Can't get AHI below 38

[Morbius]

Original diagnostic sleep study was a home study of some sort where something was put over the head like a cap of sorts.

Something like this?

[tedburnsIII]

How can we tell that all Apneas are central? Not sure how to read.

There's no flow limitation, snoring, or resuscitive burst.

Morbius-

As one with a machine not compatible with SleepyHead, I'd appreciate learning what Flow Limitation actually means and represents, what is considered normal FL, why no flow limitation may be one indicator to you that clearyt's aps may be central and not obstructive.

Also curious why no snoring or resuscitive burst is an indicator. What is resuscitive burst?

Thanks in advance.

[kaiasgram]

EF = ejection fraction?

Right. If the diagnostic is also all centrals, but the EF is <45%, we might have an issue trying to get an ASV.

I took a quick look at a ResMed brief and I understand why you're saying this. Thanks.

[clearyt]

I really wish I could get a handle on this before I try to talk with cardiologist Thursday. I don't know what some of the abbreviations mean. And especially how they are related. Can anyone help? I so appreciate all you are doing to help.

[kaiasgram]

clearyt, just sent you a PM with some explanations.

[Morbius]

It would be really nice if that was the case because having a sleep study done in a lab setting is way down on the "I want to do" list.

In addition to knowing the EF, in order to try to avoid in-lab study, it is critical to know the type of device used in the first HST. If it was Watermark ARES, that device uses hoodoo technology ("forehead venous pressure") to assess effort (essential to confirm central apnea)(while I am absolutely certain beyond a shadow of a snowball's chance of one in a million as sure as the sun rises in West (GoT reference) that this is CSR (Julie and SH were correct), "some nut on the internet told me" is not diagnostic enough to get an ASV). Anyway, it is very likely that most to all of the apneas on HST were central as well (keeping in mind 12% of CSR patients have OSA, so there could have been/be some OSA).

Anyway2, another diagnostic HST would probably be fine if the device could actually measure effort (like ApneaLink Plus or NoxT3).

The long cycle time is important in 3 (at least) ways:

• That's what makes this CSR (instead of CompSAS)
• 75 seconds is really long cycle time. If this is CHF-related, a good question to ask the cardiologist is "Is it being optimally treated?"
• Looking at the time spent in CSR, it may be that your apnea has actually gotten worse as your AHI went from 55 to 38 because the apneas have gotten longer (maybe there is a little bit of CompSAS in there as well) and you just can't stuff as many in there in the time allotted.

[Morbius]

Can you PM me for a few more details that I can't/won't share publicly until I get the OK from the OP?

PM on, sorry, skipped over this last night.

[clearyt]

Publicly discussing this is fine. I truly thank you for all you are doing in assessing this, and maybe it will help someone else. I understand what you are saying, Morbius, about not attributing my "insight" to someone on the Internet. I will pretend I actually have studied the charts and think I see something. The only problem I will have is being able to intelligently state anything. If you could give me a few simple statements to describe what I'm worried about, it would be great! I have decided that a sleep study might be a good idea. What type of study do you recommend? I want to get to the bottom of this.

[Morbius]

Sure!

Start out with:

"What's my ejection fraction?"
"Where are the results from my HST and what device did they use to do it with?"

[clearyt]

HST was done by pulmonologist. This visit is cardiologist. But he would know EF from last echo I guess. I'm taking the charts. What should I point out?

[Pugsy]

Take the reports and point out the AHI and the breathing pattern that is shown in green on the one set of wave form graphs I sent you to print out.
That Periodic Breathing/ CSR pattern pretty much speaks for itself. The machine may be calling them Obstructive Apneas but they are centrals.

He needs a different type of machine to help his breathing while asleep to become stable. The machine you have now can't address the centrals. There is another type of cpap machine that can address those apnea events...it's called an ASV type of machine (Adapto Servo Ventilation).
To get Medicare to pay for it (and it's a pricey little machine)....gotta have a sleep study (at home or in a lab) that documents the centrals. There are home sleep studies that can do it but it takes a more comprehensive home setup for testing than just a little cap thingy on the head.

Also with ASV use the heart needs to be in decent shape...hence the questions about the ejection fraction.

If the cardiologist just looks glassy eyed when you show him the reports and talk about Cheyne Stokes Respiration...ask him to point you to a doctor that actually specializes in this sort of stuff..
Now he may know about it already...give him a chance.

So take both reports that I sent you as attachments...print them out.
The one with the green all over it...that's the flow rate/wave form breath by breath graphs....that's showing the CSR breathing in detail.
The other report shows the overall AHI and graph detail...showing that this stuff has been going on for a long time and that one night isn't a random fluke bad night.
Might also take the SD card but I doubt they can use it but just in case slip it in your purse.
If you need more of those wave form reports (the one's with all the green) I think I can still get them but I would need to use a different Encore program.

[clearyt]

I do have the reports you sent printed. The green indicates PB, right? What does that signify? How do I explain that the OAs are really CAs? I sent you an email.

[Pugsy]

Green is PB and in this case also CSR....don't mention that the machine is flagging OAs at this point. It doesn't really matter what those events are called anyway but what is happening is the breathing is such that the machine doesn't really know what to do in this situation and it can't tell exactly what the actual event is.

What I would do if it were me..
I would say...."this is clearly not working and from what I have read this AHI and this type of breathing points to something else going on besides plain obstructive sleep apnea and very likely is central sleep apnea and I want it fully evaluated by someone who understands what these reports say and will do something about it"
then I would plop the reports right down in front of the doctor with the green wave form graphs right on top and point to the obvious pattern in green.
If he knows his stuff...he will be able to talk about what is going on and what is causing the breathing pattern...if he can't explain it....tell him to point you to a sleep doctor specialist who does know about Cheyne Stokes Respiration and Periodic breathing and ASV machines.

And get that echo with all the documentation about the ejection fractions dug out of the records and have it in your hot little hands.

[Pugsy]

Here's last night's report.
Changed the mask to the Respironics FitLife (the one that covers the entire face).
Interesting results...AHI is lower and the first part of the night the report was actually quite decent and the latter part when things got ugly the machine actually flagged a bunch of CAs/Centrals.

[Morbius]

A pretty good example of the birth of a CSA salvo (see viewtopic.php?f=1&t=96126&p=889893&hili ... e+#p889893 if you feel like shooting yourself in head):



But here you can see a few deep breaths turn the marginally unstable breathing into a CSR string.