Gina Johnson
Respiratory Effort-Related Arousals (RERAs) are arousals from sleep that do not meet the definitions of apneas or hypopneas but disrupt breathing during sleep and cause respiratory symptoms that may lead to an arousal. RERAs are considered in the Respiratory Disturbance Index (RDI) or Respiratory Distress Index, which reports on respiratory distress events during sleep. The RDI is calculated using the formula = (RERAs + Hypopneas + Apneas) X 60 / TST (in minutes), where TST is the total sleep time in minutes. While there is no universal consensus on whether the Apnea-Hypopnea Index (AHI) or RDI should be the standard index used to determine treatment, RERAs are increasingly being recognized as an indicator of disease severity.
| Characteristics | Values |
|---|---|
| Definition | Respiratory effort-related arousal |
| Criteria | A series of respiratory cycles of increasing/decreasing effort or flattening, recorded by nasal manometry and leading to an arousal that cannot be defined as apnea or hypopnea |
| Duration | ≥ 10 sec |
| Occurrence | ≥ 5 per hour of sleep |
| Diagnosis | Upper Airway Resistance Syndrome (UARS) |
| Indicators | Obstructive upper airway airflow reduction, increased respiratory effort, snoring |
| Treatment | CPAP therapy, weight loss, use of positional tricks, improvements in sleep hygiene, oral appliances |
| Severity | Mild, Moderate, Severe |
| Impact | Negative impact on health, excessive daytime sleepiness, cardiovascular consequences |
| Confusion | RDI definition and insurance coverage vary, AHI vs RDI debate |
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What You'll Learn
RERA is an indicator of the severity of a disease
RERA stands for respiratory effort-related arousal. It is a breathing disorder characterised by an obstructive upper airway airflow reduction, which does not meet the criteria of apnea or hypopnea. It is associated with increased respiratory effort that resolves with the appearance of arousals. An arousal is when the sensors measuring your brain activity show that your brain waves change to alpha waveforms, indicating that you have woken up, even if you don't realise it.
RERAs have been scientifically validated as a sleep-breathing abnormality that can negatively impact health. They are considered an indicator of the severity of a disease by many sleep centres and insurance companies. This is because any respiratory event that lasts at least 10 seconds and causes an arousal can cause damage and should be treated.
The Respiratory Disturbance Index (RDI) is the combined number of apneas, hypopneas, and RERAs per hour of sleep. The RDI is used to assess the severity of obstructive sleep apnea. However, there is some debate about whether the RDI should include RERAs. Medicare, for example, does not include RERAs in its calculation of RDI.
Upper airway resistance syndrome may be detected by Sleep RERAs. If left untreated, it may lead to obstructive sleep apnea, a hazardous sleep-related breathing issue that can cause diabetes, heart disease, and stroke.
The Apnea-Hypopnea Index (AHI) has been the traditional measure used to determine the severity of sleep apnea. However, the AHI does not provide any significant aspects of the breathing episode that would indicate how severe the OSA is. It does not, for example, show how the breathing stop impacts blood oxygen levels. Therefore, doctors may overlook other symptoms and health histories if they only use the AHI to provide treatment.
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RERA is a sleep-breathing abnormality
Respiratory Effort Related Arousal (RERA) is a sleep-breathing abnormality that is characterised by a limitation in breathing, resulting in increased respiratory effort, and culminating in an arousal. In other words, it is a breathing disorder characterised by obstructive upper airway airflow reduction, associated with increased respiratory effort that resolves with the appearance of arousals. It is important to note that RERAs do not meet the criteria for apnea or hypopnea.
RERAs are similar to true obstructive apneas and hypopneas in terms of pathophysiology and their complications. However, Upper Airway Resistance Syndrome (UARS), a clinical term used for patients with RERAs and symptoms of OSAS, is not considered an independent disorder. Instead, it is seen as one aspect of the spectrum of obstructive sleep disorders.
RERAs are arousals from sleep that do not technically meet the definitions of apneas or hypopneas but do disrupt breathing during sleep and cause respiratory symptoms that may lead to an arousal. A RERA is characterised by increasing respiratory effort, such as dyspnea, and decreasing oesophageal pressure for ten seconds or more, leading to an arousal from sleep. The gold standard method for measuring RERAs is oesophageal manometry, as recommended by the American Academy of Sleep Medicine (AASM).
The prevalence of RERAs in the general population is low (3.8%), and no association has been found with sleepiness, hypertension, diabetes, or metabolic syndrome. However, RERAs have been scientifically validated as a sleep-breathing abnormality that can negatively impact health. Despite this, there is ongoing debate about whether the Respiratory Disturbance Index (RDI) should include RERAs, and they may or may not be recognised and considered for treatment depending on the healthcare provider and insurance carrier involved.
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RERA is a type of arousal from sleep
Respiratory Effort-Related Arousal (RERA) is a type of arousal from sleep. It is a breathing disorder characterised by an obstructive upper airway airflow reduction that does not meet the criteria of apnea or hypopnea. It is associated with increased respiratory effort that resolves with the appearance of arousals. It is diagnosed through esophageal manometry, nasal manometry, or induction plethysmography.
RERAs are similar to true obstructive apneas and hypopneas in terms of pathophysiology and complications. However, Upper Airway Resistance Syndrome (UARS), a clinical term used for patients with RERAs and symptoms of OSAS, is not considered an independent disorder. Instead, it is one aspect of the spectrum of obstructive sleep disorders.
The prevalence of RERAs in the general population is low (3.8%), and no association has been found with sleepiness, hypertension, diabetes, or metabolic syndrome. However, RERAs have been scientifically validated as a sleep-breathing abnormality that can negatively impact health. Despite this, they may or may not be recognised and considered for treatment depending on the healthcare provider and insurance carrier.
The Respiratory Disturbance Index (RDI) or Respiratory Distress Index is a formula used in reporting polysomnography (sleep study) findings. It includes respiratory-effort-related arousals (RERAs), in addition to apneas and hypopneas. Medicare, for example, defines RDI as the average number of apneas and hypopneas and does not include RERAs. However, there is no universal consensus on whether the Apnea-Hypopnea Index (AHI) or RDI should be the standard index used to determine treatment.
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RERA is a breathing disorder
Respiratory Effort-Related Arousal (RERA) is a breathing disorder that occurs during sleep. It is characterised by a limitation in breathing, resulting in increased respiratory effort and culminating in an arousal. This is reflected in the alternative name for RERA: respiratory disturbance index (RDI).
RERAs are similar to obstructive apneas and hypopneas in terms of their pathophysiology and complications. However, they do not meet the criteria for these conditions. Obstructive apneas are defined by a drop in breathing signals of at least 90% for a minimum of 10 seconds, along with continued or increased effort to breathe due to an obstruction of the airway. Hypopneas are also defined by a reduction in breathing, but unlike apneas, they do not require a complete cessation of breathing. RERAs, on the other hand, are characterised by increasing respiratory effort, such as dyspnea, for 10 seconds or more, leading to an arousal from sleep.
The confusion around the definition of RERA and its distinction from apneas and hypopneas is further compounded by insurance carriers and healthcare providers, who may use the terms RDI and AHI interchangeably. The American Academy of Sleep Medicine (AASM) defines RDI as the average number of combined apneas and hypopneas per hour of sleep, excluding RERAs. However, the definition of RDI can vary across different sources and organisations, leading to inconsistencies in diagnosis and treatment.
The gold standard method for measuring RERAs is esophageal manometry, as recommended by the AASM. Nasal manometry or induction plethysmography can also be used. The prevalence of RERAs in the general population is relatively low, at approximately 3.8%. While RERAs have been scientifically validated as a sleep-breathing abnormality, their relevance as a specific disease and their cardiovascular consequences are still debated.
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RDI and AHI are used to determine treatment
Obstructive Sleep Apnea (OSA) can be diagnosed using either the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI). AHI and RDI both measure the quality of your breathing during sleep, but they focus on different aspects of breathing. AHI counts the average number of apneas and hypopneas per hour, while RDI counts the average number of apneas, hypopneas, and RERAs per hour. An apnea is when breathing stops for at least ten seconds, and a hypopnea is a partial obstruction of the airway.
RERAs (Respiratory Effort-Related Arousals) are similar to apneas and hypopneas in terms of their pathophysiology and complications. They are sudden changes in EEG frequency, consisting of alpha and theta activity or waveforms with a frequency greater than 16 Hz. They last for 10-15 seconds and cause a repeated waking of the brain as a result of a respiratory disturbance. While they are scientifically validated as a sleep-breathing abnormality, they may or may not be recognized and considered for treatment depending on the healthcare provider and insurance carrier.
The AHI has been the traditional measure used to determine the severity of sleep apnea and inform treatment options. However, many institutions and insurance providers are starting to recognize RERAs as an important indicator of the severity of the disease. This is because any respiratory event that lasts at least 10 seconds and causes an arousal can cause damage and should be treated.
There is currently no universal consensus on whether AHI or RDI should be the standard index used to determine treatment. While Medicare defines RDI as the average number of apneas and hypopneas (the same as AHI) and does not include RERAs, most commercial insurance companies refer to the AASM standards, which do include RERAs. This discrepancy between different insurance carriers can lead to confusion and inconsistent treatment approaches.
Calculating both AHI and RDI can give sleep specialists a clearer picture of abnormal breathing patterns and help determine the most appropriate treatment options. For example, a person may have a low AHI but a high RDI, indicating that while their airway is not obstructed, there are other factors causing breathing difficulties during sleep. By considering both indices, healthcare providers can develop a more comprehensive understanding of an individual's sleep-related breathing disorders and provide tailored treatment recommendations.
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Frequently asked questions
RERA stands for respiratory effort-related arousal. It is a limitation in breathing that results in increased respiratory effort and culminates in an arousal, but does not meet the criteria for apnea or hypopnea.
An apnea is when your breathing stops for at least 10 seconds while sleeping. Obstructive apnea meets the criteria of apnea and is characterised by continued or increased effort to breathe due to an obstruction of the airway. Central apnea is when there is no effort to breathe during the event, and mixed apnea is when there is no effort to breathe in the beginning followed by an effort to breathe in the second part of the event.
AHI stands for apnea-hypopnea index, which is the number of apneas and hypopneas per hour of sleep. RDI stands for respiratory disturbance index, which also includes RERAs. There is some debate over whether RDI should include RERAs, and this may depend on the insurance carrier involved.
The gold standard method for measuring RERAs is esophageal manometry, as recommended by the American Academy of Sleep Medicine (AASM). Nasal manometry or induction plethysmography can also be used.
RERAs have been scientifically validated as a sleep-breathing abnormality that can negatively impact health. They may be an indicator of the severity of a disease, and have been associated with cardiovascular risk and excessive daytime sleepiness.
