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Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
#1
Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
I appeal to the experts here on ApneaBoard to shed some light on evaluation of sleep arousals: their significance in sleep disturbance even if not resulting in an immediate scoreable event. With more light maybe something can be done to help me and those who write saying their AHI is good but their sleep isn't restful.


In my opinion, I move a lot in sleep, but I don't know what is normal and can only guess Snores trigger most of it. How much they impair my much improved sleep, I can only guess. What I think I see is scoring by the S10 device (via Sleepyhead) where a Hypopnea or Central is sometimes scored  though either portrays a  smaller disturbance than can be seen in the key breathing metrics for unscored spikes mentioned below.


However, the large indications of Snore when I lie down before sleeping and after a break does raise questions about Snore signal validity. Nevertheless, the questions in my mind center on what are significant arousals and what level of them should be addressed if reducing them is possible.

I don't know what the current official sleep scoring manual might say. The following site has a lot about arousals, including how serious they are or are not seen and whether they should be factored into scoring hypopneas. https://www.ncbi.nlm.nih.gov/pubmed/11984311 . The concluding paragraph for that discussion indicates arousals are not to be ignored.

"Hypopnea Summary

"The above discussion outlines the difficulties in choosing a single definition for hypopnea. Although there were dissenters, the task force reached consensus on a definition of a hypopnea rule in adults using a 30% drop in the nasal pressure excursion for 10 seconds or greater associated with = 3% desaturation OR an arousal. The majority of the task force felt that a hypopnea definition based only on desaturation would result in misdiagnosis of some patients in whom respiratory events fragment sleep but result in minor drops in the SpO2. While there seems little doubt that cardiovascular morbidity is associated with oxygen desaturation, the goals of OSA treatment address a much wider range of symptoms including daytime sleepiness, insomnia, and non-restorative sleep. The task force also recognizes that the proposed definition of hypopnea is not currently accepted by the Centers for Medicare and Medicaid Services (CMS) reimbursement. For Medicaid and Medicare patients the use of a hypopnea definition based on a 30% drop in flow and 4% or greater desaturation will need to be used to ensure reimbursement until reimbursement policies are changed to reflect the new hypopnea definition. Following the logic of the proposed revised apnea definition, the requirement that the qualifying drop in flow must occupy > 90% of the event duration was removed from the hypopnea definition."


(Emphasis added)
 
(Context: My use of an accelerometer--a mere position and motion indicating pendulum in my use--has shown me the way to almost totally eliminate scoreable OA events; it provided evidence of mainly positional apnea which motivated stopping anything close to supine sleep.  That done (AHI for past 6 months is 0.3, down from the neighborhood of 60.0 40 months ago), I still have almost continuous Flow Limitations with frequent simultaneous spikes in Snore, Flow Rate, Tidal Volume and (in somewhat fewer instances) spikes in Pulse Rate (as well as, and more importantly, a SpO2 that is a bit low (baseline near 94.5% with mostly 90% to 95% with some higher.) Besides position, the accelerometer shows the wide range of accelerations/jerks/moves it experiences when I move: the trouble being I don't yet have means of knowing how much mass is moving in the sense of energy used (or Work done=Force applied x Distance moved) as an indicator of arousal significance. Of course, a small percentage of the moves are what I'd call comfort seeking moves unaccompanied by the usual spikes.)

All and any help would be appreciated.

2SB
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#2
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
I don't think it is any secret that several of us on the forum focus not only on scored events, but sleep quality indicators like flow limitation as well. Flow limitation is one of the significant indicators of RERA and a sense that treatment is no meeting expectations. Chronic flow limits are often missed or not scored at all in sleep studies. The current state of the sleep industry is that criteria for scoring events and evaluating treatment options are directed by what Medicare or other insurers will approve. Someone that would clearly benefit from bilevel therapy faces an uphill battle in getting the best therapy for their condition. Individuals with severe upper airway restriction syndrom (UARS), complete with chronic low SpO2 may not qualify under Medicare scoring for CPAP or bilevel because their baseline oxygen level is not low enough for oxygen therapy, and does not drop enough to score hypopnea.

All of this means patients are not treated for optimal therapy, or even to meet their needs, but what insurance will approve. There is very little interest shown by most doctors and sleep labs to look at a case outside the box of what is defined as a covered condition, yet there may be very significant health and sleep disruption implications.
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#3
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
(01-24-2019, 09:24 AM)Sleeprider Wrote: Flow limitation is one of the significant indicators of RERA and a sense that treatment is no meeting expectations.  Chronic flow limits are often missed or not scored at all in sleep studies. . . .Someone that would clearly benefit from bilevel therapy faces an uphill battle....  Individuals with severe upper airway restriction syndrom (UARS), complete with chronic low SpO2 may not qualify under Medicare scoring for CPAP or bilevel because their baseline oxygen level is not low enough for oxygen therapy, and does not drop enough to score hypopnea. 
SleepRider, I apologize for being slow to acknowledge and thank you for your full response, which seems spot on in every respect.
In light of the part I quote from you and my OP topic, would you please evaluate the below sample of a particularly bad recent night for me with regard to (both the higher than usual AHI and) my many moves? Does this look like a situation where Bi Level would be appropriate, which I may be reading into your comments? I have an upcoming follow up visit with a true practicing and teaching pulmonologist after having the 2 hours of breathing tests and the chest X-Ray he ordered after my first visit. I'd appreciate getting your insights and your questions for me and for him. If new drugs, a sleep study or a surgery topic come up it would be helpful to know what, if anything, you can see in or recommend from my graphs and comments in this thread.


The fact is I often have more Snores (with their accompanying FR spikes) and more FL with a 0.0 AHI, but I wanted to show a bad night's high frequency of sleep motions, most of them small--none scored. This fact gets to my questions and to your remarks about untreated poor sleep quality arising from unscored disturbances.


Many thanks for clarifying the limitations of treatment. It's great we have ApneaBoard expertise, such as yours, to guide us forward with some seasoned assessments, even when it's the honest "We don't know", when we are outside the treatment box. First things first: The help here has gotten me down from a scoreable RDI near 60 (and OA's of 120 seconds and more) to one near 0.0, but there is much more to do I'm learning, and it may all be out of pocket from here on for me if anything can be done.

2SB


The Graphic:

First a few more words about the upper graphs that are uncommon, though you no doubt understand them. The horizontal red trace shows my Left-Right angles of rotation in side sleeping, the horizontal blue trace shows I am lying down somewhere near perpendicular to the vertical, both roughly measured at the headband on the bill of a cap--the latter being an indication of my chin tilting up and down because of upper body, head and neck-axis movements (as if lying lengthwise on a teeter-totter and rotated in any direction left, right, prone or supine). The green horizontal trace would be on the zero mark of the right vertical axis if it were always centered and aligned perfectly and if I did not move. The short verticals, all colors, show acceleration without regard to the weight of the body part moved: a sudden flick of the finger against the cap, the quick sharp jarring would produce a large acceleration and vertical trace. A slow rotational turn would produce small accelerations though the whole body moved (the significance problem mentioned in OP). The short green verticals show the total acceleration effects of the motions depicted in short red and blue verticals. Tall bars at ends and at the pee break are when sitting on the edge of the bed or off the bed while wearing the recording accelerometer.  

   
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#4
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
So if I'm reading this correctly, you spent half the session on one side (left?) from 3:00 to 7:00, and then turned over to the other side (right?) around 7:00 to the end of session. You seem to have slightly more chin tuck in the latter session or that is an artifact of the sleep orientation. Motion is slightly less active in the latter half and the largest accelerations are all reflected in the CPAP Flow rate chart.

Your Autoset is set to a range of 11.4 to 15.2 with EPR 2. Flow limitation is present throughout the night and correlates well to snore incidents. Flow limitation is higher in the latter half of the night and may correlate with body position or more likely higher angle of chin tuck. The two H events correspond to high flow limitation while on the right? side and appear to relate to some body position movement.

Interesting stuff, and a lot to digest. I'd be interested to hear what you have concluded, and why you are using EPR at 2 instead of 3 which might reduce the FL.
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#5
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
It would be very useful to have sleep stage information in the display so that we would know if the latter half, during which the greater concentration of flow limits takes place, was due to a deeper stage of sleep accompanied by less movement, BUT with more chin tuck or other head angle that was not beneficial....except that it didn't interfere with getting to that deeper sleep state.
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#6
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
(01-29-2019, 09:25 AM)Sleeprider Wrote: So if I'm reading this correctly, you spent half the session on one side (left?) from 3:00 to 7:00, and then turned over to the other side (right?) around 7:00 to the end of session. You seem to have slightly more chin tuck in the latter session or that is an artifact of the sleep orientation. Motion is slightly less active in the latter half and the largest accelerations are all reflected in the CPAP Flow rate chart.

Your Autoset is set to a range of 11.4 to 15.2 with EPR 2.  Flow limitation is present throughout the night and correlates well to snore incidents. Flow limitation is higher in the latter half of the night  and may correlate with body position or more likely higher angle of chin tuck.  The two H events correspond to high flow limitation while on the right? side and appear to relate to some body position movement.

Interesting stuff, and a lot to digest. I'd be interested to hear what you have concluded, and why you are using EPR at 2 instead of 3 which might reduce the FL.

You are correct in all observations and the ones about chin tuck caused me to revisit my worst chart and AHI going back to 8/24/18, as below. Still trying to sleep lateral with the help of a hard-stuffed fanny pack at my back, I was just getting the accelerometer (the plumb bob) data graphing down and saw those OA clusters all in the supine zone and had attributed them and the Snores to my lapsing into supine sleep despite the half-football sized pack at my back. I found a heavy duty but light canvas surveyor's vest with a sewed on, large, rectangular knapsack and filled it with a large cardboard box which does the blocking job. AHI plummeted.

I don't know yet how important the tuck thing is, but will find out (not suspecting a problem after getting my collar and its great help). Tuck is at least guilty by association with the red indicated supine sleep; disturbances are more when the blue line drops much below 90 degrees and are fewer when it's nearest to 90. 


I went looking today for a cervical collar, one wider than my 3.75" (max.) one. Someone on one of these forums was looking for a 4" one and not finding one, so I may have to improvise--try to add a half inch or more.  The small local pharmacy that has hard to find medical tapes and special things checked their supplier catalogue and found the collar width they and I have. One thing to note: The chart below reflects wearing the accelerometer on the front face of the cervical collar, whereas the more recent mount is on a cap's bill. The mounting could be improved a lot, may be a factor and may go back to the collar.

Regarding EPR: I was at 15.2/10.4 and 3.0 after Mar. 2018 until Jan. 11, 2019, when I changed to 15.2/11.4/2.0, jumping the minimum by 2.0 that way. The trial doesn't seem to help with Snore and FL, but I should go back and compare a number of before's and after's--also, I should revisit the FFM, F10, I hated as a totally ignorant newbie: see how the disturbances are there--not so bad when I looked back at a couple after your reply. I got another used S10 for "behind the recliner" and will be trying a Wisp nasal mask.

At the bottom of the graph about 3.5 minutes of the upper FR graph is zoomed-in near 04:30 in that first OA cluster. It depicts what I believe is a bit of palatal prolapse (big words I recently learned here, I think, and explaining this pattern I have seen in short and long strings), some saw teeth (seen from time to time), and (are they/is it?) a kind of wheeze at the end of almost all my expirations.

Your help and the thought from mesenteria are greatly appreciated, as all questions and suggestions will be. Does the rough correspondence of erratic up-down flurries in SpO2 with depressions in perfusion index signal at least a probable change in sleep stage, if no indication of which stage? It seems I often see those moving together.

Thank you, 2SB


    The times in the position graphic are out of step but events are synchronized.
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#7
RE: Unscored (mostly ignored?) sleep disturbance: How to sleep better after AHI is low?
I can see where supine is not your friend here, but it's a tough call whether the problem is supine sleeping or the chin-tuck associated with it. You clearly go farthest off axis when on your back, and all kinds of events break loose. We have a lot of uncertainty around palatal prolapse as it also resembles oral exhale around a mask. I had a cold a week or so ago and could feel my exhale getting cut-off by a post nasal drip until the congestion cleared, so there may be several mechanism that possibly curtail expiration flow, but we know that in some cases PP is real.

You are a lot more analytical about this than most people, but it seems to have resulted in solid solutions. Well done!
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