Hypopneas - need more info

[frequenseeker]

It's now about a week after my recent retitration study during which increase in the inhale and exhale pressures got their bipap to stop all events according to the tech. I seem to get events during REM and especially the REM in the morning hours, which tend to be the longest REM periods for people, according to the tech.

At home with my ResMed VPAP III not as good, several pretty bad days in fact as I tried several rise times, but I got best results so far last night - AI .5, AHI 2.5, in 7 hours of sleep, at the longest rise time available.

However, the graph showed each of the 2.5 hypopneas occurred in each of the last three hours of the night, and each lasted at least 45 minutes.

I suppose one conclusion theoretically could be that the machine data was wrong. The sleep center tech does not think that the data from our machines is reliable. My DME tech disagrees. They are both reasonable and well informed professionals. My own experience with my machine and its data is that my daytime feelings correlate consistently with the data of the night before.

With the better results of last night, I am feeling better, less ragged/wired and brain bruised. But still not "right" enough..

I wonder if my heightened beta activity (also noted during a daytime brain wave assessment) has anything to do with this. During the study perhaps the beta meant I was being hyperalert due to the situation and that kept me out of the hypopnea zone. I would not be happy if a reduction in my beta, which would be a good thing for my well being, would worsen my hypopneas...

Why are my hypopneas so concurrent with REM?

I want to understand hypopneas better...any information welcome.

Thanks,
frequenseeker

( the history on my study is at http://www.talkaboutsleep.com/message-boards/viewtopic.php?t=11050 )

[Toth]

If you had stopped breathing for 45 minutes you would be dead and it sure wouldn't be a 'hypopnea'.

Don't aim for perfection just yet. Aim for marked improvement and do your fine tuning abit later.

In your dream states just prior to awakening your muscles are most relaxed and you need the highest pressure to keep the airway open, but if you are at that high pressure all night long your nasal passages may start carrying picket signs!

Zero adverse events would be nice. Very few people ever have zero.

[frequenseeker]

Toth, hypopnea is a reduction of airflow, not a cessation of it. Mt tech says: "The true definition of a hypopnea is a reduction (30 to 75%) in airflow for 10 seconds or greater along with a drop in oxygen saturation of 4%."
In searching by Google I find essentially the same definition.

Am I squeezing my hose in my fist with superhuman strength or I am squeezing my bronchi..or...narrowing my nostrils..or...?

When I awake I usually feel quite good respiratory-wise, upper and lower, even if my head is cloudy.

[-SWS]

[rested gal]

frequen, thanks for sharing the info about your recent study. I did look back at what you posted immediately after the study.

Given some things that the tech, Sherry, (whom you said seemed very good) said, after titrating you with a Respironics BiPap Pro in the clinic...

[frequenseeker]

-SWS and Rested Gal, you've made my day, finding your posts this morning
I was soo hoping that you would weigh in with your perspective, -SWS. I knew you had one on this topic, and I appreciate it very much.
Rested, so glad you are doing well with the tongue keeper mouthguard!
And kudos to you for trying the bipap, in your indomitable spirit of inquiry and quest for increasing well being and not settling for less
Yes, the ease of breathing is a big reason to use bipap. As I have said before, autopap seems to make sense in that it doesn't subject you to pressures unless you need them. But when it does ramp up, you don't get a bilevel pressure experience. As you found, comfort is greater with bilevel. For those of us with lung problems, the bilevel is crucial beyond that.
When anyone posts that they can't cope with cpap, wonder how many would be able to with bilevel, eh?

BTW, I did have the Bipap Pro before the VPAP. I had trouble with the length of the inhale, and of course wanted my data. The VPAP is more customizable I think on the various settings and for me that was helpful (see below).

Now, as for me today...
I became aware just barely enough in the early am that I was struggling, not sure if snoring but something with the air and my mouth, and certainly enough arousal to bring me to that level of consciousness. Giving up and waking at 5, I spent alot of time tuning in to the pap and what was going on. It felt like my chest was pretty tight, full from the pressure. And I realized that I was getting cut off before full inhalation had completed.
This was odd, since I have the IPAP max and min settings way longer than usually recommended, and I had not felt any problem with this for nearly a year.
I tried different rise times, perhaps it was taking me too long to get to full inhale pressure? No, that wasn't it, didn't change the cutoff...
I tried breathing in more strongly, in case my usual was so shallow that the machine wasn't preceiving it and triggering the end of inhale as if it has been ended, but that didn't change anything.
I ended up extending the IPAP max and min to just about their limit, nearly 4 seconds. That solved the problem.
Looking back, I have been noticing my breaths per minute increasing in frequency. I had been 10-12 way back, which is awfully slow. The volume has always be small, but I have small peak volume anyway. I was at 12-14 for awhile when everything seemed well tuned (except for that early morning REM stuff). But lately I had noticed 18 in there..
So if my inhale has been getting cutoff, my reaction would have been to increase my respiratory rate. It was like this, when I was experimenting with it before changing the inhale lengths.
My guesses include: machine malfunction, or possibly with the higher pressure filling my airway, my inhale information is getting obscured.
I will try tonight with the changes I have made and see if it makes a difference. Then I will get my DME to check the machine!
Any other suggestions welcome!

[-SWS]

Frequen, let's assume for a minute that there are, indeed, multiple physiologic conditions that can result in hypopneic breathing patterns across the entire patient population. Let's assume for a minute that these diverse hypopneic breathing patterns can be neurological, muscular, pulmonary, immunological, skeletal (mandible-based), and so forth. Many different etiological bases across the entire hypopneic patient population. If this premise is true, then some patients will undoubtedly present hypopneas with multiple or concurrent etiological root causes.

It would thus be entirely possible to have a sleep disordered breathing condition with one or more components well addressed by positive air pressure, and yet one or more outstanding SDB components ill-addressed by PAP. A compounded SDB condition could conceivably require multiple diagnoses and multiple treatment options.

[MichHH]

She had to have one too!!! When does the PB 425 S/T ship? I need to buy
that one before she does! Shouldn't we just "collectively" buy one of every known
machine and just pass them around in a big distribution chain?

My problem is that there are too many unknowns going on to make any more mprovement.
I am not convinced that just one or two nights at a specific setting really demonstrates
anything conclusively. Statistically speaking, one needs lot of data, given the amount
of normal variation, to really demonstrate a difference. Same settings -- but one night
you have great sex and sleep like a log -- next night you come home from work all stressed out, and then a huge thunderstorm hits in the middle of the night. You sleep
terrible. Same PAP settings, but not accounting for all the other extraneous factors
which are not being kept constant, as demanded by good scientific protocol. I totally
agree with SWS in that there are so many unknown factors causing "runs" and
"hypopneas", some of which have no relationship to pressure increases. In my case
I had extremely clear oxygen saturation data and PB 420e data which showed a
dramatic difference in AHI and Snore numbers with or without the Silent Nite dental device in place. However I could never find a way to increase my "normal cycles"
above 80% or get my runs to decrease below 200. Same problem with different
masks. One night it would be fine, and the next night it would leak like crazy. I
really feel that I need more sensors (like positional [back vs side]) to make any more
progress. I can't get consistent, night after night, reproducible results. Yes, most
of my symptoms have disappeared, but I don't feel that I will ever get back to how
I was "before bad apnea" struck. The scary thing for me, is that on the S/T model,
when I don't breathe (have severe Central SA), the unit "initiates" a breath. This
is occuring about 15% of the time each night. How does that figure into the PB420e
data? The PB420e shows No Centrals most nights, but yet the VPAP III shows that
it records only 85% spontaneous breaths. I feel that I am going round and round
chasing my tail. We really need to hook up with some sharp graduate students
in Sleep medicine, as the current practitioners out there have no knowledge of
the leading trends in PAP therapy. By that I mean the pantyhose, pantyliner, and
bra strap cutting edge R&D. Well at least we all feel better, well enough to smile,
which for me is sooo much better than where I was at before.

[MichHH]

The major findings of our study are that flow-limited breaths reappear during bilevel positive-pressure therapy and that these events may worsen with widening of the PI-PE difference when the PI is set at the optimal or suboptimal level.

http://jap.physiology.org/cgi/content/full/85/5/1855

This agrees wkith frequenseeker's trials in which she moved the PI-PE difference
closer for better results.

[frequenseeker]

LOL, MichHH
and empathy too... thanks for verbalizing the experience of many here, including myself.

I am reeaallly hoping that if tonight things are better with the change I made, maybe this pesky edema will clear up as a result. It has been so erratic, I start and stop hormone supplements, reduce salt, avoid protein, my favorite foods (like Japanese and Thai) drink vegetable juices..maybe it's the hypopneas..?
The weather is warmer now which makes it worse.
The morning after the sleep study it was the best in a long time, then in the week after I regained 5 lbs of fluid..
Was down a bit this morning. Maybe my hypopnea will be better tonight and the edema will show improvement. It's hard to drag around two logs for legs all day.

[frequenseeker]

MichHH - great article, I am a little slow in fully understanding how to apply its findings. I am at 14/11 now. Was at 12.5/10.6 before the tech's recent recommendations.
I would think that rise time would factor into what the article/study was investigating, too.
Can you give discussion?

[-SWS]

Interesting study, indeed, MichHH! The study suggests a wider spread between IPAP and EPAP correlates to an increase in measured inspiratory flow limitations.

I saw no mention of rise time in that study, Frequen. A BiLevel's rise-time setting is theoretically supposed to be set to match the patient's spontaneously-generated inspiratory rise rates. Apparently finding that machine-to-patient inspiratory slope match can be quite a challenge. I would expect this to be especially true for patients who happen to generate erratic or highly variable inspiratory rise slopes.

[-SWS]

Frequen, does your edema happen to also manifest in the lungs? If so, I wonder if those highly atypical 45-minute hypopneas are both pulmonary and edematous in nature versus being associated with the upper airway dilator muscles.

[frequenseeker]

If it does, I don't have the characteristic fluid in the lungs, which would leak into them if it were standard pulmonary edema.

That is not to say we could rule out any other factors, players.

I had an echocardiogram that showed normal pulmonary system, a little elevate within normal. No valve problems.

I still have edema at night, so it would be hard to believe I would just have the lung edema in the REM early hours. No other signs of dyspepnea or anything other than general soft tissue, hands, legs, face etc. all day and night.

But the pressure in the lungs could produce repercussions on the kidneys, etc. leading to the edema that way? Guess it is time to go to bed and find out. G'night

[-SWS]