When to worry about centrals?

[FrederickRose]

So you are okay with being on APAP and having desats to the 50% range?
He sometimes has 2 hours of centrals...it's not like only 5 minutes of centrals.

No, I specifically said "I personally would not want to be on ASV if I had an AHI < 5 on CPAP" because I was not aware of any information provided outside of this thread. In the screenshot provided, it doesn't look like any of the centrals were particularly long in duration (all look to be less than 20s and most closer to 10s), and the AHIs he mentioned were less than 5. Or did I miss somewhere in this thread that he mentioned 2h of centrals?

And where did he say desat into 50% range?

EDIT: Maybe you are referring to his PSG, which I have not seen. From what has been stated in this thread, being in his shoes, I might go ahead and buy the ASV device (price is good and the PSG results mentioned suggest it may be needed at some point), but I would use it in CPAP or APAP mode until further discussion with the sleep specialist.

[Pugsy]

Or did I miss somewhere in this thread that he mentioned 2h of centrals?

I have seen them on other reports of his...either different thread here or the other forum. I forget which.

And where did he say desat into 50% range?

Hmmm.. My brain thought it saw it somewhere but now I can't find it. Obviously I misread something or other. He reporting below 88 with apap though for more than what we would like to see. He sent his doctor a copy of the pulse ox report.

At any rate...if his doctor is okay with his using the ASV (and he was originally going to do it straight away but elected to try apap first because of the altitude situation) then I think that is between him and his doctor and see no reason to go against what the doctor was willing to do and most likely would do later.
ASV was initially considered and doc was going to do that first...APAP was decided upon as a first try and then maybe later go to ASV. It's not like ASV was never a consideration. It was actually a first consideration and I assume that his doctor (cardiologist) would not have considered it if he was concerned about the use of ASV with this particular patient. It's not like I am trying to talk him in to doing something his doctor never thought about or wanted to do.
OP just doesn't want to wait until May or June to get the ASV because of all the hurdles that need to be jumped through. A reasonable thought about a machine that there's a good chance Medicare would pay for eventually anyway.

And besides...the ASV can be configured so that it can do lots of things. It doesn't have to be in full blown ASV mode if they don't want it.
Heck...they can make it work like plain old cpap if they want to. It's easy to adjust the available settings to "dumb it down" if they want to.

He could also use one of the ST machine but that means using the ventilator properties all night instead of just when needed...He doesn't seem to have any issues with centrals until the second half of the night...why use the ventilator all night when only needed for half the night???

He's not leaving his doctor out of the loop and relying on my playing doctor here.
Only thing he is doing is considering buying the machine himself instead of waiting until next spring.
I fully expect his doctor to be willing to help with the settings if he wants to buy the machine himself. After all it was the first consideration and it's painfully apparent that apap isn't going to be able to get the job done.

[Mogy]

Hi all, I really appreciate this frank discussion on when it is appropriate to move to ASV when you first find out about your complex apnea.
One issue that is important in Allissio77's case is that his original sleep study was done at 7200 ft, he lives at 3500ft.

[Mogy]

Hi FredricRose and Pugsy,
There are a couple of threads on Apneaboard that could use your good sense. They are pushing ASV at new posters that have Centrals that emerg when starting with CPAP therapy.
One thread makes me sick when I read it. He says he can't afford it but they keep pushing.
If you have the time thanks!

http://www.apneaboard.com/forums/Thread ... ght=Marine

http://www.apneaboard.com/forums/Thread ... -at-a-lost

[FrederickRose]

At any rate...if his doctor is okay with his using the ASV (and he was originally going to do it straight away but elected to try apap first because of the altitude situation) then I think that is between him and his doctor and see no reason to go against what the doctor was willing to do and most likely would do later.

I agree.

[FrederickRose]

Hi FredricRose and Pugsy,
There are a couple of threads on Apneaboard that could use your good sense. They are pushing ASV at new posters that have Centrals that emerg when starting with CPAP therapy.
One thread makes me sick when I read it. He says he can't afford it but they keep pushing.

I've tried a little bit over there under a different forum user name. It's tough because they have some forum leaders there who push pretty hard.

Even for primary CSA, most sleep medicine specialists would consider CPAP as first line PAP therapy. But over on AB, it seems the dogma is ASV first line.

[Pugsy]

One issue that is important in Allissio77's case is that his original sleep study was done at 7200 ft, he lives at 3500ft.

Yes...but he is now using the APAP at 3500 ft and still getting some fairly dense clusters of centrals. So while maybe not quite so many..still more than we could pooh pooh off especially with the desats and feeling not so great.
I am betting if he had a sleep study done at 3500 ft there would still be centrals showing up but maybe not quite so many.

It would be one thing if he had maybe 5 centrals over the entire second half of the night (on the apap) but he's having like 10 or more per hour (at times) over the second half of the night. So while overall AHI for the night might not be all that horrible...the 2 to 3 hours where the centrals seem to raise their ugly heads in large numbers and close together and giving CSR...it's pretty ugly and warrants a closer look for sure.
It was worth a try to see if apap would work...but I don't see it happening based on what I have seen from the OP and I have seen more than what is shown in this thread.

I don't frequent the apneaboard..personal reasons. If it floats your boat that's fine but it's a boat I don't care to get into. There's so much about that place that I disagree with that it is just best if I don't go there.

[FrederickRose]

It would be one thing if he had maybe 5 centrals over the entire second half of the night (on the apap) but he's having like 10 or more per hour (at times) over the second half of the night.

I've been wondering about that as a general issue. When experts write guidelines and reviews, they often refer to a number of events per hour of sleep without getting into the details of what to do when the index is okay for the night but terrible during certain parts of the night.

Meanwhile, the titration guidelines say "An optimal titration reduces RDI <5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings." That seems a very generous definition of "optimal" given the well established fact that PSG results can vary greatly from one night to the next and that 15 min is such a tiny fraction of even one night!

[Pugsy]

I've been wondering about that as a general issue. When experts write guidelines and reviews, they often refer to a number of events per hour of sleep without getting into the details of what to do when the index is okay for the night but terrible during certain parts of the night.

Meanwhile, the titration guidelines say "An optimal titration reduces RDI <5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings." That seems a very generous definition of "optimal" given the well established fact that PSG results can vary greatly from one night to the next and that 15 min is such a tiny fraction of even one night!

Yep. Sometimes the guidelines have holes in them but that's the way it is with a lot of this medical stuff. They have to have some sort of guideline but no real way to allow for exceptions that are out of the ordinary. Sometimes the medical community gets tunnel vision and can't see the over all big picture so great.

My OSA is REM dependent for the most part. Barely exciting in non REM (12 per hour over the entire night but with desats to 73% so while not very numerous...they were pretty darn long in terms of duration and harm to the body) but in REM 53 per hour and lord knows what the desats would be in REM and probably the only saving grace was I didn't get much REM because I kept waking up every time those apnea events started coming fast and furious.
There's no way to really catalog that 73% in non REM when establishing severity...so there's a big hole right there. AHI of 12....mild by the textbooks but 73% desat is far from mild in terms of what it can do to the body. Duration of event or how bad of a desat...not part of the criteria for establishing treatment or effectiveness of therapy.

[Mogy]

Hi Allissio77,
When I saw this last Feb is when I started to worry.

https://i.imgur.com/LdkpmsD.png

When I stopped worrying was about a month later. Still Centrals but significantly fewer.

https://i.imgur.com/no9Yjoq.png

Overview for year.
https://i.imgur.com/qqQpiFR.png

[Mogy]

Fairly common now and I feel very good even though I am not fully compliant.

https://i.imgur.com/Ws9CNjU.png

I still find it difficult to sleep the whole night with mask on.

[Pugsy]

When I saw this last Feb is when I started to worry.

That was with cpap.
How many centrals did you have on the diagnostic study when no cpap was used?

Centrals that pop up with cpap use and weren't present prior to cpap use...yes, in some cases they will reduce significantly in numbers and enough that apap/cpap is sufficient. Not everyone will get that lucky though. That's why ASV and ST machines are used...for those that aren't so lucky.

But if the primary diagnosis was central in the diagnostic test with no cpap being used and not obstructive sleep apnea the chances of fixing centrals with apap/cpap got a whole lot slimmer. Not impossible but a whole lot slimmer. That's what happened with the OP here. His diagnostic sleep study showed heavy centrals with very minimal obstructive. Not heavy obstructive and a few centrals. His centrals aren't cpap triggered...they were there without cpap.

Since altitude can be a factor and his original diagnostic sleep study was done at twice his normal altitude it probably will be a good idea to retest at his own living/sleeping altitude but that's something that can't be done where he lives until late next spring. His desats were significant on the diagnostic sleep study and he had well over 2 hours of CSR reported on the diagnostic sleep study. How much less would it maybe have been at the lower altitude...dunno but I have my doubts that it would have been enough to not be a concern.

Sometimes ASV or one of the ST NIV model machines is the first and right choice for some people. Especially so for the people that had a problem with centrals during the diagnostic sleep study and the didn't have a huge obstructive problem but maybe a minor obstructive problem (if any).

I know a woman on cpap/apap for over 2 years and her centrals were definitely pressure related....didn't have any without cpap and a truckload of centrals at the pressure needed to deal with her OSA. Over 2 years and she never had her body adjust to things for the centrals to reduce enough to not be a problem. 2 years is more than enough time to give cpap/apap a chance and see if the centrals will go away....they didn't in her case. Well past the time to move on to some sort of NIV therapy which she finally did. We tried everything under the sun to keep her on cpap/apap including an inordinate amount "giving it time".

[Mogy]

As we know, central sleep apnea occurs in everyone above a certain altitude, even people without apnea.

https://www.ncbi.nlm.nih.gov/m/pubmed/27343103/

Having a sleep study done at 7200ft complicates the issue.
If you read the report at this link it suggests that most people will adjust to the change it pressure in about a month. That is what happened to me when I started with CPAP.
Allessio77 is at 2 weeks. I encourage him to go another 2 weeks before he makes this decision. To me that does not seem like an inordinate amount to time to give his body the opportunity to adjust.
In the end, he is well informed and that is what is important when making this decision. I believe it is his decision, not his doctors. It is his life.

By the way, my sleep study at 2000ft said 0.7CAI. That is where it has settled on therapy.

[Allessio77]

As we know, central sleep apnea occurs in everyone above a certain altitude, even people without apnea.

https://www.ncbi.nlm.nih.gov/m/pubmed/27343103/

Having a sleep study done at 7200ft complicates the issue.
If you read the report at this link it suggests that most people will adjust to the change it pressure in about a month. That is what happened to me when I started with CPAP.
Allessio77 is at 2 weeks. I encourage him to go another 2 weeks before he makes this decision. To me that does not seem like an inordinate amount to time to give his body the opportunity to adjust.
In the end, he is well informed and that is what is important when making this decision. I believe it is his decision, not his doctors. It is his life.

By the way, my sleep study at 2000ft said 0.7CAI. That is where it has settled on therapy.

Mogy, Just to be clear. I live permanently at 3500 ft. I had (unfortunately) my studies done at 7200 ft. I am on day 16 of my APAP at 3500 ft. Last night I had 20 CA's in the last half of the night.

[Pugsy]

As we know, central sleep apnea occurs in everyone above a certain altitude, even people without apnea.

Yes.
But it also occurs in people not at altitude for any number of reasons and sometimes those reasons will prevent the "give it time" thing from working.

You didn't have centrals prior to starting cpap...so your situation isn't necessarily the same situation as OP here who had a large number of centrals without even being on cpap. Yes, he should have had a sleep study without cpap at his altitude...but he didn't and it's not possible to get one anytime soon and he doesn't want to wait 4 or 5 months. I can't say as I blame him.

Give it time doesn't work for everyone and especially the people whose centrals were a problem before cpap was even started.
Yes, give it time works for some people when cpap is the cause of the centrals but it doesn't work for everyone...hence my example of the woman I know who had been on cpap for over 2 years and her centrals were directly related to cpap pressures and after 2 years they still were a problem.
Give it time doesn't always work. It worked for you...that's wonderful so you need to remember the big sticker that comes with all this cpap stuff...YMMV.