CSA

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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Todzo
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Re: CSA

Post by Todzo » Mon Apr 14, 2014 5:04 pm

If he is proscribed a CPAP he might want to talk with his doctor about EERS[1,2].

[1] Gilmartin G; McGeehan B; Vigneault K; Daly RW; Manento M; Weiss JW; Thomas RJ. Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS). J Clin Sleep Med 2010;6(6):529-538.

We hypothesized that manipulation of arterial carbon dioxide levels might provide an alternative treatment strategy. Specifically, keeping PCO 2 just over the apnea threshold would be predicted to buffer chemoreflex influences and make the disease more purely obstructive in physiology, thus remaining responsive to positive airway pressure treatment. Central apneas and periodic breathing can be generated when the arterial PCO 2 level falls below that required to stimulate respiration, a setpoint that is unmasked during sleep. 11 Preventing hypocapnia is a powerful stabilizing influence on sleep respiratory control.


[2] David M. Rapoport, M.D. Stabilizing Ventilation in OSAHS with CPAP Emergent Periodic Breathing Through the Use of Dead Space . J Clin Sleep Med. Dec 15, 2010; 6(6): 539–540.

“Ventilatory instability” in OSAHS can be understood as an intermittent “overshoot” of ventilation, thought to be due to two factors. At the end of apnea/hypopnea, there is a simultaneous relief of airway obstruction and a transient increase of ventilatory effort that is part of the arousal. Together, these produce a transient hyperventilation and consequent drop in alveolar and arterial PCO2. Perhaps due to excessive overshoot, mechanical reflexes or “chemosensitivity” to CO2, this transient fall in CO2 initiates repetitive cycles of “central” hypopneas/apneas and hyperventilatory intervals. While usually transient, these cycles of respiratory oscillations appear to persist in a subset of patients despite removal of the obstructive component. Clinical consequences and loss of benefit from CPAP may result as the obstructive cycles are replaced by central ones with similarly disrupted sleep, and poor CPAP compliance and clinical outcomes are not surprising. Many of the patients in the current report had this presentation.

Appreciation of the role that “instability” may play in periodic breathing suggests that blunting respiratory “overshoot” should be helpful—even if the original pathology was predominantly obstructive and is now treated with CPAP. Two approaches have been taken to “stabilizing” ventilation: adaptive servoventilation provides a variable “boost” to ventilation in the form of pressure support, thus damping the expression of varying respiratory drive; adding dead space to the ventilator circuit blunts the effect of hyperventilation on CO2 and thus stabilizes ventilatory drive itself. Either approach effectively provides a “shock absorber” that reduces oscillations of effective ventilatory output and thus prevents the initiation of cycling.
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49er
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Re: CSA

Post by 49er » Mon Apr 14, 2014 6:08 pm

Todzo,

This is an experimental treatment for people who have emergent CSA as the result of pap therapy for OSA. Someone prescribed a CPAP for routine OSA is not going to be prescribed this.

49er


Todzo wrote:If he is proscribed a CPAP he might want to talk with his doctor about EERS[1,2].

[1] Gilmartin G; McGeehan B; Vigneault K; Daly RW; Manento M; Weiss JW; Thomas RJ. Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS). J Clin Sleep Med 2010;6(6):529-538.

We hypothesized that manipulation of arterial carbon dioxide levels might provide an alternative treatment strategy. Specifically, keeping PCO 2 just over the apnea threshold would be predicted to buffer chemoreflex influences and make the disease more purely obstructive in physiology, thus remaining responsive to positive airway pressure treatment. Central apneas and periodic breathing can be generated when the arterial PCO 2 level falls below that required to stimulate respiration, a setpoint that is unmasked during sleep. 11 Preventing hypocapnia is a powerful stabilizing influence on sleep respiratory control.


[2] David M. Rapoport, M.D. Stabilizing Ventilation in OSAHS with CPAP Emergent Periodic Breathing Through the Use of Dead Space . J Clin Sleep Med. Dec 15, 2010; 6(6): 539–540.

“Ventilatory instability” in OSAHS can be understood as an intermittent “overshoot” of ventilation, thought to be due to two factors. At the end of apnea/hypopnea, there is a simultaneous relief of airway obstruction and a transient increase of ventilatory effort that is part of the arousal. Together, these produce a transient hyperventilation and consequent drop in alveolar and arterial PCO2. Perhaps due to excessive overshoot, mechanical reflexes or “chemosensitivity” to CO2, this transient fall in CO2 initiates repetitive cycles of “central” hypopneas/apneas and hyperventilatory intervals. While usually transient, these cycles of respiratory oscillations appear to persist in a subset of patients despite removal of the obstructive component. Clinical consequences and loss of benefit from CPAP may result as the obstructive cycles are replaced by central ones with similarly disrupted sleep, and poor CPAP compliance and clinical outcomes are not surprising. Many of the patients in the current report had this presentation.

Appreciation of the role that “instability” may play in periodic breathing suggests that blunting respiratory “overshoot” should be helpful—even if the original pathology was predominantly obstructive and is now treated with CPAP. Two approaches have been taken to “stabilizing” ventilation: adaptive servoventilation provides a variable “boost” to ventilation in the form of pressure support, thus damping the expression of varying respiratory drive; adding dead space to the ventilator circuit blunts the effect of hyperventilation on CO2 and thus stabilizes ventilatory drive itself. Either approach effectively provides a “shock absorber” that reduces oscillations of effective ventilatory output and thus prevents the initiation of cycling.

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BlackSpinner
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Re: CSA

Post by BlackSpinner » Mon Apr 14, 2014 6:18 pm

Todzo why are you going on about obscure problems the vast majority of people don't have? For the most cpap works fine. Sure some have an issue getting their heads around using one but that is a support and mental health issue.

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Todzo
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Re: CSA

Post by Todzo » Tue Apr 15, 2014 2:04 am

Todzo wrote:If he is proscribed a CPAP he might want to talk with his doctor about EERS[1,2].

[1] Gilmartin G; McGeehan B; Vigneault K; Daly RW; Manento M; Weiss JW; Thomas RJ. Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS). J Clin Sleep Med 2010;6(6):529-538.

We hypothesized that manipulation of arterial carbon dioxide levels might provide an alternative treatment strategy. Specifically, keeping PCO 2 just over the apnea threshold would be predicted to buffer chemoreflex influences and make the disease more purely obstructive in physiology, thus remaining responsive to positive airway pressure treatment. Central apneas and periodic breathing can be generated when the arterial PCO 2 level falls below that required to stimulate respiration, a setpoint that is unmasked during sleep. 11 Preventing hypocapnia is a powerful stabilizing influence on sleep respiratory control.


[2] David M. Rapoport, M.D. Stabilizing Ventilation in OSAHS with CPAP Emergent Periodic Breathing Through the Use of Dead Space . J Clin Sleep Med. Dec 15, 2010; 6(6): 539–540.

“Ventilatory instability” in OSAHS can be understood as an intermittent “overshoot” of ventilation, thought to be due to two factors. At the end of apnea/hypopnea, there is a simultaneous relief of airway obstruction and a transient increase of ventilatory effort that is part of the arousal. Together, these produce a transient hyperventilation and consequent drop in alveolar and arterial PCO2. Perhaps due to excessive overshoot, mechanical reflexes or “chemosensitivity” to CO2, this transient fall in CO2 initiates repetitive cycles of “central” hypopneas/apneas and hyperventilatory intervals. While usually transient, these cycles of respiratory oscillations appear to persist in a subset of patients despite removal of the obstructive component. Clinical consequences and loss of benefit from CPAP may result as the obstructive cycles are replaced by central ones with similarly disrupted sleep, and poor CPAP compliance and clinical outcomes are not surprising. Many of the patients in the current report had this presentation.

Appreciation of the role that “instability” may play in periodic breathing suggests that blunting respiratory “overshoot” should be helpful—even if the original pathology was predominantly obstructive and is now treated with CPAP. Two approaches have been taken to “stabilizing” ventilation: adaptive servoventilation provides a variable “boost” to ventilation in the form of pressure support, thus damping the expression of varying respiratory drive; adding dead space to the ventilator circuit blunts the effect of hyperventilation on CO2 and thus stabilizes ventilatory drive itself. Either approach effectively provides a “shock absorber” that reduces oscillations of effective ventilatory output and thus prevents the initiation of cycling.
Rudy you live in Europe. Your symptoms do indicate a propensity toward high respiratory control loop gain and likely low arousal threshold. I think that CPAP is likely to not work for you as it tends to exacerbate both, respiratory gain for sure and low arousal threshold either through the respiratory gain or by pressure changes and noise.

As well as EERS[1,2 in history above] there is also Dynamic CO2 therapy[3] which several years ago was reported to me as being available in Europe. Please let us know if you find it.

Thanks!

[3]: Dynamic CO2 therapy in periodic breathing: a modeling study to determine optimal timing and dosage regimes
Yoseph Mebrate, Keith Willson, Charlotte H. Manisty, Resham Baruah, Jamil Mayet, Alun D. Hughes, Kim H. Parker and Darrel P. Francis
J Appl Physiol 107:696-706, 2009. First published 23 July 2009; doi: 10.1152/japplphysiol.90308.2008
Link: http://www.ncbi.nlm.nih.gov/pubmed/19628721
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Re: CSA

Post by Julie » Tue Apr 15, 2014 5:35 am

Todzo - it's not your place to advise people not to use Cpap - it's their doctor's place! Especially if your advice is based on stuff that no one has any idea about or how it relates to OSA. Just stop pushing your agenda here - do it somewhere else, because this IS a Cpap forum and not your personal blog.
Last edited by Julie on Tue Apr 15, 2014 10:38 am, edited 1 time in total.

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49er
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Re: CSA

Post by 49er » Tue Apr 15, 2014 5:48 am

Julie wrote:Todzo - it's not your place to tell people Cpap is not recommended for them - it's their doctor's place! Especially if your advice is based on stuff that no one has any idea about or how it relates to OSA. Just stop pushing your agenda here - do it somewhere else, because this IS a Cpap forum and not your personal blog.
+1

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Re: CSA

Post by JohnBFisher » Tue Apr 15, 2014 9:25 am

49er wrote:
Julie wrote:Todzo - it's not your place to tell people Cpap is not recommended for them - it's their doctor's place! Especially if your advice is based on stuff that no one has any idea about or how it relates to OSA. Just stop pushing your agenda here - do it somewhere else, because this IS a Cpap forum and not your personal blog.
+1
Ditto!

Let me propose to anyone considering ANY approach (accupuncture / accupressure / CPAP / Weight Loss / Surgery ... WHATEVER) use one simple approach:

USE THE SCIENTIFIC METHOD

First of all, study the facts about the approach. Is it safe? Is it effective? Is there INDEPENDENT research regarding the approach?

Second, especially if it is surgery. Get a second opinion of a doctor / practitioner that has no skin in the game. If a surgeon recommends surgery, remember all he has is a hammer, so hammer he will. Talk with a sleep specialist who is not a surgeon.

Third, if you decide to try to the approach, then find a way to measure things objectively (with numbers). Are you sleeping longer? Are you awakening less? Are you going to the bathroom less? Are you falling asleep less during the day? Have you Epworth sleep numbers improved? Then TRACK IT! Don't just guess.

Fourth, be willing to abandon an approach that does not work for YOU! ... Some therapies are not effective for everyone. Some are more effective than others.

Finally, after having said all of that, remember that based on a LOT of study, xPAP therapy is the most effective approach for folks with obstructive sleep apnea. It's not the only approach. But if you stick with it and make it work, it's been shown by a lot of personal experience and very well controlled studies to be an effective approach.

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Todzo
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Re: CSA

Post by Todzo » Tue Apr 15, 2014 4:13 pm

JohnBFisher wrote:USE THE SCIENTIFIC METHOD
Interesting thing here John, I am the only one in this thread to use citations of the literature.
JohnBFisher wrote:Finally, after having said all of that, remember that based on a LOT of study, xPAP therapy is the most effective approach for folks with obstructive sleep apnea. It's not the only approach. But if you stick with it and make it work, it's been shown by a lot of personal experience and very well controlled studies to be an effective approach.
citations please
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Todzo
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Re: CSA

Post by Todzo » Tue Apr 15, 2014 4:48 pm

If there is one thing you DO NOT WANT it is DISSATISFIED CUSTOMERS!!!!!!!!!!!

So now they are doing research which helps us to sort out those who are good candidates for CPAP and those who are not.

So perhaps as time passes there will be less dissatisfied customers and people will become more interested in using CPAP.
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Re: CSA

Post by JohnBFisher » Wed Apr 16, 2014 8:40 am

Todzo, as a layman, who has used xPAP therapy for well over 20 years, I have done a LOT of research on this. The following study is just one of hundreds or thousands that has demonstrated the effectiveness of xPAP therapy.

http://www.atsjournals.org/doi/pdf/10.1 ... .2.9804061

In it the study team concludes:
We conclude that, despite the importance of general measures of sleep hygiene and weight loss, CPAP is currently the treatment of choice for moderate to severe sleep apnea/hypopnea syndrome (SAHS). The study adequately supports the effectiveness of CPAP in symptomatic treatment for severe SAHS. Consequently, we believe that the indication of CPAP treatment in these patients is firmly established. Thus, our study confirms and extends previous findings on the effectiveness of CPAP and copes with some of the objections raised recently concerning this treatment. However, additional efforts must be made to further evaluate the effectiveness of the different approaches to treat this condition.
Yet, even as this study team recognizes the need to continue to explore alternatives, so do I. Please don't believe I'm trying to disrespect you. I merely note that the scientific method continues to demonstrate that xPAP therapy is the most effective method to treat sleep apnea. I do NOT discount that alternative therapies may be effective for some individuals. I do insist, whether it's xPAP therapy or any alternative therapy, that the patient be involved and use the scientific method to identify the best approach for themselves.

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rudypv

Re: CSA

Post by rudypv » Wed Apr 16, 2014 9:39 am

I see a great amount of information is being discussed here. I'd like to update you with two points.

1) After a bit of research (I'm not a medic but I've studied biology, neurophysiology and psychology at university so I'm extremely interest in researching) what I suspect is that my mitral regurgitation causes what's termed as Cheynes Stoke breathing (a type of CSA which perfectly describe what I feel like at night, when I start to feel asleep).
Since last year cardiological tests were ok, I suspect that it's a matter of tension and stress which, acting upon my mitral regurgitation, causes the abnormal breathing pattern. The abormal breathing pattern makes me obviously worried and so it becomes a vicious circle. I'd be happy to use a CPAP but honestly I'm extremely interested in the cause of all this.
I think my next step is ruling out cardiac issues definitely so I can focus on untying other knots.

2) I went to my GP and after mentioning Cheynes Stoke he asked me "What's that?". That's not quite encouraging...

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Re: CSA

Post by Julie » Wed Apr 16, 2014 10:50 am

Talk to a cardiologist or pulmonologist (and get a new GP!), but don't assume you have CS otherwise.

rudypv

Re: CSA

Post by rudypv » Wed Apr 16, 2014 1:47 pm

Julie wrote:Talk to a cardiologist or pulmonologist (and get a new GP!), but don't assume you have CS otherwise.
I'm quite unlucky with GPs.

I'm completing all the new tests right now and I think tomorrow I'll try to see a Pulmonologist privately even if it's quite expensive.

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Todzo
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Re: CSA

Post by Todzo » Tue Apr 22, 2014 5:01 pm

rudypv wrote:I see a great amount of information is being discussed here. I'd like to update you with two points.

1) After a bit of research (I'm not a medic but I've studied biology, neurophysiology and psychology at university so I'm extremely interest in researching) what I suspect is that my mitral regurgitation causes what's termed as Cheynes Stoke breathing (a type of CSA which perfectly describe what I feel like at night, when I start to feel asleep).
Since last year cardiological tests were ok, I suspect that it's a matter of tension and stress which, acting upon my mitral regurgitation, causes the abnormal breathing pattern. The abormal breathing pattern makes me obviously worried and so it becomes a vicious circle. I'd be happy to use a CPAP but honestly I'm extremely interested in the cause of all this.
I think my next step is ruling out cardiac issues definitely so I can focus on untying other knots.

2) I went to my GP and after mentioning Cheynes Stoke he asked me "What's that?". That's not quite encouraging...
I have often wondered as I did read the research which comes first. The Cheyne–Stokes respiration or the heart condition.

Frankly I believe that Cheyne–Stokes respiration is not easy on the heart.

Your number two point made me laugh out loud!!! The medical community is way way way too top heavy. So much so that it is quite ineffective. It is a disease care system not a health care system. We need to change that!!!!!!!!
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Todzo
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Re: CSA

Post by Todzo » Tue Apr 22, 2014 7:32 pm

Todzo wrote:
rudypv wrote:I see a great amount of information is being discussed here. I'd like to update you with two points.

1) After a bit of research (I'm not a medic but I've studied biology, neurophysiology and psychology at university so I'm extremely interest in researching) what I suspect is that my mitral regurgitation causes what's termed as Cheynes Stoke breathing (a type of CSA which perfectly describe what I feel like at night, when I start to feel asleep).
Since last year cardiological tests were ok, I suspect that it's a matter of tension and stress which, acting upon my mitral regurgitation, causes the abnormal breathing pattern. The abormal breathing pattern makes me obviously worried and so it becomes a vicious circle. I'd be happy to use a CPAP but honestly I'm extremely interested in the cause of all this.
I think my next step is ruling out cardiac issues definitely so I can focus on untying other knots.

2) I went to my GP and after mentioning Cheynes Stoke he asked me "What's that?". That's not quite encouraging...
I have often wondered as I did read the research which comes first. The Cheyne–Stokes respiration or the heart condition.

Frankly I believe that Cheyne–Stokes respiration is not easy on the heart.

Your number two point made me laugh out loud!!! The medical community is way way way too top heavy. So much so that it is quite ineffective. It is a disease care system not a health care system. We need to change that!!!!!!!!
I think you would be wise to study about breathing instability (ventilatory instability) in regard to sleep apnea and CPAP treatment.
May any shills trolls sockpuppets or astroturfers at cpaptalk.com be like chaff before the wind!