly increase EPAP (4, 6, 8) until they go away. If central apneas increase again lower PS to 1 cm and then if necessary back to 0 cm.

Edit: Oh and make sure machine is on auto mode (not sure what your options are). This allows the machine to increase EPAP automatically through the night if some apnea are occurring and will help determine an ideal setting.
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#13
RE: OSCAR and Watchpat Results - Need Help w Treatment
Geer1, lots of guessing maybe, but data driven guessing with hypotesis testing, which pretty much describes the scientific method!

Personally I find any PS disturbing, but I run a low pressure. Obviously any change in pressure/PS/mask/etc takes time to adjust to. Geer1's suggestion of decreasing pressure, increasing as required, and tuning PS for comfort sounds good.

I think there's clearly a correlation between the movements captured by the O2Ring and inhalation spikes. I experimented with my SleepU on my foot last night and have some graphs below. Your O2ring movement numbers seem a lot higher than my SleepU (might be my unit, or different code in the different models, or something). Even my sharp test movements only go up to 50 or so while your numbers seem higher (which is good). My small PLM twitches only register as values of 1-5 or so.

I also have a sensor on my ankle which I have been using to track PLM for the last 8 months or so. This is displayed in the "Inclination" graph here and uses a modified log scale. I also have some code to calculate PLMI based on AASM style rules. I also measure orientation and notice that a fair number of events are related to position changes as I move from back to side, etc.
   

PLM arousals sometimes aren't registered by a typical PSG which only looks at 30 second epochs. Cyclic alternating pattern (CAP) can be a result of PLM and typically isn't scored in a PSG (but seems to be more often scored in some European countries). There's also this article on how Frequent Periodic Leg Movement During Sleep Is an Unrecognized Risk Factor for Progression of Atrial Fibrillation, which is why I'm focusing fixing my PLM so much as I don't want any further progression of my AF.
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#14
RE: OSCAR and Watchpat Results - Need Help w Treatment
All I am saying is lets slow down till he gets some more accurate data. The gaps etc in data that spiked PLM thoughts were due to treatment emergent central apneas and shorter central related breaks in breathing.

Your inhalation spikes and PLM will 100% correspond with each other as those are arousals. Both PLM and breathing is related to arousals. The question is what caused the arousal? The breathing? The PLM? Spontaeous arousal that causes breathing spike and PLM? Relation does not mean causation and his PSG data will provide some of those answers and should be coming soon (if he hasn't followed up with doctors/clinic I would, my doctor thought sleep clinic would send me a copy etc instead I didn't get results until almost a month later because they only sent to him).

Not sure what you mean by PLM arousals sometimes aren't registered by a typical PSG which only looks at 30 second epochs. Every arousal should be scored and applied to breathing, PLM etc as there is data to support it, all other arousals are labelled "spontaneous". Epoch length has no effect on scoring arousals.

I would argue that PLM/atrial fibrillation article again is a good example of relation vs causation. IMO it is far more likely there is an underlying cause affecting both leg and heart function rather than PLM influencing heart function.
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#15
RE: OSCAR and Watchpat Results - Need Help w Treatment
I agree. when I said I was going out on a limb, I meant I was going to leap to a conclusion. a temptation I usually resist. not wise & not fair to the OP. let's see what the data brings.

(meanwhile, I want to digest the substance of the last 2 posts more fully, maybe copy or link to them in my plm thread; some interesting thoughts there.)
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#16
RE: OSCAR and Watchpat Results - Need Help w Treatment
Well, now I'm really confused.  Spoke with the sleep Dr. about the results of the PSG (which I'll post later today).  He said:

1. I slept for 1 hour and 2 hours for a total of 3 hours.
2. They recorded no leg movements whatsoever.  Although he said maybe the leads came off.  They did come in the middle of the night to reattach them.
3. My AHI = 1.7 so no sleep apnea
4. They did record very mild snoring
5. They didn't score RDI.  When I asked what my RDI was he just said what matters is AHI.
6. The Watchpat study is moot.  He said the PSG completely overrides it.

My Iron levels also came back completely normal.

I'm seriously confused.  They Watchpat study and my own data completely contradict these findings.  Watchpat says I'm a complete mess with a serious SBD and the PSG says I'm completely healthy.  My own recorded leg movements look exactly like PLMS while the PSG says it's nonexistant.

So frustrating...  Now I don't know how to proceed.

I've been continuing with the BiPap and I have had a couple days where I feel very good.  This is unusual.  Maybe it's a placebo effect or just chance.  I don't know, but I'll continue with it and monitor how I feel.
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#17
RE: OSCAR and Watchpat Results - Need Help w Treatment
(04-28-2021, 01:51 PM)Bijingus Wrote: Well, now I'm really confused.  Spoke with the sleep Dr. about the results of the PSG (which I'll post later today).  He said:

1. I slept for 1 hour and 2 hours for a total of 3 hours.
2. They recorded no leg movements whatsoever.  Although he said maybe the leads came off.  They did come in the middle of the night to reattach them.
3. My AHI = 1.7 so no sleep apnea
4. They did record very mild snoring
5. They didn't score RDI.  When I asked what my RDI was he just said what matters is AHI.
6. The Watchpat study is moot.  He said the PSG completely overrides it.

My Iron levels also came back completely normal.

I'm seriously confused.  They Watchpat study and my own data completely contradict these findings.  Watchpat says I'm a complete mess with a serious SBD and the PSG says I'm completely healthy.  My own recorded leg movements look exactly like PLMS while the PSG says it's nonexistant.

So frustrating...  Now I don't know how to proceed.

I've been continuing with the BiPap and I have had a couple days where I feel very good.  This is unusual.  Maybe it's a placebo effect or just chance.  I don't know, but I'll continue with it and monitor how I feel.

Here's the attached PSG report to accompany this post.  I've circled some things which I think are relevant.  RERA's were not scored, nor was RDI.  SMH.  Spontaneous arousals are at 15 though.  No way of telling if they are in fact "spontaneous" or caused by respiratory events.  If they are cause by respiratory events then I would have a high RDI and thus could be diagnosed with UARS.  Of course, this clinic doesn't even recognize it.  I called and asked if they could please score RERA's as it's left blank on the report.  They said they'll call someone and see if they can.


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#18
RE: OSCAR and Watchpat Results - Need Help w Treatment
sleep medicine seems to be a misnomer. most aren't there to deal with sleep, just apnea. and almost always only obstructive apnea at that.

you had 18 awakenings in 180 minutes of sleep time; you woke up once every 10 minutes on average. that's brutal. they may tell you you're apnea is treated but they're ignoring everything else about your lousy sleep. you were awake more than asleep. 15 arousals/hour, 6 awakenings/hour. they said you had mild motor restlessness while lying awake which may be normal or rls. in my experience rls and plm don't happen every night so maybe a one off for you. maybe you don't have plm. idk. in any event, the poor sleep efficiency, many arousals and awakenings should raise flags for anyone concerned about your sleep rather than just treating out obstructive apnea. I would push hard for additional help for the inability to fall and stay asleep. shop for a more receptive doctor if necessary. if you believe you have plm, video yourself to prove it to the doc.
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#19
RE: OSCAR and Watchpat Results - Need Help w Treatment
(04-20-2021, 05:15 PM)Geer1 Wrote: Watchpat is only as good as majority of other at home sleep tests. It can only guess what stage sleep you are in, apneas etc. Your PSG that you recently had done will have a lot more information and clearly outline sleep issues and be able to tell your if PLM is an issue etc.  With PLM it is only really an issue if it is causing an arousal, only your PSG data will be able to tell you that.

Your purchasing of a bipap wasn't stupid but setting pressure and PS as high as you did was a poor place to start. You want to start low and work your way up. Your centrals were what are called treatment emergent centrals and they were occurring because of the high pressure support. This high pressure support was too efficiently evacuating the CO2 from your lungs/blood so your brain was taking a break from breathing (since CO2 levels is what controls respiratory drive). Lowering your PS as you did stopped this from happening which is why centrals went away and AHI dropped.

^ As I previously posted.

Home sleep studies with limited data are borderline useless especially when your sleep quality is poor. They don't know when you are asleep let alone capable of determining apnea accurately. Imo because the main focus for sleep is on obstructive sleep apnea they continue to use these home studies even though they also get falsely flagged in people with other sleep issues. 

The PSG results definitely trumps the watchpat results, arguing the other way around is like a blind man arguing what colour an object is. The watchpat system has always peaked my doubts as they don't collect breathing information directly. It is based mostly on blood flow and although they have supported it with clinical backup I think it can get tricked by other blood flow issues. Here is a bit of their explanation which you can see is monitoring for sympathetic nervous system reaction which to my knowledge can be triggered by a number of things not just breathing. I am not sure how robust their system is at filtering out other causes, I am guessing minimally.

https://www.itamar-medical.com/pat-perip...echnology/

At a spontaneous arousal rate of 15 the absolute worst case would be a mild UARS diagnosis which is of borderline clinical relevance at best. Most "UARS" patients don't respond to breathing treatment because the issue isn't really the breathing but rather a nervous system issue (over reactive). If we look at other important breathing data acquired so far we also see that 

1) You had no significant oxygen desaturation in either the watchpat or PSG studies. 
2) With the limited PAP data posted it was noted that at a PS of 4.5 you were having central apneas because your body was too effective in evacuating CO2.
3) When you changed settings you accidentally decrease PS all the way to 0. Many people with SDB struggle to breath out against 0 PS and you never made any complaints about this drastic change.

Overall I would say breathing is unlikely to be your issue. There is a slight chance you have breathing issues when in the supine position (since that was not seen in the PSG) otherwise the rest of your breathing appears to be normal imo. 

The PSG also noticed no PLM and they made specific comments about it so almost guaranteed you did not have PLM that night (not that the leads fell off). 

Now the question is, what is the problem? 

What sparked your watchpat results, PLM thoughts by members on here and spontaneous arousals in PSG? This is a real sleep disturbance, it unfortunately is also one of the most difficult to analyze and treat because there isn't a measurable cause. 

It could be anxiety/stress triggering sympathetic nervous system. It could be poor sleep habits/insomnia. It could be nervous system related. 

My recommendation is threefold.

1) If you think bipap at minimum settings is helping keep using it. After a while when you aren't sure if it is doing anything (give it time to work and body to adjust fully, aka weeks if not months) then discontinue using it. The problem with PAP for many users (especially those with minor symptoms) is that the symptoms slowly go away while they adjust to PAP so it is hard to notice improvement, once you yank PAP out of the picture the body gets a hard lesson and symptoms come back much quicker then how they went away. If there is no worsening of symptoms PAP probably isn't helping you. 
2) Read up on sleep hygiene and CBT for insomnia practices. These will help your sleep quality. If anxiety or stress are issues you need to take steps to improve them, both are destructive for sleep quality. Big deep belly breaths are a simple powerful trick for turning sympathetic nervous system off and parasympathetic nervous system on.
3) This is a personal recommendation based on what has worked for me and having seen it work for some other people fighting with tough to diagnose health issues/sleep quality issues. If you are having digestive symptoms (IBS, constipation, diarrhea, stomach tenderness, bloating, reflux, nasal congestion, all of the above) then you need to treat them with diet modifications and potentially other treatments. This literally changed my life and I didn't even realize how screwed up my digestion was until I improved it (and I still think it is part of my ongoing issues). If you have digestive symptoms and would like more info I can post a few ideas to get you started.
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#20
RE: OSCAR and Watchpat Results - Need Help w Treatment
Quote:you had 18 awakenings in 180 minutes of sleep time; you woke up once every 10 minutes on average. that's brutal.


I think it's just slightly above their normal threshold so they ignored it.  Sounds high to me but maybe not?

Quote: I would push hard for additional help for the inability to fall and stay asleep.

Falling asleep has never been an issue for me.  It was only an issue during the PSG.  I could hear noises in the other rooms, light shining through the door and I was all tangled in cables.  I've just been trying to figure out why I feel so danged fatigued all the time.

Quote:This is a real sleep disturbance, it unfortunately is also one of the most difficult to analyze and treat because there isn't a measurable cause.

So, you think that the Watchpat isn't picking up breathing events but is picking up arousals/awakenings triggered by my nervous system?  Sounds plausible to me.  Would suck though if this were the case because it would basically be impossible to diagnose and difficult if not impossible to treat.

1. I will stick with the BiPap for a while.  I'll monitor how I feel and will take your suggestion if I'm feeling better to stop and monitor if I'm feeling worse.  Can't hurt.
2. I don't have insomnia.  The PSG just made it difficult to fall asleep.  Usually I'm out within 5 to 10 minutes.
3. I do have digestive symptoms.  Was experiencing random vomiting for 1 year.  Went away then came back, then went away again.  Also tender stomach and more.  Went to a GI.  They found nothing.  I did find some relief on a Keto diet but I didn't have the willpower to stick to it.  Managed 3 months.

Appreciate your insights.
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