periodic leg movement

[Damiansd]

"You guys are doing a great job with this thread. Damiansd, you are a wiki editor. Any intereste in putting some of this into a wiki so you can refer to it in the future?" -  Sleeprider

great idea.  they say the reward for good work is more work, Damian!

I shall get busy eh.

[Sleeprider]

If you need help, we'll see you in the Wiki Editor forum

[kappa]

as far as I know, we use pressure and pressure support for inspiratory flow limitations.  my vague recollection of the occasional references to expiratory flow limitations on this site led me to think there is little pap can do for these.  in contrast, if I'm reading it right, the quoted sections seem to suggest higher pressure - higher than necessary for flow limitations (I didn't see 'inspiratory flow limitations' above, just 'flow limitations') - will resolve these expiratory flow limitations and plm too?

I've always interpreted abbreviated below-the-zero-line flow rate as mouth leaks.  dark squiggles below zero suggest expiratory snoring.  what else would one look for to identify expiratory flow limitations?

Hi sheepless.

My interpretation of the paper is that the flow limitations they are eliminating with higher pressure are inspiratory, since they are looking at the shape of the inspiration flow curve: "Abnormal breathing patterns were identified and labeled not only according to AASM criteria, but also with a marking of “flow limitation” as defined in the literature. 16,19". [19] is "Analysis of Inspiratory Flow Shapes in Patients With Partial Upper-Airway Obstruction During Sleep" - https://doi.org/10.1378/chest.119.1.37

It seems they are using straight CPAP, manually controlled by sleep tech, with no exhalation relief mentioned.

Another interesting observation from the paper is that "In 1989, Fry et al [10] were the first to show that PLMs could be noted not only during baseline diagnostic recording but also during nasal CPAP titration, emphasizing that the PLM count was higher in the nasal CPAP titration night than during the baseline night and that the PLM count had increased between the initial nasal CPAP titration and the follow-up performed months later, with the persistence of abnormal sleep; this finding was confirmed by others. [23,24]".

I've been experimenting with measuring my leg movement and here's some results from last night where I tried a higher pressure. It was rather unpleasant and leg movements ("Inclination" graph) increased with PAP apart from a few windows (23:00-23:25, 23:32-23:45, 00:38-01:01). I gave up and went stopped PAP at 2:30 but there were still quite a few leg moments and position changes ("Orientation") even then:
   
Even in a half awake state I was having major leg twitches every 20-40 seconds...

[Illorum]

I think it only makes sense that they're talking about both inspiratory and expiratory: otherwise there wouldn't be the increase in gastric pressure they mention. We breathe through negative pressure to inhale and positive to exhale, so if there's a buildup of positive pressure in the stomach, that means you are having trouble exhaling. If the airway is collapsing, its difficult to both inhale and exhale. Your PLMs do seem to be coinciding with obstructive events.

[sheepless]

great comments, keep them coming! not sure what to make of if yet but hoping there's something useful for minimizing plm in there somewhere. since high max pressure hasn't helped my plm related flow limitations between kicks, I think I'll try ratcheting up min pressure support beyond what I've tried so far. I agree with the earlier comment that even if it works, the cure might be worse than the problem, if followed by aerophgia and leaks, for example. only one way to find out!

[Sleeprider]

Kappa, your last chart would have us looking very seriously at using a soft cervical collar. The pattern may be in part due to PLM, but the heavy clusters of OA, flow limitation and RERA are really taking us to positional apnea. http://www.apneaboard.com/wiki/index.php...onal_Apnea

[Shulamet]

Not sure where to post, but eventually will have to deal with the PLMS component so  for those who also have it it may save me some experimenting.
My major concern is EDS always.............been on Adderall for years and its not helping.

Average pressure  first month 2018 when original setting was 4-20cm - AHI 5.9  mean pressure 7.1 average @90% 9.1cm 

I had titration study 3/19/20, tech did not review my data ( had APAP for two years with no pressure adjustments) AHI was never below 5,  tech stopped raising the pressure at 8  because "stopped snoring". 
 He set my APAP to CPAP 8.

Report showed  54 .9 PLM  Index ( no RLS) 13 total PLMS Arousals and index of 2.1 per hour

 I reset Dreamstation  to 7-14  then a Dr set it 10-14.  My AHI are still erratic.  I have developed periodic rhinitis. 
Under 5 AHI  seen more often with 10.2 average pressure and 11@ 90%.  
However my original settings of 4-20cm resulted in mean pressure of 7.1cm and average @90% was 9.1

My study attachments are to large....wasted time so here is a summary.

A different Dr  recently mentioned  she saw Central Sleep Apnea  without elaboration.

Original study 11/17: was 59 apneas -   44 obstructive-15 Central- 0 mixed-    29 hypopneas
Titration 3/19/20 :                               0 obstructive-   3 Central     -1 mixed-  2 hypopneas 4 RERA (AHI 1 per hour)
Report 4/2/20: from SD AHI :               2.4 obstructive  1.8 Central                 3.7 hypopnea index           
                                         6.8 on APAP- 90% 9.9 ( AHI 9.2 on CPAP at 8cm) they increased to 10cm

Should I set pressure to 7-12?  I am concerned that too high is causing Central and Rhinitis . Why are they trying to set it at a CPAP pressure? Is that to get a MSLT study next?
What questions should I ask at next appointment? Over 2.5 years and not  titrated....I need to know what rx to take for EDS, if I need a AVS or Bipap and to know how PLMS fits in.

[Sleeprider]

An Oscar chart or two is going to be a big help to better understand the events and how they respond with current settings. While this thread is good for discussing PLM I really think you should start your own therapy thread.

[kappa]

Kappa, your last chart would have us looking very seriously at using a soft cervical collar.  The pattern may be in part due to PLM, but the heavy clusters of OA, flow limitation and RERA are really taking us to positional apnea. http://www.apneaboard.com/wiki/index.php...onal_Apnea

Hi Sleeprider,

I believe I was wearing my collar that night (need to keep better notes on that). I believe the OA's are misclassified, not sure about the others. 

I'm seeing similar stuff tonight, where I was definitely wearing the collar. All of the events appear to be associated with periods of leg movement...
   

Tonight I'm experimenting with C-Flex mode on the Respironics which seems to be more comfortable for me than A-Flex or no EPR, and I thought it was helping but the data suggests not. But that discussion belongs back on my treatment thread...

[sheepless]

Shulamet, how plm fits in & what to do about it is what I hope we're doing in this thread.

I don't pretend to know much about the subject but in my experience so far pap has had no bearing on my plm other than to complicate apnea treatment. only meds have helped & even then only partially.

googling EDS returned a connective tissue problem. is that right? if so, & if I understand correctly that you are taking adderall for it, I wonder what that does for you. adderall is amphetamine, to my knowledge used for adhd & masking sleepiness.

if you post some oscar charts in your thread, Sleeprider & others can help you titrate to optimize your apnea treatment.

meanwhile, my suggestion is to ask your gp or family doc for help with plm. just show them your sleep study notes documenting them.