I saw my sleep doc today and he told me that I have mild apnea and it's mostly during rem sleep. He thinks I should be more concerned about my insomnia and try to sleep more. But I have a copy of the results of my most recent sleep test from last month and it says I had 0% rem sleep. Here are the high points:

TST: 252.4 min
Sleep latency:        24.4 min
Sleep efficiency:     62.6%
REM sleep:            N.A. (% TST)
Non-REM Sleep:    100 (%TST)
Delta Sleep:          22.8 (%TST)
# of Awakenings:  49
# Stage Shifts:     129

AHI:  32.6
REM AHI:  0
Non-REM AHI:  32.6
RDI: 33.3
Snore Arousal Index:  0

Stage 1:  7.1%
Stage 2:  70.1%
Stage 3:  22.8%
Stage 4:  0.0%
REM:       0.0%
MVT:       0.0%

Central Apneas:         70     Index: 16.6
Obstructive Apneas:   53     Index: 12.6
Mixed Apneas:             1     Index: 0.2
Hypopneas:               13     Index: 3.1
Apneas + Hypopneas: 137   Index: 32.6

Total Arousals:            230   Index: 54.7
PLM Arousals:              0
Respiratory Arousals:   136   Index: 32.3
Spontaneous Arousals: 94    Index: 22.3

My questions are:

Does this look like mild apnea? I don't know how mine compares to others.
If I had 0% REM sleep as the study indicates, what tells the doctor that most of my apnea occurs during REM sleep?
If I only have mild apnea and bipap isn't helping me, is there any reason to continue using it?

Thanks for any opinions/observations.

SnoozeHunter

I should have mentioned that this was a retitration with bipap. The recommendation from the RPSGT was an increase in the settings from 12/8 to 19/15, but he requested the doctor to review and decide if those settings were best since I had more central apneas than obstructive. The doctor advised me to go in between at 17/12 and see how that works. I still haven't adjusted to the change.

SnoozeHunter

Hi SnoozeHunter:
By all accounts, that looks like one awful night of sleep.  And I use the term "sleep" loosely.
In order to try to put things into perspective, I would go back to the beginning, get the original studies including the oxygen desaturations as well as all the values you have posted here.  All the CPAP/BiPAP titration tables, including the one for this night.  And the Sleep Architecture Graphs.  Pertinent medical conditions (where are you with the CHF thing?) and medications (were you on trazodone on the night of the study?)
Write back.
sleepydave

Is there any place where I can get an explanation of what each one of these lines mean?  I see the numbers quite a bit but I am not sure what any of them mean.  Any reference points you can guide me to?

Thanks.


_________________
Dave

Thanks for looking at my study, Sleepy Dave. You're right...it was an awful night of sleep and, unfortunately, pretty typical for me.

Both parents died of heart disease (age 31 and 59), and 3 grandparents (ages 40's and 52)

I had an echocardiogram yesterday but don't have the results yet. The technologist said overall looked good but said the cardiologist might or might not mention a couple of things in the report when he reads the study: tricuspid valve regurgitation and a number that was high (don't remember what the number was.

Meds:
Toprol-XL for high blood pressure.
Maxide for water retention
Allegra-D for allergies
Albuterol inhaler occasionally for difficulty breathing

I am 51 and in relatively good health. Diagnosed with:
Bilateral vestibular weakness
Arthritis
Allergies
Asthma
Insomnia
Sleep apnea

Thanks so much for looking at my sleep study info. Any advice, opinions, and observations are welcome. I don't have the actual graphs that I've seen in the posts of others.

Here are my oxygen analysis and titration table from that same titration results I posted peviously, and below that is are the inital evaluation results and the first titration results.

Sept. 2005:

Mean SaO2 (%)     Awake: 98.0     Non-REM: 94.5      REM: N/A     TRT: 95.8
Min SaO2 (%)        Awake: 79.8     Non-REM: 78.3      REM: N/A     TRT: 78.3
Max SaO2 (%)       Awake: 99.5     Non-REM: 99.5      REM: N/A     TRT: 99.5

Pressure Level Analysis:

Pressure      TRT      REM      Non-REM      Obs.       Cen.     Mixed     Hypopeas     Total       RDI       Max      Min        Mean
(cm H20)     (min)    (min)        (min)        Apnea     Apnea   Apnea                       Events                SaO2    SaO2      SaO2

12/8            31.2     0.0           3.9             6            0          0               0              6          93.4    99.5      79.8       98.4
13/9            13.6     0.0           13.6           13           0          0               2              15        65.9    91.6      80.3       87.5
14/10          93.0     0.0           36.0           12           20        0               0              33         54.9    99.5      78.3      97.1
15/11          13.0     0.0           9.5             2             9          0               2             13         82.4    99.5      79.8       94.5
16/12          84.7     0.0           76.2           12           14         1              6              35         27.6    98.5      79.3       94.8
17/13          50.4     0.0           43.9           5             4           0              0              9          12.3    98.5       92.1       96.3
18/14          67.5     0.0           21.0           2             22         0              1              25         71.5    99.5       81.3      96.4
19/15          49.8     0.0           48.3           1             1           0              2              4           5.0      97.5      91.1       95.0

EKG Comments: Sinus Rhythm with Sinus Bradycardia.

Impression: BiLevel Positive Airway Pressure at a setting of 19.0 I/15.0 E cm/H2O was shown to improve disordered breathing events and decrease central events during Non-REM sleep stages. No snoring was heard on 19.p/15.0 cm/H2O.



Initial sleep study June 2003 (no CPAP or BIPAP:

Total recording time: 386.7
TST:  274.5 min
Sleep Latency:  34.2 min
REM Latency: 171.5
Sleep Efficiency:  71.0%
REM Sleep:  20.8 (%TST)
Non-REM Sleep:  79.2 (%TST)
Delta Sleep:  0.0 (%TST)
# of Awakenenings:  18
Stage shifts:  51

AHI:   8.7
REM AHI:  17.9
Non-REM AHI  6.3
RDI  8.7
Snore Arousal Index:  0

Stage 1:  5.1%
Stage 2:  41.2%
Stage 3:  33.0%
Stage 4:  0.0%
REM:  20.8:
MVT:  0.0%

                                   NREM          REM         Total        Index
Central apneas:                0               0             0              0.0    
Obstructive apneas           1               0             1              0.2
Mixed apneas:                  0               0             0              0.0
Hypopneas                      22              17           39             8.5
Apneas + Hypopneas:      23              17           40             8.7

                               Awake          Non-REM          REM          TRT
Mean SAO2 (%)           96.9            96.4               97.3         96.7
Min SAO2 (%)              0.0              92.6               90.6         0.0
Max SAO2 (%)            100.0           100.0             99.0         100.0


                                    Non-REM       Index       REM       Index       TOTAL       Index
Total Arousals                    22              6.1           17         17.9        39             8.5
PLM Arousals                      0                0.0           0          0.0           0              0.0
Respiratory Arousals           20              5.5           17         17.9        37             8.1
Spontaneous Arousals        2                0.6           0           0.0          2               0.4

EKG Comments: Normal Sinus Rhythm

PLM Arousal Index:  0
PLM Non-Arousal Index:  0

Impression: Consistent with Moderate REM obstructive sleep apnea syndrom
Sever disrupted sleep architecture
Mild oxygen desaturation



Titration results July 2003:

Total recording time: 445.5
Total sleep period:  434.6
TST: 326.5
Sleep Latency:  11.0
REM Latency:  356.5
Sleep efficiency:  73.3
REM periods:  2
# Stage shirft:  62
Awakenings:  25

Stage 1:  6.4%
Stage 2:  71.4%
Stage 3:  17.5%
Stage 4:  0.0%
REM:  4.7%
MVT:  0.0%

                                     NREM                REM                  TOTAL                Index
Central apneas                  9                      0                       9                       1.7
Obsturctive apneas            36                    0                       36                     6.6          
Mixed apneas                    0                      0                       0                       0.0
Hypopneas                       38                     0                       38                     7.0
Apneas + Hypopneas         83                    0                       83                     15.3


                                    Awake                Non-REM             REM                  TRT
Mean SAO2 (%)               96.5                    95.5                 96.2                 95.8
Min SaO2 (%)                  90.6                    88.7                 93.6                 88.7
Max SAO2 (%)                99.0                    98.5                  98.0                99.0



                                      Non-REM          Index           REM            Index          TOTAL         Index
Total Arousals                     90                 17.4             0                 0.0              90              16.5
PLM Arousals                       0                   0.0              0                 0.0              0                 0.0
Respiratory Arousals            83                 16.0             0                 0.0              83               15.3
Spontaneous Arousals         7                   1.4               0                 0.0              7                 1.3



Pressure         TRT      REM      Non-REM      Obs. Ap.     Cen. Ap.      Mixed Ap.    Hypopneas     Total Events    Max     Min     Mean
                                                                                                                                                                SaO2   SAO2  SAO2
4                    114.3    0.0         97.4             15               0                 0                  17                 32            98.5    88.7     95.1
5                    8.4        0.0         5.1               7                 0                0                   0                   7             98.0    92.6     96.3
6                    18.3      0.0         8.5               0                 0                 0                  7                   7             98.0    91.6      96.1
7                    30.2      0.0         7.8               4                 1                 0                  1                   6             98.5    90.6      95.9
8                    5.3        0.0         5.3               0                 6                 0                  2                   8             97.0     89.7     94.6
9                    50.2      0.0         49.0              0                 2                0                  5                   7             98.0      92.6     95.3
10                  13.4       0.0        7.6                0                 0                0                   1                  1             98.5      94.6     96.6
11                  42.7       0.0         7.9               0                 0                0                   3                  3              98.5     90.6     96.5
11/8               16.0       0.0         5.8               5                 0                0                   1                   6             98.5     91.6     96.4
12/8               146.8     15.5       116.7            5                 0                0                   1                   6             99.0     91.6      96.0

Forgot to post that I didn't take Trazadone on the nights of any of the sleep studies. My doctor prescribed it after I'd been on the bipap for about 6 months, but I only took it briefy and have been off it for over a year. He wants me to start taking it again but I have a pretty bad cold at the moment so I'm putting it off. I didn't know if it was okay to take it with Nyquil.

SnoozeHunter

I'm no expert but it appears to me that your results are more than mild. I was diagnosed with mild OSA and here are a few of the results: I had 16 apnea/hypopnea events (5 obstructive apneas and 11 hypopneas) resulting in 6.2 events per hour of sleep, sleep efficiency of 82%, 7 oxygen desaturations ( 2.4/hour), 48 arousals and 3 awakenings  during   362 minutes of recorded time. Total sleep time was 297.5 minutes. Hope this helps.

Doug wrote:

I'm no expert but it appears to me that your results are more than mild. I was diagnosed with mild OSA and here are a few of the results: I had 16 apnea/hypopnea events (5 obstructive apneas and 11 hypopneas) resulting in 6.2 events per hour of sleep, sleep efficiency of 82%, 7 oxygen desaturations ( 2.4/hour), 48 arousals and 3 awakenings  during   362 minutes of recorded time. Total sleep time was 297.5 minutes. Hope this helps.

I was thinking the same thing since the doctor read my first exam as mild to moderate and the numbers on the recent one seemed worse to me. But at two office visits following the recent study, he downplayed the results. I had not seen the actual reports until yesterday when I requested copies. When I asked about the centrals (because the RPSGT had mentioned it to me) he didn't seem concerned and only went along with checking my heart when I asked him if I should.

I don't know if I should call and question him about it or not. I'm not sure if he was looking at someone else's report or if he doesn't think I need to know, or if it even matters as far as treatment goes. I'm not bold on a good day and didn't want to go running up there, test in hand, and then find out I'm completely wrong about what the numbers mean.

Thanks very much for your reply, Doug.

SnoozeHunter

Hi SnoozeHunter:
Well, for starters, if you have hypertension and insomnia, Allegra-D is just about the worst drug you could possibly take.

Let's try to summarize so far:
In June 2003 you had an AHI of 8.7 without any pressure support.
In July 2003 you had an AHI of 15.3 during titration.
In September 2005 you had an AHI of 32.6 during titration.

OK, that includes a lot of non-therapeutic pressures in the titrations, but something's really askew here.

That kind of REM suppression usually suggests medication effect, particularly anti-depressants (and actually trazodone is NOT supposed to suppress REM).  Yeah, OSA, particularly severe OSA, can disrupt REM, but yours isn't quite that bad...

Which also leaves me wondering how you got all the way up to 19/15.

Central apneas have a few causes, in this case it could be following an arousal (in which case they are harmless); over-titration in CPAP/BiPAP titrations; and true central events, one example being reduced blood flow as you may see in CHF.  The family history, the TR, the HTN--  all clues.

There are some marginal oxygen saturations during the first and second studies, but significantly low saturations in this last one.

It has caught my eye that many pressures during the titrations have very brief trial periods that probably don't allow proper analysis of the pressure.

I think it's important to figure out what pressure you actually need, because those pressures you're on now are a bear.  And the pressure your physician has decided to put you on, yes, seems quite arbitrary.

I guess it boils down to a couple of possibilities:

First, the poor sleep architecture with frequent arousals and awakenings may have resulted in a lot of artifact.  CPAP pressures were increased without really getting good data to justify doing that.  Central apneas were created during over titration.  In your last titration, the pressures picked up where they left off at 12/8, again, not looking at the response to pressures 5-10 cmH2O where you did not do all that badly in the first titration, but never had a chance to settle in properly.

Second, there could have been a significant change in your condition in the last 2+ years.  And with all the cardiac stuff you mention, even if it is relatively mild, you now cannot rule out the possibility that all those central apneas are real, and throw the whole thing out the window.

Try to get a hold of any graphs, particularly the O2 saturation one.  If the low oxygen levels are due to desaturations, that's one thing.  If the whole baseline drops out for extended periods, then that's another.

Here's what I would do.  Get rid of anything that contributes to the insomnia.  The Allegra-D, any caffeine, whatever.  Get back for another titration.  Maybe a split-study if possible.  Do the first half to re-evaluate the severity.  Also, if you really have central apnea, it will show up in the ambient study.  Then a careful titration, allowing at least 15 minutes of continuous sleep (on each pressure) to properly assess response.  See if low level CPAP is all you need.

If you do end up having a pile of centrals, we'll pick up the discussion with "complex sleep-disordered breathing."
sleepydave



Last edited by sleepydave on Thu Nov 10, 2005 9:46 pm; edited 1 time in total

Hi, sleepydave,

I'm glad you mentioned the Allegra-D. I had wondered about it after reading the papers that come stapled to my prescriptions one day. It seemed like my prescription drugs were all working against each other.

The REM suppression concerned me because I had never heard of having no REM sleep. I have never taken antidepressants other than the Trazadone prescribed by the sleep doc, and I wasn't on that during the tests. The only "meds" I take in addition to the ones I listed are a multivitamin, b-12, vit. E, calcium, and omega-3. Even those I don't take consistently.

The doctor did not mention to me any of the things that you mentioned in your post. Regarding oxygen saturation, his only comment was that my oxygen level remained good throughout the study. I am bewildered by his interpretation of my exam.

Today I'm going to contact my family physician and see if there is a different allergy medication I can try that won't aggravate my insomnia or hbp. I'll call the sleep lab and ask if they have those graphs, and I'll call my insurance company to find out if they'll cover the cost of another sleep study. I think before setting up another one, though, I need to find out the results of the echocardiogram. I was reading yesterday on the 'net about tricuspid valve regurgitation and it sounds like it's one of those things that can be significant or not and is often considered normal. Since the US tech told me that the cardiologist may or may not mention it on the report, I have a feeling it's not going to be mentioned and I'm not sure how to follow up from there.

Before all three sleep studies, the nurse assured me that if I wasn't able to sleep they could give me something to help. I had trouble getting to sleep all three times but no one ever came back and offered a sleep aid. On one hand it seems like it would help if I could get to sleep faster and stay asleep during the study; on the other hand, would the effect of a sleep inducer skew the results?

Thank you so much for all your help with this. Your expertise in this area and insights are invaluable and greatly appreciated. I feel much better equipped to pursue this problem now.

SnoozeHunter

Didn't get very far in my quest today, but I got my echocardiogram report.

Impression:

1. Technically difficult study  (I don't know what that means exactly)
2. All four chambers of the heart are normal size without any evidence of intracardiac thrombi seen.
3. Mild concentric left ventricular hypertrophy with normal systolic function.
4. Normal right ventricle and right atrial sizes and systolic function.
5. Normal valvular morphologies.
6. Color flow Doppler showed physiological mitral and tricuspid regurgitation.

My physican's nursed called me this afternoon after I'd alread read the report myself. She said that the ventricular hypertrophy is due to hypertension, she didn't mention the valve regurgitation at all (it was described as "trace" in the body of the report and I read on the 'net that a lot of people with normal hearts have it), and she said that no further cardiac follow-up is recommended.

I also called my insurance company and was told that they will cover another titration as long as my physician states in writing that it's medically necessary. Now all I have to do is call tomorrow and ask if I can redo it as a split study.

SnoozeHunter

Hi SnoozeHunter:
I think there are 3 goals here:

Fix insomnia.
Fix obstructive component.
Fix central component.

OK, maybe 4, figure out where the REM went.

The toughest problem will be the insomnia.  Yes, you can take a sleep aid, like Ambien (and if you go this route, probably AmbienCR, cause they will wake you up at about 1 AM to resume the CPAP if you do a split, and plain Ambien will probably have worn off) but sleep aids are only temporary, you shouldn't rely on them, you have to fix the underlying problem.  So you really have to work on optimizing your sleep hygiene prior to the study and thereafter.

If you put a big dent in the insomnia and sleep fragmentation, and it turns out you have plain OSA, CPAP titration will take about an hour.  If you're up and down every 2 to 10 minutes tho, titration will be difficult.  But I again stress to analyze each pressure carefully before you move on to the next (I added "on each pressure" to the above post to make that more clear).  I really think that's the issue, those high pressures that you're working with are creating CPAP/BiPAP intolerance.  BTW, another clue that that may be the case is the progressively higher number of awakenings and stage shifts through the studies.

If there are, in fact, centrals now, that's going to be a big pain, but not insurmountable, but again, careful titration is called for.

If after sleep fragmentation is improved and effective CPAP/BiPAP is set, REM should reappear (cause you did have normal REM% in the original study.)  But we can't deal with that till all the other stuff is resolved.

Thanks for sharing this interesting challenge.
sleepydave

On Monday I had a nice phone chat with the RPSGT who scores the sleep tests at my sleep lab. I explained what I want to do and why, and he was very supportive. He got me in to talk to the sleep doc again yesterday, and now I'm scheduled to have a split study this weekend, and the titration part will be started with the machine on lower settings. I talked to both of them about using a sleep aid this time and neither seemed sold on the idea because of it possibly affecting the test results. We left it that I'll try to do it without a sleep aid but will take something if it looks like I'm having a lot of trouble sleeping. I'm taking some Trazadone with me to have on hand if needed. The tough part this time will be that I'm scheduled to do the test at a different site and I don't know the nurse or the tech at this one. I don't know what they'll think when I arrive and explain about doing the titration so I have enough time for good analysis at each pressure setting.

I haven't been able to use the bipap at all since last week due to a really bad cold. I tried it off and on but all it did was make me cough worse and feel suffocated. Surprisingly, I got more sleep than usual because I took some days off last week and stayed dopey on an over the counter cold medication. I even had some very vivid dreams on a couple of occasions. Welcome back REM!

I've promised the doc that I'll go back on Trazodone regularly no matter how the sleepover goes (for the insomnia) and, if it turns out that the machine really does need to be at the high settings, I'll make myself get used to it. But even he agreed this time that the machine doesn't seem to be helping me much and that we need to figure out where all those centrals came from on the last study.

Thanks for all your help, sleepydave. I wouldn't have gotten anywhere without your advice. I'll post the new test results when I get the report.

SnoozeHunter

Just back from the sleep study. I was a little worried that the folks at the lab would think I'm nutty asking for another one, but if they thought anything of it they didn't show it. The person who took care of me was very nice and understanding. We did a split study but, because the doctor didn't want me to use a sleep aid, I wasn't able to fall asleep for quite awhile so there probably won't be much data to go on for the first part of the night. The tech said she only had about an hour and that I had some centrals during that time.

As for the rest of the night, by then I was tired and sleepy so I think I did pretty well. I even had a dream about the sleep lab and then dreamed that I was telling someone about my dream! Does that count as two REM periods?     

Understandably, the tech didn't give me a lot of information this morning. I'll have to wait until the study is scored and then get a copy of the report later this week. What she told me was that I still had both central and obstructive apneas, and that they seemed about even in number. She said she had to take the machine up to 19 but then stopped because she didn't want to go any higher than that. From my end of the test, I was aware of being uncomfortable from the pressure at times. Sometimes it felt like it was filling up my stomach and throat, and sometimes it was difficult to coordinate breathing with the machine. Once, I woke up feeling a little light-headed or dizzy. Even so I managed to get a pretty good night of sleep.

SnoozeHunter

Hi Snoozehunter:
Sounds like 2 REM periods.  Too bad you weren't dreaming about dreaming about the sleep lab.  That would count as an additional REM period.  LOL!  Zany sleep humor!

Yeah, not happy to see that 19 either.  But no matter at this point, as long as there was good analysis time spent on all the other pressures, determination of what's going on can be made.  Better to have more data than less to look at anyway.

And again, we're not just looking at a single number and coming to the conclusion that everything's peachy.  There are multiple issues here, and they all have to be either ruled out or properly addressed.  CPAP/BiPAP titrations like your first two can be caused by a myriad of things, the worklist including:

1. Additional sleep issues, such as severe PLMs.
2. Severe sleep fragmentation from other causes, such as medication effect, fibromyalgia, GERD.
3. CPAP/BiPAP intolerance.
4. Underlying insomnia.
5. Poor titration, or over-titration.
6. Refractory complex sleep related breathing disorder (CSBD).

In the meanwhile, I'll start a post about that last one, Complex Sleep Related Breathing Disorder.  It's actually not very very common, and the definitive treatment is still in development right now.  But discussion regarding this entity is kinda interesting, sometimes a little over the top technically, but can give some insights as to why some people do well and some people don't.  And those underlying cardiac issues that you mentioned, even though very slight, may have a bearing here.

There's practically a book already written on a thread in another forum, if you wanna just kill some time till you get the results.

Complex Sleep Related Breathing Disorder

Or I'll make the Cliff Notes.
Hang in there.
sleepydave