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UARS / Irregular breathing pattern
#1
UARS / Irregular breathing pattern
I am two months into APAP now, trying to treat an assumed UARS condition. Two nights in the sleep lab revealed only a small number of apnea but a large number of arousals, so they suggested to "give it a try" (non sleep-related causes are pretty much checked, nothing could be found.) Unfortunately, my daytime sleepiness has not improved at all, and I feel quite desperate about it.

I look at my data every day, and I am certain that obstructive apnea (if any) are under control. There are some minor clusters of central apnea when changing between wake and sleep, but I think that's kind of normal. My ResMed indicates some flow limitations that I could reduce by increasing the minimum pressure to 7.

The one thing that irritates me the most is this strange kind of irregular breathing pattern shown in the image below. It appears that about every 20 seconds I take one breath that is significantly stronger/sharper than the others. This can go on for minutes/hours. I do have phases of totally regular breathing, too. But there is not a single night without the irregular pattern.

Does anybody have an explanation for this? Do you find a similar pattern in your data?


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#2
RE: UARS / Irregular breathing pattern
The closeup of the flow rate is useful, but I really need to see a more complete graph of your daily results with events, flow, pressure, flow limitations, and leaks, along with the respiratory and machine information in the left column. There is a link in my signature links showing how to Organize your Sleepyhead graphs. UARS infers that your problem will consist of flow limitations, and your most important tool to deal with that is EPR, as well as pressure.
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#3
RE: UARS / Irregular breathing pattern
Thank you, here are my past two days.


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#4
RE: UARS / Irregular breathing pattern
My impression is that with fairly low pressure, respiration is close to normal. There is some evidence of inspiratory flow limitation, but it is mild enough that pressure is not being driven higher, with some minor exceptions. There is some sleep fragmentation and your time in therapy is fairly short at 4-6 hours. You have what appear to be recovery breaths with larger volume and flow rate approaching 40+ mL/sec, followed by a series of lower flow breaths in the 26 to 30 mL/sec range. I also see a drop in flow immediately before inhale that is probably also present on the mask pressure. This is caused when the trigger for IPAP lags behind your effort, and can be addressed in the Aircurve 10 Vauto using higher trigger sensitivity, but this is not an adjustment on the Airsense 10.

It's hard to say whether you would benefit from higher lower pressure, but it seems like a worthwhile experiment to see if it yields better or more comfortable results.
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#5
RE: UARS / Irregular breathing pattern
Sleep fragmentation: I have always been a light sleeper and used to wake up 2-3 times per night. I don't know why. This has become worse with CPAP, I wake up 4-6 times now, but usually have no trouble falling asleep again. After 4-6h of wearing the mask I get so annoyed by all of it - then I spend the rest of the night without the mask. I know I shouldn't do that and am trying to improve on this.

Recovery breaths: Is there a theory why someone would have those recovery breaths? My SpO2 looks fine throughout the night... And could it be that the recovery breaths have a negative impact on sleep quality?

Inhale flow drop: I just checked the mask pressure graph (attached) and I think it shows exactly what you describe. Is this something that is likely to affect sleep quality or is it a minor issue? It should not happen if I turn off EPR, right?

I am slowly trying different settings hoping to get to a situation that makes me feel better. I started pressure at 4 but quickly increased it to 6 because I had the feeling that I just don't get enough air below 6. Then I increased to 7 and found the frequency of flow limitations to go down by almost 50%. Just recently I increased to 8 but I did not observe any further changes yet.


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#6
RE: UARS / Irregular breathing pattern
nevermind: I don't know if this applies to you but you might add it to your list of possible explanations to consider.

did they check you for periodic limb movement?

the pattern you show in your first post looks very similar to one that is prevalent throughout my flows. after getting a copy of my detailed sleep study results I discovered that I had a number of periodic limb movements I wasn't told about, the vast majority of which caused arousals. since then I have associated reports from my wife of my periodic limb movements with times this pattern appears. it's is quite regular or uniform. in my case about 4 to 9 breaths followed by a spike (if it's 4 it's always 4ish for the duration of that plm 'attack', but the next period of plm's same night may a different number of breaths between spikes). in my case the exhale side of the spike is often but not always followed by what looks like a snore but is a moan/groan. so I get a body/leg jerk, sharp inhale in response, followed sometimes by a complaining moan.

I also suffer from fragmented sleep with flows that look a lot like yours with 5 or so awakenings sufficient for me to remove the mask and turn off the machine for a bit. (I am also aware of many shorter awakenings that I ride out without stopping therapy.) having reduced my ahi to mostly under 1, I am convinced that many of my remaining awakenings are caused by the leg movements.

did you have a sleep study and did it identify any periodic leg movements?

have you observed the pattern in question leading up to the end of sleep sessions before an awakening?

have you noticed if the pressure waveform rises at about the same time as your spikes? this might not be as evident with apap as it is with my resmed asv auto (asv pressure support responses are really fast and swing up and down a lot; if recollection serves, apap is more gradual). with asv I see pressure support rapidly rising with these spikes.

I don't think it's possible to determine from the data if a larger inhale is in response to increase in pressure or if higher pressure is in response to the larger inhale. the former might be considered a recovery breath, particularly if it's preceded by a fairly substantial flow limitation. I think recovery breaths are more likely to follow a full or partial apnea or hypopnea. my spikes, and maybe yours, look too regular and don't have obvious breathing related precursors.

do you notice restless legs while awake? rls and plm are often but not necessarily associated.

it's not possible to know without help whether you have plm issues. someone else has to observe it or you can use a video recording camera to see. while far from definitive, an audio recording can help too (I have heard sounds I associate with kicking).

walla walla has suggested that some physical movements and maybe some spikes are the result of our struggles to breathe. it's a fair suggestion. before treatment I thrashed a lot and made strange noises. but in my case since my ahi is pretty good now, I don't think that's as much of an issue as it once was.

in my case the evidence is pretty strongly suggestive of plm being the source of my flow pattern (similar to yours) but I can't be certain without a camera. I'll be curious what you end up concluding in your case.
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#7
RE: UARS / Irregular breathing pattern
This is interesting: Actually my sleep doc mentioned that there was substantial PLM in my sleep study! However, she assumed that my arousals were likely to be related to breathing, so I did not give the PLM thing a second thought (and she did neither). Also, I do not notice restless legs while awake. So I went down the UARS path, started CPAP, and forgot about PLM.

If your theory is correct and the spikes are actually related to PLM, then this would mean the following to me (just a wild guess):
  • The limb movements would be the primary cause and not an effect of a breathing disorder. (Because the breathing apart from the spikes looks quite regular.)
  • The limb movements would occur so frequently that I expect them to impact my sleep quality badly.
Concerning the waveform:
  • The spiky pattern is so common that I cannot directly associate it with the ending of a sleep session or an awakening
  • Looking at the mask-pressure waveform I do generally not see pressure spikes associated with the flow spikes. An exception to this are the most extreme flow-spikes, they are sometimes accompanied by (smaller) pressure spikes.
Now given that there was substantial PLM in my sleep study and that I don't feel better at all using CPAP I think it makes sense to take a closer look at the PLM issue now.  I will discuss this with my sleep doc in our next meeting. The standard procedure against PLM is to take some Dopamine modulating medication, right? This is probably something that should be carefully considered... Thinking-about
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#8
RE: UARS / Irregular breathing pattern
The leg movement explains the jagged irregularities in your breathing. I should have picked up on it, but good job by sheepless to see it and bring it into the conversation. This sounds like a good path forward. Please keep us posted. Your solutions can help others that come to the forum with similar problems.
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#9
RE: UARS / Irregular breathing pattern
(03-16-2019, 06:05 AM)nevermind Wrote: This is interesting: Actually my sleep doc mentioned that there was substantial PLM in my sleep study! However, she assumed that my arousals were likely to be related to breathing, so I did not give the PLM thing a second thought (and she did neither). Also, I do not notice restless legs while awake. So I went down the UARS path, started CPAP, and forgot about PLM.

If your theory is correct and the spikes are actually related to PLM, then this would mean the following to me (just a wild guess):
  • The limb movements would be the primary cause and not an effect of a breathing disorder. (Because the breathing apart from the spikes looks quite regular.)
  • The limb movements would occur so frequently that I expect them to impact my sleep quality badly.
Concerning the waveform:
  • The spiky pattern is so common that I cannot directly associate it with the ending of a sleep session or an awakening
  • Looking at the mask-pressure waveform I do generally not see pressure spikes associated with the flow spikes. An exception to this are the most extreme flow-spikes, they are sometimes accompanied by (smaller) pressure spikes.
Now given that there was substantial PLM in my sleep study and that I don't feel better at all using CPAP I think it makes sense to take a closer look at the PLM issue now.  I will discuss this with my sleep doc in our next meeting. The standard procedure against PLM is to take some Dopamine modulating medication, right? This is probably something that should be carefully considered... Thinking-about

This thread is, overall, most interesting, to me; but particularly this post. All concerns and questions here are so familiar in my own case, particularly the first two bulleted items and their connection with my sleep motions. (Context: My AHI is now generally less than 0.5 and OA, was once very high, and is now infrequent unless I (a side sleeper by necessity) roll into anything approaching supine position. I learned the need and how to prevent supine sleep from use of an accelerometer to document and graph my sleeping positions and motions. The link below shows my most recent post of the X16-1D's graphed data.)


Before doing anything more (like getting a VPAP or trying more to assess sleep disturbances from my snores and sleep motions or the motions' causes--PLM?) I await a follow up visit, April 4, with a pulmonologist. He has a sleep clinic and will review with me the results of his initial breathing tests he ordered at a local hospital's pulmonary center. I too, as in the thread linked below, believe my sleep, much improved as it is, is far from what it could be despite my cutting RDI down from near 60.)

Graphics depicting sleep motions in the thread I started here, http://www.apneaboard.com/forums/Thread-...AHI-is-low show a lot of FR spikes, most of which are at Snores, even lesser ones (on most nights), and the FR spikes are almost always matched by some degree of bodily movement. I expect to dig into the motions matter more if the MD session is inconclusive; he is reputed to be the best in our area and my hope is high.

It seems likely that you knowledgeable and analytical participants in this thread and in these precincts could tease some useful conclusions out of my new sleep tool's graphics. I might heed to post some zoomed in views to help. Please, one or all, take a look. Here and now I haven't begun to wring everything out of this this interesting and on point thread: so much about wave forms and timings that I'm presently unschooled in. But I want to be armed with the best questions for the pulmonologist and your help would be appreciated . Further, after seeing its use, [b]nevermind [/b]might find that an accelerometer would be a worthwhile help[b].[/b] 


Anyway, NM and all, thanks for the enlightening thread.

2SB
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#10
RE: UARS / Irregular breathing pattern
(03-16-2019, 06:05 AM)nevermind Wrote: This is interesting: Actually my sleep doc mentioned that there was substantial PLM in my sleep study! However, she assumed that my arousals were likely to be related to breathing, so I did not give the PLM thing a second thought (and she did neither). Also, I do not notice restless legs while awake. So I went down the UARS path, started CPAP, and forgot about PLM.

If your theory is correct and the spikes are actually related to PLM, then this would mean the following to me (just a wild guess):
  • The limb movements would be the primary cause and not an effect of a breathing disorder. (Because the breathing apart from the spikes looks quite regular.)
  • The limb movements would occur so frequently that I expect them to impact my sleep quality badly.
Concerning the waveform:
  • The spiky pattern is so common that I cannot directly associate it with the ending of a sleep session or an awakening
  • Looking at the mask-pressure waveform I do generally not see pressure spikes associated with the flow spikes. An exception to this are the most extreme flow-spikes, they are sometimes accompanied by (smaller) pressure spikes.
Now given that there was substantial PLM in my sleep study and that I don't feel better at all using CPAP I think it makes sense to take a closer look at the PLM issue now.  I will discuss this with my sleep doc in our next meeting. The standard procedure against PLM is to take some Dopamine modulating medication, right? This is probably something that should be carefully considered... Thinking-about

This thread is, overall, most interesting, to me; but particularly this post. All concerns and questions here are so familiar in my own case, particularly the first two bulleted items and their connection with my sleep motions. (Context: My AHI is now generally less than 0.5 and OA, was once very high, and is now infrequent unless I (a side sleeper by necessity) roll into anything approaching supine position. I learned the need and how to prevent supine sleep from use of an accelerometer to document and graph my sleeping positions and motions. The link below shows my most recent post of the X16-1D's graphed data.)


Before doing anything more (like getting a VPAP or trying more to assess sleep disturbances from my snores and sleep motions or the motions' causes--PLM?) I await a follow up visit, April 4, with a pulmonologist. He has a sleep clinic and will review with me the results of his initial breathing tests he ordered at a local hospital's pulmonary center. I too, as in the thread linked below, believe my sleep, much improved as it is, is far from what it could be despite my cutting RDI down from near 60.)

Graphics depicting sleep motions in the thread I started here, http://www.apneaboard.com/forums/Thread-...AHI-is-low show a lot of FR spikes, most of which are at Snores, even lesser ones (on most nights), and the FR spikes are almost always matched by some degree of bodily movement. I expect to dig into the motions matter more if the MD session is inconclusive; he is reputed to be the best in our area and my hope is high.

It seems likely that you knowledgeable and analytical participants in this thread and in these precincts could tease some useful conclusions out of my new sleep tool's graphics. I might heed to post some zoomed in views to help. Please, one or all, take a look. Here and now I haven't begun to wring everything out of this this interesting and on point thread: so much about wave forms and timings that I'm presently unschooled in. But I want to be armed with the best questions for the pulmonologist and your help would be appreciated . Further, after seeing its use, [b]nevermind [/b]might find that an accelerometer would be a worthwhile help[b].[/b] 


Anyway, NM and all, thanks for the enlightening thread.

2SB
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