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"REM-Related" Sleep Apnea
"REM-Related" Sleep Apnea

Lately, this has seemed to be something we have talked about in the sleep center I am working, and I wrote this up. Does anyone have any further thoughts on the matter? If not, I hope you found the information helpful or insightful. 

Have a great day!


REM-Related Sleep Apnea?

[Image: SleepStageChart.png]

The topic of rapid eye movement stage sleep with sleep apnea has been a subject that has come up often over the past month. Per usual, when something comes up frequently I begin to dwell on the topic and simply want to know more, and more, and more, and more - yeah, it can be exhausting. But, that means I typically grow to have a clearer understanding. However, what I found was something that I did not expect to encounter, and I thought it may be something of interest to some of you!

First off, let me get some terms out of the way. I will refer "rapid eye movement" as REM. So "REM" sleep - or - "REM" related sleep apnea. I am sure most anyone could put that together, but maybe it will save me a few confusing emails! I'll also use the common acronyms such as CPAP (continuous positive airway pressure) and OSA (obstructive sleep apnea).

REM-related OSA has been coined by healthcare community to signify when a person has a significant number of sleep apneic events that manifest primarily in REM stage sleep and decrease substantially, or entirely, when in any other stage of sleep. The trend of REM-related OSA is highly variable ranging from anywhere between 10% to as much as 36% in controlled studies (Mohklesi & Punjabi, 2012). To me, that seems to be a small number of patients when it comes to the overall amount of people newly approaching a possible diagnosis of sleep apnea. The prevalence of REM-related sleep apnea has led to the questioning of whether it has a clinical significance or not. Should REM-related sleep apnea be treated or is it a natural phenomenon or a clinical entity that deserves treatment?

Per several different articles and even consulting other professionals, it seems that the consensus throughout the sleep community is the factor of co-morbidities. If a person has REM-related OSA with no other causes for concerns such as any other conditions, then the significance of REM-related OSA may be something natural that does not need to be treated. However, if a patient has any other diagnosis such as anxiety, depression, pulmonary disorder, a cardiac, or neurological problem (along with many others), then treatment with CPAP should be considered to correct. The application of therapy also comes into account too if the apnea events found in REM are highly severe, moderate, or mild. Mind you, dear reader that is the data I have found looking over the internet and talking with others. You are allowed to have your own opinion. Don't shoot the messager!

My perspective:

I am sure the depending on who one chooses to speak with will certainly sway their opinion on this matter. Some physicians may adhere to attempting treatment whenever possible while others may prefer to not utilizing CPAP in most instances. Some sleep centers may not allow their staff to treat if apnea is found primarily in REM while others may choose to do so regardless. As most any professional in the sleep technology field would agree there are certain problems, such as this one, that is very debatable to if, and how, a person may be treated or not.

Overall, I try to keep my perspective according to the guidelines in place by the American Academy of Sleep Medicine (AASM) and otherwise adhere to a physician's order/recommendation. That is pretty typical to how most technologist/technicians would approach the matter. We have certain guidelines that we must adhere too and a referring doctor that likely has a particular manner into how the patient is to be treated. The interesting part of this, for me, is proper treatment. The few that I have spoken with have suggested auto-CPAP would be the best treatment utilized to treat a patient. While others have felt that bi-level positive airway pressure (BiPAP/VPAP) would likely be the optimum form of therapy. I cannot find any studies that help to indicate which treatment mode would be the best option.  The only studies that are available suggest that a titration sleep study should be performed to decipher what treatment method would be the best available to assure patient comfort, adherence, and optimal control of apneic events.

I think that most anyone in the sleep industry would agree with the approach. However, as most sometimes understand even medical studies and a specialized physician do not get the option to make these decisions. Insurance agencies sometimes just won't approve for a patient to return to a sleep center and simply want them prescribed a home unit to assume treatment. With REM-related sleep apnea, this is where the topic can become dense. The only controlled study cannot accurately allocate to whether 1 in 10 or 3 in 10 patients have this possible problem and therefore cannot recognize it as a particular condition. Without a particular condition, it seems that there cannot be a recommended specific treatment. I do not feel that auto-CPAP would be the best option due to the algorithm placed in the home CPAP units would not be able to accurately increase/decrease pressure quickly enough in the amount of time for REM sleep apnea to properly treated. However, it is an option for any type of treatment of insurers just won't allow a patient to return for a full titration visit.

Overall, if you have "REM-related sleep apnea" it is worth thoroughly discussing with a physician to if it should be treated, and if so, a full titration sleep study would likely be the most viable option to assure proper CPAP/auto-CPAP/bi-level PAP settings. I hope that this information is helpful and I would love to hear thoughts from the sleep community! 

Moklesi B, Pnjabi NM. “REM-related” Obstructive Sleep Apnea: An epiphenomenon or a Clinically Important Entity? Sleep. 2012;35 (1):5-7. Doi: 10.5665/sleep.1570

Berry, R. B., Brookes, R., Gamaldo, C.E., Harding, S.M., Lloyd, R. M., Marcus, C.L., & Vaughn, B.V. (2016). The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specifications: version 2.3. Darien, IL: American Academy of Sleep Medicine.
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I have REM related sleep apnea (nearly all RERA). As a result, I barely qualify for a machine through insurance (in my case Medicare) because my apnea is so limited. I think they fudged my data to avoid additional paperwork. I would have qualified for a machine anyway due to low oxygen from a heart problem.

Honestly, this is a case where an APAP is ideal because pressure is low most of the night, only rising during the REM or Near REM period, then dropping low again. I found Respironics 560 didn't work for me, but the Resmed S9 and Airsense handles it just fine. Not sure how a bipap would be an improvement on this issue specifically.
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I think if the person has desats that are of concern and/or symptoms of sleep disturbed breathing in addition to their REM related apnea that they should definitely be treated. There are probably some other comorbidities that should necessitate treatment but I am not aware of them off the top of my head.

I think you are selling the Resmed auto machines short when you make the statement that the auto machines can not react quickly enough.

Of course, you could always attach sensors to their eyelids and when rapid eye movement is detected give the person a jolt of electricity to take them out of REM. That would fix it! .....Just kidding.


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After writing this up and posting it, I've gotten some feedback, and they are trending to exactly what you are saying! The Respironics and Fisher/Paykel auto-paps do no increase or lower pressure fast enough, while the Resmed treats much more quickly. I am trying to find some controlled clinical trials or any study data that may indicate that the Resmed algorithm is optimal in auto concerning "REM-related" events.
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(04-17-2017, 08:08 PM)thecpapguy! Wrote: After writing this up and posting it, I've gotten some feedback, and they are trending to exactly what you are saying! The Respironics and Fisher/Paykel auto-paps do no increase or lower pressure fast enough, while the Resmed treats much more quickly. I am trying to find some controlled clinical trials or any study data that may indicate that the Resmed algorithm is optimal in auto concerning "REM-related" events.

I have what you're looking for, but note that Resmed sponsored partial funding for this study. http://openres.ersjournals.com/content/1/1/00031-2015 

You can recognize the Resmed algorithm compared to the others very readily.  The purple and blue lines are both Resmed standard and soft responses.

[Image: F3.large.jpg?width=800&height=600&carousel=1]
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Er ... 

Check the spelling in 3rd paragraph, 1st sentence.
Please organize your SleeyHead screenshots like this.
I'm an epidemiologist, not a medical provider. 
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thecpapguy and Sleeprider, it's discussions like this that are the reason I check the board so often. Great information and thought provoking. I now understand much better how the algorithm of different manufactures treat apneas and why it can be so important to have min pressure set close enough to the pressure required by each individual.

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I found that during some periods in the night I show a different breathing pattern than at others, and have come to believe these are while I am in REM sleep.  While I am in those periods, my breathing is more erratic, but does not trigger many event counting.  I have seen others that Geiger out during transition to those same periods.  I am sure glad I am not suffering that, and sorry for those that do.

There are some studies that found that breathing feedback loops become less sensitive or somewhat lethargic during REM sleep.  So, for example, the amount of CO2 can rise a bit more before the brain whispers breathe.  Breathing can become shallow and a bit more rapid (TV may drop as much as 20%, but MV usually remains nearly constant.)

Hope this idea finds some application in your current work.

Do you know what is the initial trigger for REM related apneas, and are they mostly OA or CA?


Dedicated to QALity sleep.
You'll note I am listed as an Advisory Member. I am honored to be listed as such. See the fine print - Advisory Members as a group provide advice and suggestions to Apnea Board administrators and staff concerning Apnea Board operation and administrative policies. Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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With the resmed test, you have to take into account that the machines were used in their out of the box default states. So were not tweaked for best results for the test conditions.

I've got a resmart auto 3b as a spare. There is a sensitivity to events, setting that can be boosted to 5. You can also put it in auto titrate mode and double the speed of rise to events, flow restrictions, obstructive is 2 events in 3 minutes, hypopnea 3 in 3 minutes.. Although a chinese clone and a bit of a brick. I think it's a better machine than indicated in this test. As an aside I read that Resmed won a court case on resmart cloning, resmart is paying a per unit royalty, as part settlement.
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If you're writing the article in Microsoft Word, there is a "F-K Score" checker you can use to make the composition more readable.

Here's a link to instructions however Google is your friend.

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