Sleep Fragmentation

[Eishan]

Nobody has mentioned RERA’s yet AND it appears they are turned off. I have been on APAP for 4 years now and have noticed slow CONTINUOUS progress over the full 4 years. I have gotten my AHI to less than .5 every day. HOWEVER, I still do wake up 4 or times a night. Never do I have to get up but I still wake up. 

It seems the more RERA’s, the more I wake. Still can’t prove a timing relation but I can prove a pressure relationship. They all (almost all) happen at max pressure. 

Because my RDI is so low, I can’t say for sure RERA’s are the answer, but I would turn on RERA and explore that possibility.

What is RERA and how does it function ?
Is it supposed to reduce the number of wake ups during a person's sleep?
How do I turn it on ? ( am using a Resmed Airsense Autoset 10)

Coming back to the question of sleep fragmentation, I was told by a doctor friend that it could possibly be due to a lack of Vit D.
I have checked and coincidently my Vit D levels are indeed low and thankfully i am now on supplements.
Anyone having similar issues ?


Thanks Rcgop

[Eishan]

Your chart looks way better at 13 than it did at 6.4-20.

You might find that you can stay asleep longer if you turn ramp off and let yourself get used to the fixed pressure before you fall asleep.  Fewer changes to deal with.  The feeling of pain in your lungs is something that will go away with time.

If the pressure is too uncomfortable to breathe out against and you simply can't sleep, you could certainly try 9-14.  Or you may be in the same boat as me and need bilevel.    It's a delicate balancing act between comfort and getting the right level of therapy air.

I have posted the additional 3 day charts upon using the fixed pressure of 13.
But I noticed few changes
a. Feeling of aerophagia in the morning is quite apparent although not too severe
b. There have been unexplainable large leaks figures now which were previously 0 during the APAP 6.4-20 period
c. My CA's are now higher that my OA's 

I would probably take your advice and shut off the ramp tonight and maybe reduce the fixed pressure to 12.8 or 12.6 to see if there is any improvement in my sleep and most importantly less wake ups

Thanks geauxdbl

P/S : By the way, can anyone guide me on how to post the entire set of charts for a day in one particular file / screenshot ? Tq

[geauxdbl]

Respiratory Effort Related Arousal. In a nutshell, you don't get enough oxygen (for a variety of possible reasons, frequently flow limit) so your brain wakes you up. But it's not a hypopnea and not an apnea. Hard to quantify without an EEG to tell if you're asleep or awake, but the Resmed algorithm does a decent enough job.

It should show up as its own category of event in OSCAR if it's happening. But if I recall my Apnea Board trivia correctly, wasn't there a problem with earlier Airsense 10 Autoset models not flagging RERA? Mine does but I seem to remember reading this somewhere.

I struggle with these as my biggest source of sleep disruption, and am currently on bilevel with slightly better results. Still a work in progress.

[slowriter]

RERAs aren't necessarily caused by oxygen desaturation; more just a sensitive autonomic system that is sensitive to flow limitations. Effectively, you arouse because your brain is trying to present airway collapse, rather than arousing because not enough oxygen.

Also, in my experience, RERA tracking on Resmed machines is not reliable. You can still have them even if the machine says you don't.

[Geer1]

RERA flagging is not accurate as these machines don't have EEG. You don't turn it on, they just flag them if they think they occur.

I agree that single pressure may be advantageous but 13 seems too high. It isn't a lot of pressure but extra pressure only helps if it is making a difference and I don't think it is helping that much especially if you are having some aerophagia and perhaps the odd central because of it. Higher pressure makes it more difficult to exhale which also promotes mouth breathing which may be the large leaks you are seeing.

I would knock the pressure down to 10 and try that for a bit to see what happens.

I would turn off ramp as well, especially if you are going to keep resetting your machine each time you wake up. Ramp delays treatment and the machine does not flag breathing events when in ramp. You should only use ramp if you need to (can't fall asleep) and you should try to minimize time in ramp.

I would stick with a set pressure for now for one simple reason, you like to turn off machine and that screws up APAP machines as it resets you back to starting pressure and the machine has to work its way back up and it does this by waiting for you to have trouble breathing then increasing pressure slowly. When in APAP mode resetting the machine is a bad habit, in CPAP mode it isn't as effected (not affected at all if you turn ramp off). If you are finding it tough to get to sleep then I would consider lowing pressure back down and using APAP again, say 8-14 but if you do this you should have ramp off and stop turning the machine off.

Collect a few days of data and then lets see some screenshots showing zoomed in views of about 5 minute duration prior to the awakenings. Messing with CPAP settings only helps you if breathing is what is causing the arousal. There are other things that could be causing you to wake up.

[Eishan]

Thanks guys. Advice noted. I would probably lower down my fixed pressure and post some datas in a few days time.
As for the waking up, I am not sure if it is due to either RERA's or breathing issues but one thing for sure, it happens at the end of every sleep cycle and I am assuming this because I will always wake up after completing a dream ( after the REM Sleep stage )

[slowriter]

I just think you need to look more broadly than CPAP. Diet, supplements and drugs, sleep hygiene, etc.

[Sleeprider]

Eishan, it will help us to interpret the charts better if you will include the Flow Limitation and leak charts. This will require you to vertically resize the Events, Flow Rate and Pressure currently showing. We don't need to see both pressure and mask pressure as it is the same thing for our purposes, so move one of those down and out of sight.

At one time I suggested a narrow range of auto pressure from 9 to 14 cm. I still think it would be helpful to see variable pressure and how you respond to it. We could actually use 9 to 13 pressure and see where things fall out. To do this, enter the clinical settings, set Mode to Autoset and select the minimum and maximum pressure. You have been using EPR full-time at 3, and I don't see any reason not to continue that.

I understand you are marking your waking by stopping and restarting the machine. I think this is unnecessarily disruptive to your sleep. Even though you awaken, it is much less disruptive if you just continue to lay quietly and wait for sleep to come, than if you actually power off the machine. I can't imagine what benefit turning the machine off and on might have, and I think it just reinforces fragmentation.

[Dormeo]

Thanks guys. Advice noted. I would probably lower down my fixed pressure and post some datas in a few days time.
As for the waking up, I am not sure if it is due to either RERA's or breathing issues but one thing for sure, it happens at the end of every sleep cycle and I am assuming this because I will always wake up after completing a dream ( after the REM Sleep stage )

Eishan, waking up after REM is pretty normal.  Also people dream in other sleep stages.  The real question to my mind is this:  what are you doing during the long breaks in your night-time sleep?  Are you getting up?  Lying in bed with the machine off?

And again, you will probably make progress consolidating your sleep if you can stop napping, hard though I know that is.  Do you think that is something you can try?

[Rcgop]

Here is what a RERA looks like for me. It appears that I am sleeping prior to and awake shortly after, or at least partially awake. You can turn them on or off with the "Flags" button in the bottom left hand corner of the screen. 

I don't worry about these as I feel I am getting enough sleep and they probably happen at the end of a sleep cycle.