Dave,

I don't get it. Wellbutrin, Lexapro and Lamictal cause sleep fragmentation and might explain why the high pressures aren't eliminating the hypopneas? I've seen 2 sleep specialists so far and sppecifically called their attention to the meds I'm on. Neither one said anything about them. I believe you and am a loss about why they didn't recommend changing my meds. One reason might be that I have atypical depression and it's taken years to get my meds balanced so I don't feel depressed most of the time. My shrink also didn't say anything about the meds causing sleep apnea when I told him I'd been diagnosed.

What do you think I should do about this? At the least, I'll contact my current sleep specialist to ask whether we should consider changing my psych meds at this point. It seems ridiculous to put me on super-high pressures that are going to be very difficult to tolerate, when it might be the meds that are causing or contributing to the fragmentation.

The doctor I saw yesterday did say that I might have underlying insomnia as well, so that difficulty staying asleep could be contributing to the severe sleep disorder. His plan is to try me on a month of bipap with Smart Card monitoring and then evaluate that data.

Also, I got my graphs and titration table. Thanks for alerting me to the need for them. What do I do with them now?

God, I'm grateful for you.

Friends,

I want to thank all of you who responded to my cry for help. I was so pleased when I saw my new sleep specialilst yesterday. I liked him immediately, because he welcomed me with a handshake, looked at me directly, and treated me like an equal in solving my sleep problem. More than that, though, I felt really well prepared going into the visit. I was surprised that I actually understood most of the sleep report, thanks to the info I've learned from this site. Wow!

Thanks to you especially, Rested Gal, for your advice about what machine to demand. He recommended the Respironics BiPAP with Biflex, heated humidifier, and Smart Card. I was grateful that due to you, I was able to say, "Great idea, but let's try the AutoBiPap version." He though it wasn't  out on the market yet, and I was able to tell him it was and whip out the printout from cpap.com for him to have.

He was also pleased with my choice of mask, the Fisher Paykel 431, saying he thought it was the best on the market. He especially likes that mask because it has a glide feature. Instead of the headpiece attaching directly to the mask, which tends to cause leaks when you move around, this one was wires between the headpiece and mask that allow them to glide in relation to each other, so the mask stays in the right position even when you move.

And thanks to the CPAP director at a local sleep center, I could tell him the name of the highly-recommended DME I wanted to work with.

I'm blown away at how fast you can obtain excellent info and advice on the Web (if you can tell who's trustworthy).
Power to the patients! That's us!

....



Last edited by another_guest on Tue Oct 31, 2006 10:25 pm; edited 1 time in total

Miss Rumphius wrote:

I don't get it. Wellbutrin, Lexapro and Lamictal cause sleep fragmentation and might explain why the high pressures aren't eliminating the hypopneas?

Not exactly.  Scoring technicians, and autoCPAP machines, for that matter, decide what a hypopnea should look like, and act accordingly.  Sometimes (most times, actually) it's pretty straightforward.  Sometimes it's not.  Right now you've got a titration that didn't go well (gee, s.d., ya THINK) where you had basically all hypopneas but the pressure went through the roof and didn't do much.  I mean, you "shoulda" needed 6, 8, maybe 10, and you got to 25/15?  How much do you need, 50?

Soooo, we still got option 5.  And there's no way we're gonna tell if that's the case, cause we can't see the study.  Until it's ruled out, tho, frankly I think event misidentification is #1 on the list.

As a fr'instance, here's a PSG, the breathing waveform is called PTAF/CPAP.  A hypopnea is a 50% reduction in flow, so tell me how many hypopneas you see here:



Keep in mind 2 things.  First, this is a nice study.  In severe fragmentation, the waveforms can look like a wreck.  Second, most sleep systems have an automatic scoring function.  Press the button and FOOM! all the events are scored.  Works great in a straightforward case.  May not work at all in severe fragmentation.  What's the advantage of computer scoring?  In a tough case, manual scoring can take maybe an hour.  Computer event scoring takes 20 seconds.  Get the idea?

Ergo, drugs do not cause hypopneas, they cause fragmentation which might be interpreted as hypopneas.  And I'm playing Mr. Skeptical today.
sleepydave

Dave,

Thanks for the explanation. How do I get my graphs and tables to you?

Nancy

It is in progress.
d.

OK, let's see how this looks:

Dave,

Did you get the rest of the pages we e-mailed you? Total of 7 altogether. Also, take a close look at the sleep stages strip.  The report said I spend almost all my time in Stage 2 -- but the graph shows me mostly in Stage 1!

Nancy

Dave,

And take a look at the SaO2 tracing, too. Doesn't it show my SaO2 repeatedly dropping to 40?

Nancy

Dave,

And take a look at the SaO2 tracing, too. Doesn't it show my SaO2 repeatedly dropping to 40?

Nancy

Hi Nancy:
The labels on the sleep architecture graph shift a little on the way down.  The amount of Stage 2 is appropriate to the text report.

The O2 saturation drops to 40% are motion artifact.

What is incredibly odd is that your sleep is continuous.  You hit a sleep stage and stay there.  Despite an incredible amount of arousals, 500, as a matter of fact.

More often than not, an arousal will result in a stage change.  The arousal bumps you back into at least one stage lighter sleep.  Because of scoring rules, this is especially true of arousals in Stage 2, you almost always get bumped back into Stage 1.

So you've got 500 arousals, but they only result in a total of 25 stage changes.  That's basically a normal number of stage changes.  You should have had hundreds.  You should ask that question.  "How can I have continuous Stage 2 sleep in the face of hundreds of arousals?"  At this point, the scoring credibility comes into question.

Which brings us back to where we started.  Are they really hypopneas.

The only way to tell for sure is to look at the PSG itself.

But frankly, I would say event misidentification is very high on the list of possible explanations.  And the use of those enormous pressures unfounded.
sleepydave

OK, pencils down!  What's the answer to the number of hypopneas question?

If you said anything other than zero, you are wrong!!!

As Paul Harvey might say, "Here's the rest of the story."



These variations in respiration are caused by PLMs!  There are brief periods of hyperventilation following each PLM, which gives the baseline ventilation pattern the appearance of hypopnea.

But hit the automatic scoring module on this one and guess what you'll end up with.

Right.

There are a couple of other subtle things in here, too, but that's a story for another time.
sleepydave

Dear Dave,

Thanks so much for examining my graphs and answering questions I had. I think I need to call your feedback to my sleep specialist's attention. OK with you as long as I don't identify you as anything other than a sleep lab manager?

I expect him to investigate this. If he dismisses the info, I'll definitely get a second opinion from a sleep specialist at another institution.

Nancy

Hi Nancy:
Actually, I'm fine with "some nut on the internet."

Ooh, I forgot one other thing.  Your oxygen saturation shows an overall baseline drop, rather than a pattern of desaturations, such that your level is just barely acceptable, even at that brief period when you are finally able to put together some real continuous sleep at about 6:00AM.  (Medication effect wearing off?)  You might want to consider getting that worked up and/or using a little supplemental oxygen.
sleepydave

Hi Dave,

I'm feeling pleased with myself. Looked at the strip of "hypopneas" you posted and said to myself, "WHAT hypopneas? I don't see any." I'm actually starting to understand this stuff.

Nancy