Low CA at sleep lab, high CA at home

[HoseCrusher]

If you want to play a little...

Try moving both your minimum and maximum up 1 cm H2O for a few nights. That would put you in the range of 8 - 11.

[avi123]

If you want to play a little...

Try moving both your minimum and maximum up 1 cm H2O for a few nights. That would put you in the range of 8 - 11.

comment,

Raising the max pressure to 11 cm is likely to get rid of the obstructives but increase the centrals. But it worth a try.

So far, central aponeas are dominating Papit's results.

[robysue]

Papit,

Here are my comments about your situation. First, a quick review of some pertinent numbers:

(From the first post in the thread)
Pretreated numbers from my Nov2011 sleep lab were: CA 5.2, OA 24.1, HA 8.1 >>> 37.9 AHI. (RERA was 29.9, giving a DBI of 68.)
Those numbers over previous 7 weeks,CPAP 8 cmH2O: CA 6.4, OA 0.7, HA 0.6 >>> 8.5 AHI, 95%Leak 8.4, Slept 7.15 hours avg.
Those numbers over past three weeks,CPAP 7 cmH2O: CA 9.2, OA 0.4, HA 0.7 >>> 10.7 AHI, 95%Leak 2.4, Slept 4.53 hours avg.

(Most recent numbers)
My averaged numbers for the four days that I’ve been using the S9 Autoset in Auto mode, and the stats for the past 10 days, are shown below along with CMS-50 pulse ox data (lowest desat reading and total time spent at 90% desat level and below) which have also improved. Below the stats are last night’s screen shots produced by both ResScan and Sleepyhead. I use them both. Hopefully, this four-day trend is real and will hold.

April 19 to 22 Averaged CA: 5.3, OA: 0.7, 95%LK: 9.8, AHI: 6.3 , Oxd: 87.3; T<90: 1.3 min.
___________________
April 22, 2012 Night 136 CA: 3.0, OA: 0.0, 95%LK: 10.0, AHI: 3.6 , Oxd: 88; T<90: 0.4
April 21, 2012 Night 135 CA: 5.5, OA: 1.2, 95%LK: 9.6, AHI: 7.1, Oxd: 87; T<90: 2.2
April 20, 2012 Night 134 CA: 7.1, OA: 2.2, 95%LK: 10.0, AHI: 9.8, Oxd: 87; T<90: 2.1
April 19, 2012 Night 133 CA: 5.0, OA: 0.2, 95%LK: 9.6, AHI: 5.4
___________________
April 18, 2012 Night 132 CA: 11.9, OA: 0.1, 95%LK: 2.4, AHI: 12.9, Oxd: 83; T<90: 0.4
April 17, 2012 Night 131 skipped cpap Oxd: 75; T<90: 24.1
April 16, 2012 Night 130 CA: 17.8, OA: 1.3, 95%LK: 0.0, AHI: 20.4, Oxd: 80; T<90: 9.8 (seconds??)
April 15, 2012 Night 129 CA: 6.6, OA: 0.0, 95%LK: 0.0, AHI: 6.9, Oxd: 86; T<90: 1.6
April 14, 2012 Night 128 CA: 8.4, OA: 2.5, 95%LK: 3.6, AHI: 10.9, Oxd: 83; T<90: 4.8
April 13, 2012 Night 127 CA: 3.3, OA: 0.2, 95%LK: 2.4, AHI: 3.8

Your pretreatment numbers indicate that CAs were already a clinically significant problem in that the CAI > 5. Of course, pretreatment, the number of CAs paled in comparison to the number of OAs.

As you've commented throughout this thread, the OAs and Hs have responded nicely to PAP therapy: The non-CA part of your treated AHIs is consistently below 5 and usually well below 5. Indeed, the OAI+HI numbers appear to be consistently below 3 and usually below 2.

But the CAs have not responded positively to therapy, and indeed, as others have commented, it's easy to say that the CAs have responded negatively to straight CPAP therapy by increasing during the 15 weeks of straight CPAP. The O2 saturation numbers also look like they continue to be a problem, although I'm not quite sure if the units are seconds or minutes on some of the lines. So it's reasonable to conclude that any remaining sleep apnea-related problems are indeed connected to the remaining CAs.

Four days of APAP therapy data is not enough to be confident of detecting a trend. But the early evidence is that the CA data seems to be moving in the right direction, as is the O2 data. We can hope that it continues to move in this direction. If the CAI continues to slowly decrease or even hold steady for the next week or so, prudent watchful waiting may be a reasonable course of action to take for the next few weeks. But if that CAI starts to climb again or winds up leveling out at >5 or the O2 numbers start to deteriorate, then its definitely time to follow up on JohnBFisher's excellent advice and insist on a consult with a neurologist.

In this thread you specifically note:

I understand, Pugsy. Except for two replies, in the absence of suggestions from all of the group's most active members it's been looking like my 'dominant central apneas' syndrome has everybody stumped. My doc has been focused on the problem for awhile now, but he seems rather clueless. He dropped my pressure from 8cm to 7 three weeks ago, and CA worsened. It's strange how the trend developed. Centrals never did come down much from the 5.2 CA measured during the lab test, while OA came down very nicely from 24.1 to now consistently under 3 and often under 1.0.

It's not a surprise at all that the CAs have not come down on straight CPAP: After all, CPAP (and APAP) are not really designed to deal with clinically significant central sleep apnea. Sometimes (maybe even most of the time) the CAs do come down when someone is put on CPAP because of an overwhelming number of OAs. I think the theory is that for some folks with severe OSA, some/most of the CAs are simply caused by the CO2 levels getting out of whack due to the repeated cycles of OA, severe O2 desat, followed by large recovery breaths. It's possible to hyperventilate during those recovery breaths I suppose. And that could cause some centrals to sneak into the untreated OSA breathing pattern. And when the OSA is fixed, that particular pattern goes away. And if that was the root cause of the CAs, the CAs disappear. But if the CAs are caused by some other medical condition---i.e. their root cause is NOT periodic hyperventilating after the OAs, those CAs are going to remain even after the OAs are titrated away and the OSA is under control.

And that seems to be what might be going on with you: There's a good chance that you actually have CAs caused by something other than severe OSA, and now that the OSA is under control, the CAs are still being caused by whatever it is that's causing them. And perhaps you are also one of the unlucky PAPers who is sensitive to pressure in the sense of having pressure induce additional CAs as well. So we look to other things in your medical history: And it's certainly clear from other parts of this thread that you have multiple health/sleep issues going on:

• average sleep time has fallen off from 7.15 to 4.53 hours per night
• Gerd problems, including a switch of meds from Nexium to Prevacid
• polymyalgia rheumatica, which is treated with prednisone, but you are also in the process of being weaned off the prednisone, which is a tricky thing to do; and it's the second attempt at weaning you off the prednisone

And all of these are also capable of adversely affecting your sleep. Are they capable of inducing CAs? I'm not a doctor, and I haven't the foggiest. But you also note:

As I related in earlier posts, I have polymyalgia rheumatica. That and my "severe overall obstructive disordered breathing (RDI 68) that is associated with . . . oxygen desaturations to 80%,” were both diagnosed in Nov. 2011 (by separate docs). They are each aware of both conditions.
I have been treated for the polymyalgia (with prednisone). One of the reasons why I love this site is the open sharing of personal medical information by so many contributing members. Late today I came across another thread about " Central Sleep Apnea - More info?,” started by Morfenmom, viewtopic.php?f=1&t=76618&p=700479&hilit=fibromyalgia#p700479. He reports in his thread that, “The fact that I have central SA surprised the doc but then as he was taking my history (Fibromyalgia . . .) he said it made more sense.” A lookup of my and his “myalgia’s” suggests some neurological commonality. So that may be a promising track to ask the neuro/sleep doc about. Thank you, Morfenmom.

And so I do think that some pointed questions to both the sleep doc and the doc treating the polymyalgia rheumatica are in order. It would be wonderful if you could get the docs to actually talk to each other instead of simply sending memos about your last visit back and forth.

The long-term upshot of all this is, however, the following pertinent question for your sleep doctor: If the CAI does not come down in the next few weeks and stay there, should you be moved to a different machine? And if so, should that machine be a BiPAP/VPAP ST or an ASV? It's well worth raising the issue of how much longer the sleep doc wants to wait before sending you off for a bi-level ST or ASV titration study.

As for your other data:

The 95% leak rates for the APAP nights are all still well under the 24 L/min RedLine. Don't worry about leaks unless they're waking you up or keeping you from getting to sleep. You have bigger fish to worry about than leaks at this point.

Usage time is still problematic. And if you are using the mask the whole time you are asleep (except that day you didn't use the mask at all as an experiment), then your sleep time is problematic. It's all over the place: Some nights you get 3 hours, some you get 8 hours. You may be able to get to sleep more quickly and stay asleep more soundly if you work on cleaning up the sleep hygiene by establishing a more regular WAKE UP TIME seven days a week followed by a more regular bedtime that is about 7 or 8 hours before your WAKE UP TIME. It won't help with the CA problem, but getting quality sleep takes more than just solving the CAI problem: You need to actually be sleeping with the mask for an appropriate period of time every night.

"Papit, are your above graphs of 3 hours a section of longer time? I am wondering what caused the pressure to go up to 10 cm at 4:15 a.m.?"

Thanks for the scrutiny. I got to bed late and had a short night of it. Interesting question you have. Maybe some of our more experienced members can jump in here about that. My guess? Well, check out the similarity with the pressure graphs on the 19th and especially on the 20th. That makes 3 out of 4 nights that I've been using the Auto mode that the high end pressure got "pinned" at 10 cm, at least for a time (multiple times on the 20th). My guess is the graphs are talking to me and saying, "Hey, buddy, you may need a higher maximum pressure setting for your APAP pressure range."

Many (if not most) of your pressure increases are not happening because of obstructive events. The Flow Limitation graph is cut off in the relevant posts and the snore graph is not present.

My guesses on the pressure graphs: The rises in pressure to 10cm are probably being triggered by a combination of flow limitations and snores along with an increasing leak. Whether the leak is caused by the pressure increase or the pressure increase is driven in part by the leak is not particularly relevant if there are flow limitations or snoring going on.

And I would NOT conclude that you need to bump that max pressure up to 11cm! Particularly since you are fighting CAs of unknown origin. Now---if those pressure peaks/plateaus at 10cm were being accompanied by a mass of OAs or Hs, I might feel a bit different. But as it is, there are no obstructive events or very few obstructive events that occur during those pressure peaks AND you've got the CAs to deal with. Leave the top pressure alone.

[avi123]

delete, Papit is not replying.

[HoseCrusher]

RobySue, the suggestion to set the pressure a little higher was based upon two observations.

The first is that oxygen saturation is below 90%, and the second is because the machine is topping off at 10. While the machine is not scoring obstructive events, some obstruction is taking place as evidenced by the lower O2 levels.

While I am not sure that an increase in pressure will resolve the O2 levels, I think it is worth a try.

[Papit]

Thanks so much, robysue, for the thorough review and feedback. You covered all the bases that you could, given the data I posted. I am in the process now of following up with both of my docs and, as you and others who have contributed generously on this thread suggest, I have begun searching for an MD accomplished, and practicing, in both neurological and sleep medicine. I'm open to MD recommendations in this highly specialized niche from anybody in our forum who has been treated effectively by such docs. Both Raleigh and Baltimore are not too far from the Washington DC area near where we live.

I need to clarify and fill a couple gaps in the data I posted earlier. All T<90 figures (total time spent at 90% desat level and below) are now confirmed as in minutes, not seconds, including 9.8 minutes and lowest desat at 80% on 4/16 per the Sp02 Report below, and 24.1 minutes and lowest desat at 75% on 4/17 excluding artifacts. However, I had no headaches upon arising or afterward. In addition, as you noted, the charts I posted were lacking in Snore and Flow Limitation. My Snore is hardly there and Flow Limitation seems moderate I think. They are shown here below along with the other relevant graphs for my last sleep on cpap and, with the passage of a couple more days, the following six sleeps on apap.

Perhaps with these clarifications you may have additional comments. Once more, thank you (thank you all), and I will keep you posted as we move ahead with this.

[avi123]

Your last (6th) graphs on APAP don't show the ending. This is b/c you set the window total time at 8 hrs instead of 10 hrs.
In this case an aditional Statistics window would be helpful.

Something like this:



Also, if you change your mask to a plain nasal such as the Resmed Mirage Softgel or Activa, etc. plus a chinstrap, then imo, your leaks would drop and thus the rise in pressure could be avoided, unless the rise is related to your Flow Limitation. Still, with a new mask I would try to raise the max pressure to 11 cm and leave the min pressure at 7 cm. It might knock off those few obstructives left.

I mean here:



Your Flow Limitation is not much worse than my and in my case it did not raise the pressure.

See it here:






p.s. it seems to me that in my case the pressure at 00.00 hour and 5 to 6 a.m. is hugging the 9 cm min pressure. So I should reduce it to 8 cm and the max reduce to 12 cm.

[Papit]

I set it for 8 hours of display time, Avi, because my sleep time for that night was 1:36 - 9:21 am, just under 8 hours.
Look at it full screen on your monitor. Here's the Statistics page you asked about for that session.

[avi123]

Thanks Papit. You may qualify for an ASV machine if you meet these:


The following information is from the CMS web site on Respiratory Assist Devices

for Central sleep apnea, defined as:

1. Study showing AHI > 5 events/hr. and
2. Central apneas/hypopneas greater than > 50% of the total apneas/hypopneas, and
3. Central apneas or hypopneas >=5/hr., and
4. Symptoms of either excessive sleepiness or disrupted sleep.

for Complex sleep apnea

CompSA is a form of central sleep apnea specifically identified by the persistence or emergence of central apneas or hypopneas upon exposure to CPAP or an EO470 [Bi-level] device when obstructive events have disappeared. These patients have predominantly obstructive or mixed apenas during the diagnostic sleep study occurring at >= 5 times per hour. With use of a CPAP or EO470 [Bi-level], they show a pattern of apneas and hypopneas that meets the definition of CSA described above.

If you're interested to check what kind of Central Apnea you might have then you could check your respiration waves patterns.

You need to have the FLOW and the EVENTS graphs in your upper panel like this:



Are you familiar with this:

http://montfordhouse.com/cpap/resscan_tutorial/

Then pick a central apnea flag and center the lower panel on it. Next, reduce the time scale to 5 min. Next, scroll the lower panel horizontally to find Sheyne Stokes or Periodic Breathing pattern of waves in the FLOW graph. Usually, after a central apnea on the graph. Next, take a screen shot of it and post it here.

Sheyne Stokes. It is waxing and waning :



Periodic Breathing. Wave patterns that repeat after central apneas:




Lately, I been using the ScreenHunter 6 Pro software to take screen shots. It's free for ... but then it expires. To renew they charge $30.
License Agreement Copyright ©2012 Wisdom Software Inc.

[Papit]

Good find. Thanks for the info. I hope I don't need it, but I do see the real possibility now.

Check out another thread I began earlier this evening,

viewtopic/t77234/I-Ran-this-TEST-on-My- ... n-too.html

[Papit]

Oh crap...I just realized that I spelled idiopathic wrong. ...

When I'm talking about myself, "idiotic" seems more accurate than "idiopathic".

Not to us, John! We all know better than that. You and your finally discovered super doc did a great job and you continue to share with us. Kudos, man!

[Papit]

... I think that I am going to contact John Fisher's Doc whom he mentioned before, if and when I'll have problems with my sleep. ...

". . . He started in emergency medicine (so has a very calm demeanor). He can come across as gruff and no nonsense. However, he is a straight shooter . . . And he actually enjoys having patients that are involved in monitoring their own therapy"

Is he a neurologist MD as well, John. I haven't forgotten the message that you, Pugsy, avi, robysue et al sent me earlier.

[Papit]

. . . You may qualify for an ASV machine if you meet these:
The following information is from the CMS web site on Respiratory Assist Devices
for Central sleep apnea, defined as:
1. Study showing AHI > 5 events/hr. and
2. Central apneas/hypopneas greater than > 50% of the total apneas/hypopneas, and
3. Central apneas or hypopneas >=5/hr., and
4. Symptoms of either excessive sleepiness or disrupted sleep.
for Complex sleep apnea
CompSA is a form of central sleep apnea specifically identified by the persistence or emergence of central apneas or hypopneas upon exposure to CPAP or an EO470 [Bi-level] device when obstructive events have disappeared. These patients have predominantly obstructive or mixed apeneas during the diagnostic sleep study occurring at >= 5 times per hour. With use of a CPAP or EO470 [Bi-level], they show a pattern of apneas and hypopneas that meets the definition of CSA described above.

If you're interested to check what kind of Central Apnea you might have then you could check your respiration waves patterns. You need to have the FLOW and the EVENTS graphs in your upper panel . . .[Sheyne Stokes or Periodic Breathing pattern of waves in the FLOW graph. Usually, after a central apnea on the graph. Next, take a screen shot of it and post it here.
Sheyne Stokes. It is waxing and waning . . . Periodic Breathing. Wave patterns that repeat after central apneas. . . . "

Yes, I'm interested, but it took a while to get myself to take a look. Today I did it. The charts are posted below (too many, I know). I find them somewhat disquieting as I'm seeing a fair amount of periodic wave patterns, some in the absence of apnea (maybe present, but undetected ones?); and some periodic patterns that immediately follow central apneas. Except for very few obstructives and an occasional hypopnea, the only apnea I have these days are centrals. Fixed Cpap at 8 (now 7cm) and Apap at 7-10cm --both with EPR set at 3 full time-- have done a great job on the OA.
Last night, as a trial test to see if a lower EPR setting might reduce centrals (nothing else has), I changed EPR from 3 to 2. But the Centrals moved up from an average 6 to 10 last night. I know, that was just one night. Anyway, here are a TON of the kind of charts you suggested I make. I saved the graphs as I did the study, not just on one Central, but most of the more obvious central events that were detected last night. I mainly used Sleepyhead so I could include time-aligned oxygen and pulse rate graphs.

Thoughts and comments are invited from all, and especially from those more knowing than average about centrals, my main nemesis. These pictures make me a bit nervous. (They got my pulse racing some just looking at 'em.) Yes, of course I'll show them to my doc, but I'd like very much to have 2nd, 3rd, etc. opinions.) G'night all and thanks.

Note: The time span beginning at 4:48am is rather dramatic. Ditto the charts at 6:26, 6:38 and 7:46am, all of which show Tidal Volume/respiration jumping up and down apparently in time with the rhythmic periodic patterns. Is that typical and common?

[avi123]

Papit, you have a Central Sleep Apnea Syndrome (CSAS). Instead of hurrying to see a proper doctor to take care of you, you're wasting time on this board with all kinds of posts. IMO, the S9 Autoset is not the machine for you. robysue, also posted this: The long-term upshot of all this is, however, the following pertinent question for your sleep doctor: If the CAI does not come down in the next few weeks and stay there, should you be moved to a different machine? And if so, should that machine be a BiPAP/VPAP ST or an ASV? It's well worth raising the issue of how much longer the sleep doc wants to wait before sending you off for a bi-level ST or ASV titration study.

[Papit]

Thanks so much, Avi, for the concern and for having taken the time to back me up on my uncommon centrals condition. Your focus and analysis of close-up 5-minute graphs has taught me a lot. Most of us aren't accustomed to zooming in like that.
Don't worry, I'll get my charts to my doc and will be seeing him next week. Posting my graphs here could be helpful to others in coming up the same learning curve so I don't mind doing it. And it helped contributors like you to help me.