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RDI, Esophagel Pressure, and UARS: Help Interpreting Data

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RDI, Esophagel Pressure, and UARS: Help Interpreting Data

Postby pooped » Sat Sep 22, 2007 2:06 am

Hi all. I'm thankful for finding this board. Thanks in advance for any help!

So, I just underwent a second polysomnogram. The reason for the second study is that I was on some heavy duty psychotropic drugs (one of which is notorious for REM suppression) when I underwent the first polysomnogram. During the first study, my RDI was 5. Nearly all of the respiratory disturbances were during my 45 minutes of REM. Now that I am no longer on the REM-suppressing meds, we figured that the RDI would be much greater (based on extrapolation). My doc also mentioned that I may have UARS. (See http://www.talkaboutsleep.XXX/sleep-dis ... ract13.htm -- replace XXX with com.)

Unfortunately, I had even less REM during the second study -- a mere 5 minutes. However, I had a great number of arousals -- unlike during the first study, when I was Seroquel. I would really appreciate some feedback from the experts on this board. I've tried to perform my own due dilligence, but I am stumped.

Data from Second Study:

***Note, I took regular ambien to fall asleep. I have delayed-sleep phase syndrome, and there is no way I could have fallen asleep otherwise at 10:30 p.m.

Time in bed: 416.5 min.
Sleep time: 317 min.
Sleep efficiency: 76.1 min.
Sleep onset: 13 min.
REM latency: 227 min.

Stage 1: 9.1%
Stage 2: 81.5%
Stage 3: 7.6%
Stage 4: 0
REM: 1.7%

Arousal Index (AI): 40.3
Resp. Disturb. Index (RDI): 34.3
AHI: 2.8

Note, no device was used to measure esophageal pressure, which I believe is necessary to measure respiratory effort related arousals (RERAs). (See link above.) Which leads me to ask how the RDI can be any higher than the AHI? It's my understanding that RDI equals AHI + RERA -- I've read many sleep docs don't consider RERAs, in which case AHI and RDI are one in the same. Based on the RDI of 34.3, I have a diagnosis of severe OSA. According to my own research, I dont believe I have OSA at all, as my AHI is lower than 5. It would appear that I may have UARS, however, I believe this dianosis requires measuring esophageal pressure. (See link above.) Which leads me back to my first question: is there any merit to this RDI number? I cant imagine the tubes in my nose could have meaningfully measure esophageal pressure.

Also note, the RDI is less than the AI, suggesting that something was measuring the nature of the arousals. I think, at least.

Anyone able to offer some insight regarding these issues? I need a real smarty pants. Obviously I have severely fragmented sleep, a lack of REM, and a lack of restorative delta sleep. (That's good to know, as I am always fatigued and exhausted.) I

I really want to know what else I can do to improve the quality of my sleep. Do you think CPAP is waste of time for me? It will be covered by my insurance without any out-of-pocket expense based on this sleep study. I also qualify for an oral appliance, for what that's worth.

Sorry if this is less than coherent. Sleep study was last night, and I'm even more tired than usual.

Again, thank in advance for any insight. (Unfortunately, my sleep doc doesn't give me much bandwidth, so I want to come to the next appointment, armed with information!)

Best,
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Postby Linda » Sat Sep 22, 2007 8:00 am

Hi pooped,

We're not experts. We're not medical professionals or researchers, we're patients like everyone else. I had known abour RERAs, but your question prompted me to Google yet again. A quick (very quick) browse through a couple of sites found by Google has led me to believe that measuring RERAs in a sleep study is not done by measuring esophageal pressure as you described. But I'm not sure from my quick googling exactly how RERAs are measured during polysommography. It seems it's done with the use of the chest bands or the air cannula at your nose or maybe a combination, unless I've misinterpreted what I'm reading. I believe the chest bands measure resiratory effort and the cannula at the nose measures airflow. But how they score the RERAs, well, I'm still learning. All I know is that many sleep study reports give RDI and specifically mention RERAs, and I'm pretty sure they're not using anything in addition to the standard method of polysommoraphy used for measuring sleep apnea.

I googled searching "measuring RERAs" and here are a couple links related to this:
Click here for link
Click here for article - see FAQ

Again, I'm a novice at all of this. Others might be far more knowledgable. But I don't think arousals are all respiratory-related. I think arousals can also include being suddenly woken or semi-woken. Afterall, we sometimes move in our sleep, cough or affected by outside stimuli (a door slamming, etc.). That's why the distinction between all arousals and those that are respiratory-related.

I would guess that if the cpap titration sleep study is ordered on the basis of this sleep study, then that RDI is viewed as significant enough for therapy. Or did you have a split night study where they also measured you with cpap? I'm also guessing you may benefit from cpap. It may help your sleep architecture and make you feel more rested. And while you may not be experiencing drops in oxygen levels as the result of your condition, that doesn't mean your health isn't affected. It's not good for the heart to jumpstart your breathing, however it's done. Oral devices are only good if the obstruction is due to the jaw structure and if you can stand wearing that contraption. lol I would say try cpap first.


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Postby pooped » Sat Sep 22, 2007 5:10 pm

Linda, thanks for taking the time to respond.

Perhaps I did not read up enough on RERAs -- I think the link I posted mentions the balloon catheter as a means of measuring RERAs. I will check the links out that you mentioned. (I may have been partly confused by my insurer's guidelines for CPAP for claimants with UARs, with less than 5 RDI, but more than 10 EEG arrousal -- under these circumstances, esophageal pressure must be below a certain threshold (such that the arousals qualify as RERAs) to qualify for CPAP.

I in fact did have a chest band on, as well as the tubes in the nose, so perhaps the RERAs were measured properly, and the 34.3 RDI is legit. It is also possible that the study discussed in the link I posted (1997) pre-dates advancements in technology used to measure RERAs.

As it seems you may have inferred, there was no issue with my SO2. Average was 94, and it didn't drop below 89.

While I am concerned whether I could ever acclimate to a CPAP, it certainly is worth a try. I have not done a titration yet, as apparently my doc wanted as much data as possible, and therefore he ordered no CPAP in less obvious apnea.

My insurance does not require a titration, so I expect that my doc will prescribe it, and I will go for it. I certainly hope it helps. I've been fatigued and exhausted for nearly 2 years now. And my blood pressure and pulse have been elevated, in spite of me appearing physically fit.

Again, thanks.

Best,
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Measuring RERAs

Postby pooped » Sat Sep 22, 2007 6:29 pm

2007 guidelines provide:

When scoring RERAs, the use of
esophageal pressure is the preferred
method of assessing change in respiratory
effort, although nasal pressure and
inductance plethysmography can be used.

Because the esophageal catheter is found to be very uncomfortable, thereby impacting sleep, many docs prefer to use rely on nasal pressure or abdominal bands, based on my research.
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Postby Linda » Sat Sep 22, 2007 6:54 pm

Thanks for the info, Pooped!

We just gotta get you fixed up and feeling better, so you can change your username! ;-)
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Postby pseudonym » Sat Sep 22, 2007 8:20 pm

Hello pooped!

I was diagnosed with hypopnea/UARS, using a PES (esophageal pressure monitoring). My sleep study prior to that one consisted of everything the same EXCEPT no PES. That first sleep study found NOTHING.

I am not fully clear on exactly what PES does to change the picture, I have an AHI of 53.6 hypopnea/UARS, no apneas and no RERA's. I have an RDI of 86.7 indicating many other arousals believed to be of respiratory effort but not diagnosed.

I am using CPAP and my AHI is averaging 4.4. I am still aware of many awakenings per night -- 10-20 is not uncommon -- I average 3-5 hours sleep in an 8-10 hour period devoted to it. Very fatigued and very sleepy during the day, problems staying awake in meetings at work, while driving (even short distances).

Wish I had some answers for you but I am still looking myself. Please post here anything you find, OK?

Blessings,
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Postby pooped » Sat Sep 22, 2007 8:22 pm

Thanks for your kind words, Linda.

You wrote, "We just gotta get you fixed up and feeling better, so you can change your username!"

Fixed, feeling better AND a disability insurer that will leave me alone, and then I post my real name. ;-)

I am relieved that there is some objective explanation for how I feel. It's "tiring" to be told that it's idiopathic or psychosomatic, or that you're just depressed, etc. Followed by repeated medicine trials, most notably including anti-depressants, stimulants and provigil, none of which result in any material improvement. Indeed, some exacerbate the underlying sleep condition. The longer we go untreated, the worse things get. Lack of delta-stage sleep harms us mentally and physically.

Doctors, particularly primary care physicians and psychiatrists should be required to be better educated about these disorders!

I'm looking forward to trying the CPAP. Hopefully it will make me nicer.

I thought this was an inspiring story. I think I will send it to many of my loved ones.

Best,
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Postby pooped » Mon Sep 24, 2007 8:50 pm

Whoops, I see I forgot the link to the inspiring story: http://www.viasyshealthcare.com/prod_se ... s_uars.pdf
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Postby pooped » Mon Sep 24, 2007 9:02 pm

pseudonym, thanks for the reply. i am a little confused by the data you provided. based on my studies, RDI either equals AHI, or is AHI + RERAs/hr. some doctors measure for RERAs and include them in the RDI, as they are a form of repiratory disturbance. others don't. it sounds to me like you have a ton of hypopneas and definitely have OAS. the other respiratory disturbances are similar to hypopneas, but less severe -- you are aroused before you stop breathing. the remedy (whole or partial) is the same -- CPAP.

it sounds to be like your sleep remains quite fragmented, and you need some medicine. i've taken every sleep med under the sun, including many off label medications. one thing that i find effective, that is said not to interfere with sleep architecture is flexeril. i take 20 mgs. it really helps me, because i have a lot of body pain, as a consequence of some issues with my cervical spine and shoulders.

can you describe the PES for me? that's a means of measuring RERAs. i dont think that was used on me.

feel free to send me a PM if you want to chat about meds.

take care,
pooped.
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Postby pooped » Wed Sep 26, 2007 5:10 pm

Hi Linda.

You are correct, repiratory efforts are determined by chest and abdominal bands and the cannula at the nose. While the PES is the gold standard of determining RERAs, apparently the "poor man's approach" (pretty much used by everyone but Stanford) is by reading the data from the bands and the cannula.

This is how my doc diagnosed me with UARS, today. He prescribed CPAP, so I will be off to the races soon. He suggested that it should bring tremendous relief given the extent of my RDI.

Thanks for your help,
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Postby pseudonym » Wed Sep 26, 2007 5:39 pm

pooped wrote:pseudonym, thanks for the reply. i am a little confused by the data you provided. based on my studies, RDI either equals AHI, or is AHI + RERAs/hr. some doctors measure for RERAs and include them in the RDI, as they are a form of repiratory disturbance. others don't. it sounds to me like you have a ton of hypopneas and definitely have OAS. the other respiratory disturbances are similar to hypopneas, but less severe -- you are aroused before you stop breathing. the remedy (whole or partial) is the same -- CPAP.

Stanford is who diagnosed me and they are not classing my UARS in with RERAs -- I don't know the reason. I will be going back to Stanford again next week, I will ask about that....

Yes all hypopneas although my auto CPAP has recorded a stray apnea now and again. PES monitoring was able to tell them my hypopnea is caused by the length of my airway collapsing partially due to relaxed muscle tissue. I don't have classic obstruction such as thick tongue, small airway, etc. Tonsils and adenoids gone a long time ago. Uvula and soft palate normal and lots of room.

pooped wrote:it sounds to be like your sleep remains quite fragmented, and you need some medicine. i've taken every sleep med under the sun, including many off label medications. one thing that i find effective, that is said not to interfere with sleep architecture is flexeril. i take 20 mgs. it really helps me, because i have a lot of body pain, as a consequence of some issues with my cervical spine and shoulders.

can you describe the PES for me? that's a means of measuring RERAs. i dont think that was used on me.

PES uses a small catheter through your nose, threaded down just to where it hangs down into your throat a ways. It discharges saline into your esophagus at intervals throughout the night and measures the pressure. You would know if you had it! It wasn't at all painful, but it was very uncomfortable and distracting. I am side sleeper and everytime I rolled over that tube flopped to one side of my throat and bugged me. It was also irritating to swallow, somewhat painful in that it felt like when throat is irritated from post nasal drip and I try to swallow.

I have been on dozens and dozens of meds for sleep, including several off-label experiements. None work or work marginally, but the side effects are too great for the benefit. I have not taken Flexeril, or any of the other pain meds as I have no pain. I also don't have PLMD or RLS.

Yes my sleep is extremely fragmented. That's one of the reasons I'm going back to Stanford next week, more investigation into why I remain most of the night in Stage 1 with only a little bit of Stage 2, no stages 3/4 or REM.

UARS and RERAs have been a confusing area for me, and I get conflicting information even from the techs at Stanford vs. the doctors. I had expected RERAs on my study reports when the tech told me PES was positive. Yet RERAs are listed at 0 on the two studies I have had there so far, but RDI remains high while AHI (both studies saw hypopnea only) remains high but signficantly lower than RDI.

Blessings,
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Postby pooped » Wed Sep 26, 2007 9:35 pm

Thanks for the reply, pseudonym.

You're in good hands at Stanford, even if you hear different things from the techs.

As for UARS, it's my understanding that it's a syndrome, not a symptom, and its determined by the number of respiratory-related arousals.

I believe that a RERA is a type of respiratory arousal that is gauged by the PES. (I cant imagine sleeping with that balloon in my throat. That would have kept me VERY aroused -- and not in a good way!) My confusion about your results is that an AHI does not include respiratory disturbances, so, based on your AHI and RDI, it appears you have some form of OSA as well as UARS. I have read that you do not need RERAs to be diagnosed with UARS, unless your arousal index is on the lower end. No doubt, yours is not on the low end.

I believe that your RDI is higher than your AHI because it is the index of your hypopneas plus your other respiratory disturbances (that are not apneas or hypopneas). But the bulk of your RDIs are hypopneas.

I'm glad you dont have pain -- it would not be easy, with your lack of delta sleep, which is required to heal at a normal pace. Incidentally, flexeril is not a pain medicine, per se, it's a muscle relaxant, and not a terribly strong one, IMO at least. But it does make you sleepy, and a little looser. I suppose it could be problematic for some with breathing issues. Some experts suggest that it encourages delta-stage sleep. Given your medication experience, I assume you tried seroquel -- not sure what that does to delta, but it's the only thing that consistently knocked me out and kept me asleep, though it dummied me in the morning.

I wish you the best re your follow-up. I'm interested to hear what more you learn, if you wish to share.

Best regards,
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Postby pseudonym » Thu Sep 27, 2007 10:10 am

pooped wrote:My confusion about your results is that an AHI does not include respiratory disturbances, so, based on your AHI and RDI, it appears you have some form of OSA as well as UARS. I have read that you do not need RERAs to be diagnosed with UARS, unless your arousal index is on the lower end. No doubt, yours is not on the low end.

I believe that your RDI is higher than your AHI because it is the index of your hypopneas plus your other respiratory disturbances (that are not apneas or hypopneas). But the bulk of your RDIs are hypopneas.

You are correct, I have a diagnosis of BOTH the OSA (from hypopneas) *and* UARS.

pooped wrote:I'm glad you dont have pain -- it would not be easy, with your lack of delta sleep, which is required to heal at a normal pace. Incidentally, flexeril is not a pain medicine, per se, it's a muscle relaxant, and not a terribly strong one, IMO at least. But it does make you sleepy, and a little looser. I suppose it could be problematic for some with breathing issues. Some experts suggest that it encourages delta-stage sleep. Given your medication experience, I assume you tried seroquel -- not sure what that does to delta, but it's the only thing that consistently knocked me out and kept me asleep, though it dummied me in the morning.

A muscle relaxant is not indicated for me, since both my UARS and hypopneas were dx'd as being from too-relaxed muscles allowing partial collapse along the length of my airway. Yes I have tried Seroquel and it had no effect on me whatsoever for sleep. I did feel pretty drugged, but that was all. Same old story as with most other meds.

It is interesting to me that BEFORE my severe insomnia started, I was almost hyper-sensitive to sedating medications, even some so-called "non-drowsy" OTC preps would make me nod off a bit. Now I seem to be relatively immune to most forms of sedation.

pooped wrote:I wish you the best re your follow-up. I'm interested to hear what more you learn, if you wish to share.

Thanks very much, I will be happy to share what I learn in this next round at Stanford.

Blessings,
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Postby pooped » Thu Oct 11, 2007 2:02 am

Hey Pseudonym, just just checking back in.

So, I was dianosed with a severe case of UARS. RERAs were ~ 35.

I am now on the APAP. It's going pretty well. I have the Swift Mirage Nasal Pillows mask, and I finally found a way to ensure that I keep my mouth closed -- I used my cervical collar. Not the most ergonomic, but it works, and I am not waking up to a sore throat.

Incidentally, I dont know how accurate the APAP machine is (Respironics, S8), but, so far, it's reporting that I have an avg. AHI of around 7. That doesn't surprise me that much, as I do have hypopneas during REM, and I am probably having more REM now that my sleep is less fragmented. Hopefully, as I acclimate, the AHI will drop.

Anywho, hope all is well for you. Look forward to hearing about your follow up.

Best,
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Postby pseudonym » Thu Oct 11, 2007 9:12 am

pooped wrote:Hey Pseudonym, just just checking back in.

So, I was dianosed with a severe case of UARS. RERAs were ~ 35.

I am now on the APAP. It's going pretty well. I have the Swift Mirage Nasal Pillows mask, and I finally found a way to ensure that I keep my mouth closed -- I used my cervical collar. Not the most ergonomic, but it works, and I am not waking up to a sore throat.

Incidentally, I dont know how accurate the APAP machine is (Respironics, S8), but, so far, it's reporting that I have an avg. AHI of around 7. That doesn't surprise me that much, as I do have hypopneas during REM, and I am probably having more REM now that my sleep is less fragmented. Hopefully, as I acclimate, the AHI will drop.

Anywho, hope all is well for you. Look forward to hearing about your follow up.

Best,
~pooped

Hi pooped!

Hey if the cervical collar is working and not causing any new problems, why not? Holds your neck in a good position too I would imagine. Besides we look silly enough with the mask so what's not to love about a collar? :-)

You mention your APAP is Respironics S8, but if you have an S8 that is a ResMed. Just wanted to bring your attention to that so you would be sure to look at the right manufacturer's info for your machine if so inclined. I have a Respironcs REMStar M-Series Auto CPAP, it has 90% pressure stats vs. 95% some ResMeds track, just little differences that make for big confusion if you are expecting something else :-)

My recent Stanford visit was interesting, thanks for asking. They took several hours with me, especially regarding my persistent insomnia, but came up blank. I am on a trial of Provigil now during the day to see if 'upping' my alertness levels during the day will help my sleep to consolidate better to nighttime. My doctor has no real evidence to support this idea, but as it is something we haven't yet tried, and she is not expecting any harm to come from it, so... why not. We'll see how it goes.

My Stanford doctor has also raised my APAP minimum pressure from 8 to 10. My 90% pressure had been 8.8 and average AHI around 2.2. So I was surprised at her recommendation for new pressure. She explained she is trying to target that unknown RDI component of index 30, with the increased pressure. The machine doesn't have any way to show stats on that, and my AHI is not expected to change significantly. We'll go strictly by whether I notice any positive changes such as feeling less tired, getting more consolidated sleep, fewer awakenings, etc. We'll see how that one goes too.

Oh and my foggy brain forgot to ask why my 'suspected' UARS was not scored as RERAs. Sorry I didn't find out! Ack. I hate this 'fog'...

Different topic. One thing I have observed since having an APAP. My APAP started out at min 5, my AHI was averaging about 5.6 with 90% pressure ranging from 8.8 to 9.6, so not bad therapy. After a month or so my local sleep doc moved the minimum up to 8, and my 90% pressure settled around 8.8 and AHI average dropped to 2.2.

Runningbare mentioned this APAP 'phenomenon' to me in another post on this forum, and my local sleep doc explained it to me this way: Although it would seem like the Auto should be able to adjust to whatever pressure is needed (isn't that the point?), in fact they perform much better if the starting pressure is very near your minimum effective therapy pressure.

So, after you have collected stats for a few more weeks, ask your doctor about moving your APAP minimum up near your 95% pressure (raising the max too, if needed). You might find the machine is able to bring your AHI down like it did for me? You may need to do this more than once to fine-tune your minimum pressure, but if it works, you might see some more improvement. Just a thought. Your doctor might, of course, have other ideas!

Blessings,
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