Using the S9 Autoset w/ Centrals... Suggestions appreciated

[unadog]

DreamDiver, do I understand correctly that your central dysregulation problem is largely manifest immediately after bathroom breaks?

Yeah, I saw that this morning. That is kind of "normal centrals." We will have to see what future days look like?

I do belive you about the fatigue, and about the brain fog (though you aren't going to make a good disbility case posting analysis like these!) I've been there long enough to know that, even if no-one will listen, you know what is going on ....

Unfortunately, lots of potential causes ... We may need a full medical history.

[dsm]

DD, I don't think those flat spots are what get scored as hypopneas since they appear shorter than 10 seconds. Rather, I think they are just treated as post-expiratory pauses because of their short duration.

However, there are several consecutive low-amplitude volumes----just to the left of that first circle----that the machine might have scored as a single hypopnea. Recall that a hypopnea can actually take several breaths---and it is an amplitude reduction compared to a running baseline of previous breaths. By contrast to that initial hypopnea, the second set of reduced amplitudes are perhaps: 1) a little higher at the peaks, 2) peak-compared against a slightly lower running amplitude baseline, and/or 3) might not hit the necessary 10-second amplitude-reduction criterion to qualify.

Does the data set per chance tell you the duration of the hypopnea on the left? If so, you can probably figure out how many reduced inspiratory breaths were included. According to eyeball, each inspiratory peak seems on the order of 5 second periods/breath-rate (visually normalize flow periods w/in a 1-minute epoch then divide 60 by total periods----thus 60 divided by a rate of 12 or 13 normalized breaths = about 5 seconds per breath).

My apneas seem to cluster primarily after the bathroom break as I'm trying to fall back to sleep. I seem to do pretty darned well for the first part of the night.

I agree that you seem to show a slight tendency for post-bathroom/awakening central periodicity there. That's not to say you have a periodic breathing problem.

That said, it might be interesting to run an experiment with fluid intake during the day. If it were me, I'd try a few days in which I completely eliminated late-day fluid intake---trying to avoid bathroom breaks. If I succeeded avoiding those bathroom breaks, then I'd compare: 1) periodicity patterns in the data set, and ESPECIALLY 2) how I seemed to sleep that night and subjectively felt during the following days. If there was a marked improvement, then I'd consider changing fluid intake and/or asking the doctor for an ASV trial based on the data and subjective results of that experiment.

Good luck, DD! Thanks for sharing those most interesting graphs!

SWS

Very impressive analysis ! In following it point by point, the conclusions seem very well supported by the data.
Glad we have you here to do that sort of analysis.

Thanks

DSM

[-SWS]

To be perfectly candid: Just on the basis of residual "brain fog" and periodicity alone I'd want to trial ASV if I were DD. But I also fear DD might have difficulty getting a doctor to agree to that trial.

DreamDiver, do I understand correctly that your central dysregulation problem is largely manifest immediately after bathroom breaks?

Yeah, I saw that this morning. That is kind of "normal centrals."

That's why I suspect some sleep doctors might not agree to an ASV trial. Is DD's central dysregulation limited to a little bit of periodicity after bathroom breaks with associated central apneas? If so, those somewhat "common" central apneas are related to CO2 homeostatic adjustment during rapid sleep onset----a somewhat normal occurrence.


However, I still think this would be a good experiment for DreamDiver:

I agree that you seem to show a slight tendency for post-bathroom/awakening central periodicity there. That's not to say you have a periodic breathing problem.

That said, it might be interesting to run an experiment with fluid intake during the day. If it were me, I'd try a few days in which I completely eliminated late-day fluid intake---trying to avoid bathroom breaks. If I succeeded avoiding those bathroom breaks, then I'd compare: 1) periodicity patterns in the data set, and ESPECIALLY 2) how I seemed to sleep that night and subjectively felt during the following days. If there was a marked improvement, then I'd consider changing fluid intake and/or asking the doctor for an ASV trial based on the data and subjective results of that experiment.

Rationale: If DreamDiver's central problems are largely manifest immediately after his brb's, AND he can somehow experimentally mitigate those central episodes, then he might gain an idea how those central dysregulation episodes contribute to daytime symptoms.

DSM, thanks.

[JohnBFisher]

... Going through the hurdles to get approvaed for an ASV is another question! My centrals are from medication, so it is a different "sub-category" I believe. It won't just "go away." Approval is easier there I think. ...

It might be easier to obtain, since it won't go away, there are articles on point.

http://www.ncbi.nlm.nih.gov/pmc/article ... .4.311.pdf
http://www.ncbi.nlm.nih.gov/pmc/article ... .4.305.pdf

And a commentary on the second article:

http://www.ncbi.nlm.nih.gov/pmc/article ... .4.321.pdf

... The steps outlined in this BCBS Policy Manual are quite daunting! ...

and when the back-up rate or ASV device has been shown to be effective in the sleep lab. ...

Essentially, if your doctor shows that it is medically necessary the insurance companies tend to not complain about the units. They might monitor compliance to be certaint he unit is used. But you should certainly qualify if there is no other way to treat your central apneas.

[unadog]

Essentially, if your doctor shows that it is medically necessary the insurance companies tend to not complain about the units.

I talked with my doctor on Monday. He is going to do an ASV titration next week! If all goes well I should be able to get a unit soon! If it helps and insurance won't pay right away, I'll buy my own machine until I can get a replacement from them.

I am a little more worried about our friend here though. We will see. Sometimes you (he)(me) just need to commit to doing whatever it takes to get healthy. Have to make sure we have the right solution first though.

I appreciate your help last week! Plus the links here, and on the "central" thread. I'll read it all again. Sometimes I get a bit stuck in a loop when my a) my memory doesn't work, b) I am pissed at the system, c) I don't sleep with insomnia, and/or d) I swich or run out of meds. Random personality disorder - plus I babble!

Thanks!
Michael

[DreamDiver]

Thinking out loud ...
Perhaps Resmed can add a new feature to another model of S9 called PBC that can be activated & deactivated & perhaps have 3 or so levels of drive.
The name meaning Periodic Breathing Control feature. Sort of like the EPR feature which was a bilevel functionality disguised as an add on feature.

ASV machines are just going to remain far too hard to get approval through both Drs and Health insurance. At least until their cost drops a great deal..

DSM

-2 qualified meaning of approval in last line

Also thinking out loud... Since the machine includes an SD card, my hope has been that they may have considered a method to update firmware by dragging a file onto the SD card. If that's the case, it may be as simple as asking for modifications by software. I personally wouldn't mind being a guinea pig in that situation. I wouldn't have to give up the machine, and it could be actively adapted to my needs. ResMed - are you listening?

unadog - thank you for the BCBS info and a breakdown from the slides.

SWS - I'm not so sure it's just around bathroom breaks anymore. That may have been a hasty judgment. The next night, after the bathroom break there were no centrals at all until I got cluster just before I woke up. If it happens at all, it seems to be clustered as I fall asleep and as I wake up, with spotty centrals here and there. If I'm really tired when I go to sleep and fall asleep quickly, clustered centrals tend to be avoided. If I sleep a long time, centrals will sometimes cluster at the end of the sleep period. Getting up to go to the bathroom, if I wake up sufficiently, I have to attempt to get back to sleep - causing a cluster of centrals as I attempt to relax. Until I have a few days more data, I'm going to say it's still when i'm 'getting in and out of the pool'.

JohnBFisher - If I understand correctly, opiates were used to induced a state similar to that of people with CompSA. I know there's no implication here, but on the flip side, I generally have to avoid narcotics. When I took them for my appendectomy and my septoplasty, I was constipated for weeks. I think I've got enteric nervous system issues that are not well understood. I'm wondering how/whether the ENS, along with the Vagus bundle might be involved in regulation of CO2, and whether part of the problem might not necessarily CNS, but rather ENS/vagus. The two times I had a colonoscopy, I went unsedated. It's just easier. It's also fascinating to watch the video.

I put the alarm on my oximeter last night to wake me if the O2 level drops below 85. It didn't.
Apparently the key is to find a doctor who believes in and understand CompSA and CSA.
I still have to check my numbers this AM.

[snnnark]

DD I have a question about your o2 levels. Have you worn the oximeter for 24 hours? When I look at your charts you seem to start high +- 98, drop to 94 - 95 then go up again in the AM. What is your average wake o2 level?

[JohnBFisher]

... there were no centrals at all until I got cluster just before I woke up. If it happens at all, it seems to be clustered as I fall asleep and as I wake up, with spotty centrals here and there. ...

The centrals as you fall asleep and awaken are perfectly normal. Unless they severely disturb your ability to sleep there is no real need to address those. So, this includes before or after bathroom breaks. This is - I suspect - why -SWS wondered about the timing. It's the centrals that occur throughout the night while asleep that definitely must be addressed.

Though it is heavy duty reading, you will want to read the following article titled "Ventilation is unstable during drowsiness before sleep onset":

http://jap.physiology.org/cgi/reprint/99/5/2036

In conclusion it states:

At the start of sleep onset when drowsy, and when the PCO2 is close to or at that when awake, apneas and periodic breathing will occur with changes in cerebral state. The most ready explanation for these findings is that the PCO2 when awake is close to or at the apneic/hypopneic CO2 threshold. This explanation would also account for the apneas and periodic breathing frequently observed at the onset of NREM sleep and is likely to be most prevalent in subjects with a high-ventilatory sensitivity to CO2.

... If I'm really tired when I go to sleep and fall asleep quickly, clustered centrals tend to be avoided. If I sleep a long time, centrals will sometimes cluster at the end of the sleep period. Getting up to go to the bathroom, if I wake up sufficiently, I have to attempt to get back to sleep - causing a cluster of centrals as I attempt to relax. Until I have a few days more data, I'm going to say it's still when i'm 'getting in and out of the pool'. ...

I predict that staying still will have no impact. It's just the fact that your body is switching from one form of control of breathing to another. Again, as long as they do not disturb the process of falling asleep or awakening, you can safely ignore this type of cluster.

They can be so intense that it interferes with sleep. That is very rare indeed and tends to indicate an issue with the central nervous system (brain stem in particular). I do have that issue and won't recommend it to anyone.

... JohnBFisher - If I understand correctly, opiates were used to induced a state similar to that of people with CompSA. ...

Yes, opiates act as a central nervous system depressant. In particular it supresses normal operation of the brain stem which helps regulate the autonomic nervous system, including breathing.

... I generally have to avoid narcotics. When I took them for my appendectomy and my septoplasty, I was constipated for weeks. ...

This is a known result from something that interferes with the brain stem. Why do I think that? Neurological disorders that interfere with the brain stem tend to also cause poor regulation of the autonomic nervous system. Chronic problems that result often include respiratory problems, sleep apnea (both obstructive and central), urinary issues (including ED) and gastrointestinal problems (including constipation). Probably the classic neurological issue that deals with this is Multiple Systems Atrophy (MSA). You can read more about it here:

http://www.shy-drager.org/msa-faq

... I think I've got enteric nervous system issues that are not well understood. I'm wondering how/whether the ENS, along with the Vagus bundle might be involved in regulation of CO2, and whether part of the problem might not necessarily CNS, but rather ENS/vagus. ...

I am not a neurologist, so do not know if there might be a relation here. However, it is far more likely that you have two different issues. With opiates you experience normal autonomic nervous system depression. With sleep onset and awkening, you experience normal instability of breathing.

Again, unless it causes you problems, I would not worry about it. But if it is so severe that it keeps you from falling asleep or causes you to bolt awake, then it should be addressed. That's one of the problems I had. But I also have central apneas throughout NREM sleep and very few during REM sleep. That, by the way, is one of the markers of problems with the brain stem. During REM sleep the brain activity appears to reinforce the normal function of the brain stem, improving the regulation over the autonomic nervous system. I did discuss this with my neurologist who got excited that "I got it" and asked me to specifically keep tracking both the SpO2 levels and my sleep via my ASV unit.

By the way, my central apneas are so deep that the AUTO OFF feature on my BiPAP unit would turn off my unit many times throughout the night. During the resulting BiPAP titration they found that I have six times the number of central apneas as obstructive apneas.

... The two times I had a colonoscopy, I went unsedated. It's just easier. It's also fascinating to watch the video. ...

I can understand the curiosity. The more I learn, the more I learn that I really want to learn.

... I put the alarm on my oximeter last night to wake me if the O2 level drops below 85. It didn't. ...

I don't know about you, but the alarm on my pulse oximeter would not awaken me. Just not loud enough. I need it to be REALLY loud.

... Apparently the key is to find a doctor who believes in and understand CompSA and CSA.
...

Well, it also takes data that also substantiates CompSA and/or CSA. But yes, not all doctors finish at the top of their class. I had one doctor tell me that "Central sleep apnea is very rare, so you can not have it". What? How do the two relate? Do the sleep studies show central apneas? Does CPAP or BiPAP therapy address those apneas? Do I have more than 5 central sleep apneas per hour? How are we addressing those?

Of course, that was the same doctor that complained that my pulmonologist (who was my previous sleep doctor) had jumped to BiPAP too quickly. [ I was having problems with sleep and neurological issues, so I went to a neurologist who specialized in sleep issues. ] He ordered another sleep study that showed... I needed BiPAP with a slightly different pressure and the central apneas were still there - worse than previously.

So, yes. The doctor needs to believe you might have an issue with it. But as I also note, during normal sleep those centrals need to exist. Understand I am not questioning your situation. Rather I am proposing you ask your doctor if the sleep study demonstrated central apneas, if they are frequent enough to require something to address them, and if they might be contributing to ongoing day time symptoms. Essentially, you need to note if your therapy is effective or not and then guide the questions into a potential area of concern. You can also request (and probably should) the information from your sleep study.

Anyway, I hope the information helps.

[DreamDiver]

DD I have a question about your o2 levels. Have you worn the oximeter for 24 hours? When I look at your charts you seem to start high +- 98, drop to 94 - 95 then go up again in the AM. What is your average wake o2 level?

It's a little impractical to use the monitor all day without an ear monitor. I spend a lot of time typing on the laptop. As to O2 during sleep - it does seem pretty typical for it to be around 94/95 while sleeping and then wander back up to 97/98. During the day, if I'm sessile, it will also typically be around 94/95. Moving around brings it back up to 98.

Last night's numbers:
AHI: .8
CI: .7
HI: .1
No horrific desats. I feel pretty good.

The O2 seen here is more typical of what I would see on the M-Series Pro.


That hypopnea thing again... Obviously, I don't have a good enough understanding of what they are to be able to pick them out myself on a graph without help from the ResScan software. Odd, because I could probably do it for any of the apneas.


I wonder if EPR was causing some of the clusters and O2 swings. I reduced EPR to 1 last night. Still at APAP min 10.6/max 13. Pressure actually changed last night! I didn't notice it. I must have slept pretty solidly. I'm going to look closer at the graphs to see if I can deduce what precipitated the changes. Wish me luck.


Here's a fun look at FOT and COS in combination during that 23 second central...
View is a thirty second window.

[snnnark]

I think the hypopnea actually starts at 00:17:05. They don't give you the length of hypopneas, only apneas.

As for the 23sec central. With oximiter on, breathe out and hold for 23secs. No significant desat, at least I didn't

[dave21]

Hi DreamDiver,

I've started to see that a lot of us are constantly repeating answers for newbies and I've put together a simple but hopefully effective page for newbies that covers a number of things like the bare basics on Sleep Apnea and machines and masks along with more detailed information on how to interpret the graphs for Obstructive Apneas, Hypopneas, and Central's. As well as providing links back to some very good forum posts for the S9 here at CPAPTalk.com.

http://www.osahelp.com

I wondered if you would mind me using the above graph in the page to depict Central Apneas? I do have Central Apneas but not that often and most of my Apneas are more Obstructive so I thought it would be good to see a lot more Centrals on a graph. I've placed it under the link http://www.osahelp.com/index.htm#8 (it's the second graph) so you can see how it would look. If you would prefer for me not to use the image I'll respect your decision and remove it (I just wanted to check you're okay with it first).

Likewise if you have any other graphs or content or any other areas that you think could be good to add or want to help add to the page, I'd more than welcome it.

Thanks
Dave

[JohnBFisher]

... I've started to see that a lot of us are constantly repeating answers for newbies and I've put together a simple but hopefully effective page for newbies that covers a number of things like the bare basics on Sleep Apnea and machines and masks along with more detailed information on how to interpret the graphs for Obstructive Apneas, Hypopneas, and Central's. ...

Good material.

Might I suggest, that you also consider building a Wiki article. As a registered member you can register to add/edit pages in the Wiki.

But goot stuff!

[dave21]

That's a good suggestion John, didn't realise I could do that as a registered member, I'll take a look at that too!

If anyone else wants to help contribute then the more information the better.

Thanks
Dave

[DreamDiver]

Dave,

Feel free to use any of my images for this purpose.
If you need more images or something more unique or specific, let me know.
I'm so glad someone has the energy to do this.
(So long as the images and content remain free and available to anyone on the web, eh? )

Way to go.

Note: there are a couple great html-to-wiki online editors out there, if you want to convert simple stuff like the page you created.
Google 'html to wiki converter'.
http://toolserver.org/~diberri/cgi-bin/html2wiki/
http://www.uni-bonn.de/~manfear/html2wiki-tables.php

[dave21]

Thanks DreamDiver! Of course it goes without saying that they'll remain free and available to anyone on the web