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optimizing pressure for CA's and arousals
#1
optimizing pressure for CA's and arousals
Hi, I'd like to get tips on optimizing my pressure for a Resmed Airsense 11. I've been using it for over a year, but I have problems getting refreshing sleep even though the AHI is well below 5. My events are mostly clear airway (CA), but I have intermittent early morning arousals, with difficulty falling back asleep.

I tried using the range 5-10 as recommended by the titration study below, but that led to worse results than what I was previously getting based on trial and error. This used the range 13-14 w/ EPR2 and yielded an average AHI of 1.47 for 137 days. (I had sent the OSCAR reports for the previous year to the nurse before the study, and she said that this was a reasonable setting. She didn't think the titration study was needed, but I was hoping it would shed light on my CA's.)

I'm now experimenting with the range 15-18 w/ EPR2 to see if that helps with early morning arousals, because many seem to coincide with pressure increases. The results are better with an average AHI of 0.80 for 19 days. However, the quality of sleep doesn't seem to be improved.

As an aide, I do have PLM (periodic limb movement), as noted in the study. I take Gabapentin, Tizanidine, and other medication for a lumbar injury, but the effects are marginal.

Best,
Tom

................................................................................

Excerpt from Titration study:

THERAPEUTIC POLYSOMNOGRAPHY REPORT

Hypopneas were scored per AASM Hypopnea definition VIII 4B (4% desaturation}

Summary:

ECG: sinus bradycardia (average HR of 48) with rare PVC (epoch 293)
Patient used CPAP mouth tape to prevent leak

DX: OSA (G47.33)

Impression:

1. CPAP was initiated at 4 cm and increased incrementally to 6 cm
   a. 6cm was effective in preventing obstructive breathing and snoring in the lateral position
   b. At CPAP of 6 cm, lateral REM AHI was. Oxygen saturations remained stable and above 90%. Mask
      and pressure were well tolerated
   c. Supine REM occurred only at 4 cm, with supine REM AHI of 15.4 and SpO2 nadir of 92%. The majority
      of supine REM events were central in nature
   d. Oxyhemoglobin saturation within normal limits -oxygen nadir 92%
   e. No audible snoring was reported at optimal/final

2. Frequent periodic limb movements were present with few associated arousals. PLM index 47.2, PLM arousal
   index 1.4
3. N3 sleep was absent and REM percentage was within normal limits, with REM percentage of 25.5%
4. Primarily supine sleep noted; supine TST 79.27%. No supine sleep occurred at 6 cm
5. Normal sleep and REM latencies noted. Sleep latency 6.5 minutes; REM latency 71.5 minutes
6. Possible REM Alpha intrusion is noted

Recommendations:

APAP 5 cm—10 cm.


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#2
RE: optimizing pressure for CA's and arousals
I know it's not what you want to hear, but your chart actually looks great.  Your CAs are few in number and nothing to worry about.  The only thing I can suggest is that you raise your EPR to 3.  That may make you more comfortable and will drop your already low flow limits even lower.  As to early morning wake-ups, there's not much I can suggest.  Here's a link to sleep hygiene practices that may help improve your sleep:

https://www.apneaboard.com/wiki/index.ph...ep_hygiene  Smile
Machine:  ResMed AirCurve 10 Vauto
Mask:  Bleep DreamPort Sleep Solution
Post Reply Post Reply
#3
RE: optimizing pressure for CA's and arousals
What about the report for the actual initial sleep study? Mentioning because you are concerned over CA, of which if this OSCAR is a reasonable representation, is of little concern. In other words, if the CA average like this, they're not going to be a big deal. I'd probably turn Min pressure down slightly and add EPR 3 full time.

Back to the sleep study, you're in the US, so HIPAA law says you can request and receive it. Even the detailed one. If they refuse, report them to your local or regional medical board.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: optimizing pressure for CA's and arousals
(07-05-2024, 11:44 AM)Deborah K. Wrote: I know it's not what you want to hear, but your chart actually looks great.  Your CAs are few in number and nothing to worry about.  The only thing I can suggest is that you raise your EPR to 3.  That may make you more comfortable and will drop your already low flow limits even lower.  As to early morning wake-ups, there's not much I can suggest.  Here's a link to sleep hygiene practices that may help improve your sleep:
Thanks. I'll review the hygiene steps: my main culprit is sleeping in on weekends. I'll try EPR3: previously it led to issues, which I believe was increased leaks. (I thought I took notes on the reason.)

The 4th was a much better than normal day (AHI=0.25): I chose it to contrast with the case using the recommended settings, for which screenshots are now attached (AHI=4.77). Although a bit worse than typical, it illustrates the clusters that tend to occur.


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#5
RE: optimizing pressure for CA's and arousals
(07-05-2024, 12:37 PM)SarcasticDave94 Wrote: What about the report for the actual initial sleep study? Mentioning because you are concerned over CA, of which if this OSCAR is a reasonable representation, is of little concern. In other words, if the CA average like this, they're not going to be a big deal. I'd probably turn Min pressure down slightly and add EPR 3 full time.

Back to the sleep study, you're in the US, so HIPAA law says you can request and receive it. Even the detailed one. If they refuse, report them to your local or regional medical board.

Below is the diagnostic report (i.e., without CPAP), which is quite detailed. There was only one CA, but they seem to be a relic of treatment.

Attached is a sample from May 25th with an intermediate pressure range [10-15] with 10 CA's and an AHI of 2.97. It illustrates what happens when I get catch-up sleep.

I'll have to requested details from the titration study. I asked if they had OSCAR-style reports, but said no. (The first study was done at different facility, which is probably the best in town. I had a titration scheduled with them, but it wasn't performed because it was erroneously booked as a split study, and my numbers weren't high enough for it to proceed. The second place is more mom and pop like, so I doubt the report will be so thorough.)

Thanks,
Tom

--------------------------------------------------------------------------------

POLYSOMNOGRAPHY

   Last, First:                    xxxxx, xxxxxx                MRN:                            57135
   Gender:                         Male                         Age (years):                    60
   Weight (lbs):                   132                          DOB:                            07/18/1963

   BMI:                            21                           Scored by:                      xxxxxx xxxxx, RRT-SDS
   Epworth Score:                  5                            Referring:                      Rani Das

   Technician:                     xxxxx, xxxxx                 Interpreting:                   xxxxxxxxxxxxxxx MD JD MPH
   Study Type:                     NPSG                         Ordered Study Type:             NPSG

   Study date:                     09/29/2023                   Location:                       Heart Hospital of Austin




 IMPRESSIONS
          Mild obstructive sleep apnea, moderate in REM sleep - AHI 8.7, REM AHI 18.0
          Significant nocturnal oxygen desaturation - SpO2 min 89%
          Treatment is recommended for patients with symptomatic OSA with an AHI of > 5 (AASM Guidelines, J Clin Sleep
          Med 2009;5(3):263-276)

 DIAGNOSIS
          Obstructive sleep apnea (G47.33)

 RECOMMENDATIONS
          Follow up with sleep specialist to review symptoms, findings, and treatment options




 CLINICAL INFORMATION
 The patient was referred for evaluation of suspected sleep apnea.

 MEDICATIONS
 Levothryoxin, Gabapenin, Clonazepam, Eszopilone, Propanolol, Tizanidine

 SLEEP STUDY TECHNIQUE
 The patient underwent an attended overnight Level one polysomnography. The following variables were monitored:
 EEG (F4-A1, F3-A2, C4-A1, C3-A2, O1-A2, O2-A1), EOG, submental and leg EMG, ECG, oxyhemoglobin saturation by
 pulse oximetry, thoracic and abdominal respiratory effort belts, nasal/oral airflow by pressure sensor, body position
 sensor and snoring sensor.

 Hypopneas were scored in accordance with AASM Hypopnea rule 4B (4% desaturations).


 TECHNICAL COMMENTS
 NPSG ordered and performed. 4 REM periods observed. Patient tolerated study well.


 SLEEP ARCHITECTURE
 The study was initiated at 9:23:48 PM and terminated at 4:45:54 AM. The total recorded time was 442.1 minutes. EEG
 confirmed total sleep time was 270.3 minutes yielding a sleep efficiency of 62.4%. Sleep onset after lights out was 43.8
 minutes with a REM latency of 66.5 minutes. The patient spent 12.1% of the night in stage N1 sleep, 54.8% in stage N2
 sleep, 4.8% in stage N3 and 28.3% in REM. Wake after sleep onset (WASO) was 119.0 minutes. The Arousal Index was
 13.1/hour.


 RESPIRATORY PARAMETERS
 There were a total of 39 respiratory disturbances out of which 33 were apneas ( 31 obstructive, 1 mixed, 1 central) and
 6 hypopneas. The apnea/hypopnea index (AHI) was 8.7 events/hour. The central sleep apnea index was 0.2
 events/hour. The REM AHI was 18.0 events/hour and NREM AHI was 5.0 events/hour. The supine AHI was 8.7
 events/hour and the non supine AHI was 0 supine during 0% of sleep. Respiratory disturbances were associated with
 oxygen desaturation down to a nadir of 89% during sleep. The mean oxygen saturation during the study was 96%. The
 cumulative time under 88% oxygen saturation was 0.0 minutes.

 LEG MOVEMENT DATA
 The total leg movements were 326 with a resulting leg movement index of 72.4/hr .Associated arousal with leg
 movement index was 2.4/hr.

 CARDIAC DATA
 The underlying cardiac rhythm was most consistent with sinus rhythm. Mean heart rate during sleep was 54.9 bpm.

Procedure
Polysomnography was conducted on the night of 9/29/2023. The following parameters were monitored: frontal, central and occipital
EEG, electrooculogram (EOG), submentalis EMG, nasal and oral airflow, anterior tibialis EMG, body position and electrocardiogram.
Additionally, thoracic and abdominal movements were recorded by inductance plethysmography. Oxygen saturation (SpO2) was
monitored using a pulse oximeter. Hypopneas were scored per AASM definition 1B; ≥30% flow reduction lasting ≥10 seconds
associated with a 4% desaturation.


Sleep Data
LIGHTS OFF (LO) : 9:32:00 PM                                  LIGHTS ON (LON) : 4:45:06 AM
LATENCIES              From Lights Off (min)
Sleep Onset            43.8 min
N1 :                   43.8 min
N2 :                   47.3 min
N3 :                   173.3 min
REM :                  110.3 min

DURATIONS
Time in Bed:            433.1 min
Sleep Period Time:      389.3 min                             Sleep Efficiency:                 62.4%
Total Sleep Time:       270.3 min                             WASO:                             119.0 min
SWS Time:               13.0 min                              TWK Time (tot):                   162.8 min
REM Time:               76.5 min                              Inter-Sleep WK:                   30.6%
NREM Time:              193.8 min                             Stage Shifts:                     49
Sleep Stage Distribution
                Episodes      Duration    TIB         TST                            Episodes    Duration          TIB    TST
                  (# of)       (min)      (%)         (%)                              (# of)     (min)            (%)    (%)
 WK (SPT):          12         119.0       ----        ----                   N1 :       17        32.8             7.6   12.1
 WK (TIB) :         13         162.8      37.6         ----                   N2 :       14       148.0            34.2   54.8
  REM:               4          76.5      17.7        28.3                    N3 :        1        13.0             3.0    4.8

 Respiratory Data
                                                                     Unclass.     Central      Obs.
                        CA          OA          MA        Apnea       Hypop       Hypop       Hypop     Hypop*       A+ H       RERA         Total
 Number:                   1          31           1         33          0          0             6           6         39         0          39
 Mean Dur : (sec)        13.0        21.1        36.0       21.3        0.0        0.0          35.7        35.7       23.5       0.0        23.5
 Max Dur (sec):          13.0        37.5        36.0       37.5        0.0        0.0          41.5        41.5       41.5       0.0        41.5
 Total Dur (min) :        0.2        10.9         0.6       11.7        0.0        0.0           3.6         3.6       15.3       0.0        15.3
 % of TST:                0.1         4.0         0.2        4.3        0.0        0.0           1.3         1.3        5.7       0.0         5.7
 Index (#/h TST) :        0.2         6.9         0.2        7.3        0.0        0.0           1.3         1.3        8.7       0.0         8.7
 REM Count:                1          16           1         18          0          0             5           5         23         0          23
 NREM Count:               0          15           0         15          0          0             1           1         16         0          16
 REM Index                0.8        12.5         0.8       14.1        0.0        0.0           3.9         3.9       18.0       0.0        18.0
 (#/h): Index
 NREM                     0.0         4.6         0.0        4.6        0.0        0.0           0.3         0.3        5.0       0.0         5.0
 (#/h):*Above Index Values Based on Total Sleep Time ■ Hypopneas scored based on 4% or greater desaturation ■ UH + CH +OH = Hypopnea Total
 Cheyne Stokes Breathing: None observed during study.


 Oximetry Summary
 Average SpO2 (TST):                       95.50%                         Total Sleep Time 90 - 100%:                    267.20 min
 Average SpO2 (TIB):                       96%                            Percent Sleep Time 90 - 100%                   98.85%
[*]
 # Desaturations:                          20                             Total Sleep Time 80 - 89%:                     0.20 min
 Desaturation Index:                       4.5 /hr                        Percent Sleep Time 80 - 89%                    0.07%
 Min SpO2 Value During TIB:                89%                            Total Sleep Time <88%:                         0.00 min
 Min SpO2 value During TST:                89%                            Percent Sleep Time <88%                        0.00%

 Oximetry Evolution

 Snoring Summary
 Snoring Episodes:                           4
 Snoring Index:                              0.89 /hr of sleep
 Total Time with Snoring:                    1.5 min (0.6% of sleep)


 Leg Movements Summary
                                                       Count              Index (#/h)
 Total Leg Movements:                                  326                72.4
[**]
 PLMS:                                                 297                65.9
 PLMS Arousals:                                        11                 2.4

 Arousal Summary
                               REM                     NREM              Arousals         Awakenings      Ar + Aw           Ar + Aw Index
 Respiratory:                  8                       2                 12               2               14                3.1
 Leg Movements:                11                      6                 18               2               20                4.4
 Snore:                        0                       1                 1                0               1                 0.2
 Spontaneous:                  7                       12                24               0               24                5.3
 Total:                        26                      21                55               4               59                13.1
 Arousal Index:                20.4                    6.5               12.2             0.9             13.1
**Events occurring during Wake are not included in the table above.**

 Body Position Summary
                          Sleep         TST         REM        NREM     CA       OA       MA      HYP      AHI      RERA      RDI        Desat
                          (min)         (%)         (min)      (min)     (#)      (#)      (#)     (#)    (#/h)      (#)     (#/h)         (#)
 Supine                   270.3        100.00        76.5      193.8      1       31        1       6      8.7        0       8.7          21
 Non-Supine                0.00         0.00         0.00       0.00    0.00     0.00     0.00    0.00    0.00        0      0.00         0.00

 Cardiac Summary
 Average Pulse Rate During Sleep (TST):                                        54.6 bpm
 Highest Pulse Rate During Sleep (TST):                                        77 bpm
 Highest Pulse Rate During Recording (TIB):                                    77 bpm

 Cardiac Event Observations
 Type                                                   Yes             No        Rate / Duration
 Bradycardia:                                                                    Lowest HR Scored: 47 bpm
 Unclassified Tachycardia:                                                       Highest HR Scored: 186 bpm
 Sinus Tachycardia During Sleep:                                                 Highest HR Scored: N/A
 Narrow Complex Tachycardia:                                                     Highest HR Scored: N/A
 Wide Complex Tachycardia:                                                       Highest HR Scored: N/A
 Asystole:                                                                       Longest Pause: N/A
 Atrial Fibrillation:                                                            Duration Longest Event: N/A


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#6
RE: optimizing pressure for CA's and arousals
OK thanks, you had minimal Central and mixed Apnea, 1 each on the diagnostic test. So these CA here will likely be treatment emergent based.

Just for a night, either try EPR 1 or off just to see what CA become. It'll likely increase other events, so it'll not be ideal. Report back with OSCAR chart and tell us how you felt differently. And yes this would only based on CA response over one night, so again not an ideal setting scenario.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: optimizing pressure for CA's and arousals
(07-06-2024, 06:00 AM)SarcasticDave94 Wrote: OK thanks, you had minimal Central and mixed Apnea, 1 each on the diagnostic test. So these CA here will likely be treatment emergent based.

Just for a night, either try EPR 1 or off just to see what CA become. It'll likely increase other events, so it'll not be ideal. Report back with OSCAR chart and tell us how you felt differently. And yes this would only based on CA response over one night, so again not an ideal setting scenario.

Sure, I'll try that tonight. (I didn't notice the notification until this morning.)
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#8
RE: optimizing pressure for CA's and arousals
(07-06-2024, 06:00 AM)SarcasticDave94 Wrote: Just for a night, either try EPR 1 or off just to see what CA become. It'll likely increase other events, so it'll not be ideal. Report back with OSCAR chart and tell us how you felt differently. And yes this would only based on CA response over one night, so again not an ideal setting scenario.

I ran into a large-leak issue that skewed the results. See oscar-8jul24-epr1.png. Sleep wasn't good. (I had taken an OTC sleep pill.)

Also, included is the result from the previous night with EPR3. The sleep was better, but I had taken a prescription sleeping pill.

For the sake of a better comparison, I'll try again at EPR1 with the prescription (which I try to moderate).


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#9
RE: optimizing pressure for CA's and arousals
A 4.39% leak is not enough to skew your results, so don't worry about that. What you posted is fine for people to analyze.
Machine:  ResMed AirCurve 10 Vauto
Mask:  Bleep DreamPort Sleep Solution
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#10
RE: optimizing pressure for CA's and arousals
(07-09-2024, 03:41 PM)tomasohara Wrote: I ran into a large-leak issue that skewed the results. See oscar-8jul24-epr1.png. Sleep wasn't good. (I had taken an OTC sleep pill.)

Also, included is the result from the previous night with EPR3. The sleep was better, but I had taken a prescription sleeping pill.

For the sake of a better comparison, I'll try again at EPR1 with the prescription (which I try to moderate).

Hey Tom, the chart with EPR1 looks better, EPR3 needs more pressure to be as affective and to me it was less comfortable, so keep it on 1 for now if you felt okay (less events too). Smile
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