Centrals Now?

[WearyOne]

What does it all mean? I'm confused.

My first sleep study revealed OSA and Mixed, but no CSA.

My titration, that's a different story and that's what's confusing. (I just realized today that I had the tiration report, but not the graphs and had them fax it to me.)

They started me at 5. I was awake for more than an hour then had what looks like about 10 centrals as I was bouncing around between awake, REM, and stages 1 and 2. Finally went to sleep and went through all the sleep stages, for about 45 minutes. Then she bumped it up to 6, at which time I had several arousals, but nothing else noted. Bumped it up to 7 and had several arousals and one central. She went to 8 and then 9. During this period, I had some arousals, but only one central right before she woke me up--nothing else. Sleep tech mentioned to me she had to raise the pressure very slowly because everytime she tried to raise it, I'd start to wake up.

I'm sure (hoping) all the arousals not associated with the centrals were because of her raising the pressure and my not behing used to the mask. (On my first study, I didn't have any arousals that weren't associated with OSA or mixed.)

Is this weird? On my first study, I showed only mixed and OSA/H, no centrals, but on the titration, even at the start, I showed no OSA/H or mixed, only centrals?

His last paragraph on the titration study report: "...CPAP at 9 cm is effective in eliminating apneas and hyponeas during REM sleep. Though the patient had difficulty maintaining sleep until 1:00 a.m [all those centrals and arounsals I had], and then betwen 2:45 and 3:45 a.m., sleep architecture was better maintained druing the early morning hours."

Been doing this now about a month. AHI and leak numbers look good, I feel horrible. I don't have the software yet, just going by the LED screen data. Trying to figure out if something is causing a bunch of centrals, or what's going on. (I'm only at 8 now.) I keep waking up from the middle of very vivid dreams, startled. (I tried sleeping half a night twice w/o the mask, and the same thing happened with the dreams.) I quickly use my pulseoxymeter and everything's fine. (But it's probably too late by then if there was a problem)

Thoughts?

Pam

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, AHI, CSA

[rested gal]

They started me at 5. I was awake for more than an hour then had what looks like about 10 centrals as I was bouncing around between awake, REM, and stages 1 and 2.

I'm no doctor or anything in "sleep", but from what I've read about "sleep onset centrals", sounds like that's what you might have been having if you were having trouble maintaining sleep. If so, sleep onset centrals are nothing to worry about.

As StillAnotherGuest mentioned to someone in an older thread:

"Assuming that the obstructive events are properly managed, then the likelihood of these being sleep-onset centrals is fairly high (you'd need PSG to be 100%) and those things are pretty much a normal event."

[Guest]

you are really going to hate this but:

Hey welcome to the club

That central you experienced during the titration was the lab tech increasing your pressure. When you blow a central it wakes you up. That is the problem with them, unlike an arousal from say a Hypopnea or apnea, the central ones wake you up. That is why you want to avoid them at all costs.

and with all due respect, I totally disagree with this statement below as it relates to this syndrome:

As StillAnotherGuest mentioned to someone in an older thread:

"Assuming that the obstructive events are properly managed, then the likelihood of these being sleep-onset centrals is fairly high (you'd need PSG to be 100%) and those things are pretty much a normal event."

So SAG doesn't feel bad, I disagreed with my ABSM certified doctor on the same subject (but I think the sleep tech knows more anyway)

Assuming that the obstructive events are properly managed,....

I guess that is the key statement; and that is the problem with this syndrome, it is very difficult to manage with conventional xpap therapy. Even with straight cpap is difficult to use, just when you think you have the ideal pressure dialed in a whole series of runs kick in and it is like you are not on any therapy at all.

Sleep-onset centrals are just that, when you first start to sleep and/or transition from wake to sleep state, but when they progress throughout the night until you wake up in the morning, I don't think they are any longer sleep-onset centrals (in my book anyway).

And another I disagree to "normal" is because centrals generally WAKE a person from sleep state to a completely wake state (as opposed to other SDB events which may only kick you from REM to stage2 etc.) My experience with centrals you go from deep to wake or from REM to completely awake.

But I guess they technically they can be classified as sleep-onset since you are waking a half dozen times per night. So you are falling back asleep over and over again. But waking up a half dozen or even 2 times per night is what we are trying to avoid, so how is that "normal".

If I have only 2 of those per night that wake me up, I don't consider that "normal", for me it shorten my time asleep and leaves me completely fatigued the next day.

Pam, your criteria nearly matches the criteria I've stated all along and matches mine, RG's (without her permission, only going by her 420e report) and many others I've seen here. Our lab titrated pressure requirement is nearly always 8 or 9cm and nearly always below 10cm. Every once in a while we may need a higher pressure but rarely. When they put you behind most autopaps on the market they just go nuts with pressure, if no Max limit is set they go all the way to the top.

If your SDB pattern is what I think it is (and I haven't seen any of your reports other than what you just posted above). I bet they are full of FL's and Hypopnea and your AHI only climbs up as higher pressure gets increased, it climbs higher because the frequency of events or runs increase.

My experience is you will be very difficult if not impossible to manually titrate. The pressure found that may work early on in sleep won't work later on. Your 90% pressure becomes a moving target from night to night. If they bump the pressure up so it handles all your events it fires off centrals throughout. Most of the machines out there including the Remstars are unable to detect those and adversely respond.

The more pressure you receive the more your events will increase in frequency. Straight CPAP doesn't seem to work either, it may work fine for a few hours then the FL's and Hypopnea start in again.

The only machine I have found that works is using an autopap at very low pressure like 6 or 6.5cm and also limiting the Maximum pressure. If you were on a 420e it may be much easier to get a handle on your sleep, just like RG's settled down, mine did the exactly same thing.

At our pressure (usually 9cm or below) we can get along fine without Cflex, the machine still offers some relief as we exhale. I didn't see any difference changing Cflex settings.

Note: A mixed apnea (MA) is central apnea. A mixed apnea is a central apnea combined with a obstructive apnea, hence the term "mixed". Meaning you can have a central apnea and transition immediately into a obstructive apnea end for end (or vice versa) and effectively doubling the time you may go without breathing. My avg. Apnea duration reported by EncorePro was 55 seconds.

The 420e appears to work better in these situations (with FL disabled and command on apnea lowered) because it detects cardiac occilations via open airway and avoids any response to CA's. Problem still comes into play when it is a mixed apnea because with one the airway is open (central) and with the other the airway is closed (obstructive apnea). But as a mixed apnea transitions from a central to obstructive (mixed) machine seems to even get a sense on these and respond or not respond appropriately.

Based upon your SDB pattern, I would avoid using a Resmed Autoset machine (for your disorder), they are too trigger happy when it comes to FL's and this particular SDB pattern.

Is this CSDB? I have no idea, why create a whole new category for a disorder when all it takes is the right machine for therapy.

I've gone from a couple dozen CA's per night (remember each one can WAKE you) down to 1 per night, many nights completely CA free since using the 420e. The frequency of SDB events is half of what they used to be.

Since I also used the Soyala mask with my Remstar Auto's, I can only attribute the improvement to the 420e and its ability to tweak parameters not found on all other machines I've tried to date. Ask anyone, I used to beat up that poor little 420e more than anyone after having 2 of them die on me.

In hindsight, I wished after the first two of my 420's died on me I would have stuck with them and gotten a 3rd, because I could have slept much better for the past couple years and saved myself a lot of money on autopaps in the process.

I can tell you right now, the Remstars cannot accurately differentiate these events, nor can the Resmed, both respond terribly to this pattern, straight cpap is no better in fact I found it worse. What you want is a machine that better avoids the centrals and responds to the obstructive events.

[StillAnotherGuest]

I was awake for more than an hour then had what looks like about 10 centrals as I was bouncing around between awake, REM, and stages 1 and 2. Finally went to sleep and went through all the sleep stages, for about 45 minutes. Then she bumped it up to 6, at which time I had several arousals, but nothing else noted. Bumped it up to 7 and had several arousals and one central. She went to 8 and then 9. During this period, I had some arousals, but only one central right before she woke me up--nothing else. Sleep tech mentioned to me she had to raise the pressure very slowly because everytime she tried to raise it, I'd start to wake up.
I'm sure (hoping) all the arousals not associated with the centrals were because of her raising the pressure and my not behing used to the mask. (On my first study, I didn't have any arousals that weren't associated with OSA or mixed.)

Is this weird? On my first study, I showed only mixed and OSA/H, no centrals, but on the titration, even at the start, I showed no OSA/H or mixed, only centrals?

you are really going to hate this but:

That central you experienced during the titration was the lab tech increasing your pressure. When you blow a central it wakes you up. That is the problem with them, unlike an arousal from say a Hypopnea or apnea, the central ones wake you up. That is why you want to avoid them at all costs.

and with all due respect, I totally disagree with this statement below as it relates to this syndrome:

As StillAnotherGuest mentioned to someone in an older thread:

"Assuming that the obstructive events are properly managed, then the likelihood of these being sleep-onset centrals is fairly high (you'd need PSG to be 100%) and those things are pretty much a normal event."

So SAG doesn't feel bad, I disagreed with my ABSM certified doctor on the same subject (but I think the sleep tech knows more anyway)

Assuming that the obstructive events are properly managed,....

I think in this case, SAG would say they are more likely post-arousal centrals. Something aggravates you, you have an arousal, a brief period of hyperventilation occurs followed by a compensatory pause in breathing which appears as a central apnea. The response is normal, the thing that aggravates you isn't. Only having a few of them during a period of major sleep disruption suggests this.

To be certain, you would dig up the actual PSG. A post-arousal central looks like this:



Without getting really involved with PSG interpretation, you can see that everything seems to going along well, then things get askew, 3-5 seconds later there is a big breath (seen in the Thermistor channel) followed by the central apnea. In this case, the chore would be to find out the cause of the arousals, not the centrals. In your case, the cause could very well be pressure increases or some sort of CPAP intolerance, but probably not pressure per se, only the aggravation it causes.
SAG

[WearyOne]

So, basically, I need an apap--which is what I've been thinking. Below are my sleep charts. First one is sleep study and second is titration. The report on the first study indicates hypopneas, moreso than apneas! I don't have reports from the cpap because I don't have the software. And if end up getting a different machine, I'd rather wait and get the software for that machine. What do you think about these? (Had to draw over the "position" lines on the chart because they weren't dark enough to show!)
I think I did it right, getting these charts on here.

FIRST SLEEP STUDY



TITRATION SLEEP STUDY

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, CPAP, APAP

[WearyOne]

I'm just bumping this up a little bit since I put my charts in here. Hope that's okay.

Pam

[Snoredog]

Thanks SAG for the comments, I see the event before the central. Does a mixed apnea
look similar to that post arousal-central?

PAM: FYI-SAG is owns/runs a sleep center and knows his stuff as compared to me, I only have bad experiences as a patient. But here's my take on your graphs:

First Sleep Study (diagnostic):

Sleep Stage:
For me, this is the most important graph as it says how MANY times you are at the
"W" or wake state during the night and how fragmented your sleep is. If you are tired during the day it is probably because you don't sleep during the night. Since it is thought we get most of the restorative effects of sleep during Stage3/4 and/or REM the amount of time we spend there can be important. If you are not spending time getting the restorative effects of sleep you are spending it elsewhere either awake or at Stage1/2.

PSnores/PLMEs/Arousals/Respiratory Events:
It is good you don't have any snores (lack of snores typical of those with Central/Mixed apnea syndrome according to one paper I've read). No limb movements or leg movements is also good. Arousals: Lots of them, it is interesting to note they are heavy from sleep onset (about 45-minutes after onset) until around 2:45AM where they completely STOP. Then 2 hour period of NO arousals until about 4:45AM where they start in again. Seeing that, I have to ask; since most medications take about 30-45 minutes to get into the blood stream and have a half life of about 4hrs, I have to ask did you take any medication before bed? If you look at the time frame of about 10:50PM to 2:45AM you are nearly one solid arousal (if you squished everything together). I found next to SDB events that cause your oxygen levels to drop, arousals are just as bad as it relates to the quality of sleep you get. So even though the event may not cause your blood oxygen level to drop, it can interrupt your sleep quality (hence the term sleep related arousals). They are the bad guys that can keep you up at the Wake state. If they know what they are by correlation they can say this arousal is caused by that hypopnea, or apnea or mixed apnea or central event. Without that correlation they are of unknown origin and referred to as microarousals or spontaneous arousals. When they are spontaneous they become very difficult to address, and as you can imagine nearly impossible to find treatment options.

Body Position: I don't see any real pattern to your sleep position other than you never sleep while on your right side, so I would avoid that sleep position. However, if you have some kind of muscle-skeletal pain you experience while on your RIGHT side I would pay special attention to that pain. But there doesn't appear to be any correlation with body position as it relates to arousals and sleep that I can see.

HeartRate Trend: Looks like they didn't have your EKG range set high enough, it was flat lining at 100BPM which suggests it is a bit high overall.

Treatment: That graph is a bit light to make it out, most likely because this is the diagnostic PSG and there is no CPAP treatment J

Oximetry: The important thing to look at are the times it drops below 90%, more specifically 89%. The next graph gives a better summary, you would use this chart to correlate to SDB events above (matching the drop in O2 to an event like an apnea).

SaO2 Histogram: Sums up the Oximetry results, any time you get below 89% it becomes medically significant, looks like you got down to about 85-86% from the graph. Oxygen levels in the blood drop because the airway is blocked and/or you have stopped breathing. On Mythbusters day before yesterday they buried Jamie alive in a casket by dumping dirt over it (cheap casket, lid collapsed on him). The EMTs on site indicated if his SaO2 level
drops by 4% it becomes a concern, a 10% drop becomes critical and life threatening. But us untreated OSA patients see more than a 10% drop all the time. The important thing to know is you need to do something about it when it continually gets below 89%.

Now your Titration Study on CPAP:
Sleep Stage: Here's that chart again. To be honest I don't see any improvement over your First chart. Sure you have more REM sleep but your sleep is still fragmented throughout the night. If you count up all those "W"'s it is no better than the first. Stage3/4 or deep sleep is about the same. If you were laying down in bed and I came up and poked you in the arm and woke you up only to ask if you were sleeping, that would get annoying after a while. By comparison, I counted up to 38 times you woke up during this study which when you compare to the first study is NO real improvement at all. Again, if you don't have uninterrupted sleep at night you will be tired during the day.

PSnores/PLMEs/Arousals/Respiratory Events: This time around the arousals are spread out throughout the night, you didn't even get the 2-hour clear arousal free period like your first study. The good news is the mixed apnea is gone, but the residual of those mixed now is the centrals are left remaining. Centrals by themselves don’t respond to pressure. If they do it is a result of improved sleep which is what you want to see. Are those arousals above the cluster of centrals related? Could be but when you observe where you don't have centrals the arousals are just as many. The important thing to note is when you correlate those centrals to the Sleep Stage chart above you will notice you are taken back to a WAKE state with every one of those seen.

So just don't let anyone tell you they are "insignificant" or "normal" findings. FACT is they wake you up. They are what leave you fatigued the next day. Have too many of those clusters of centrals and you will feel like the walking dead the next day and your overall health will quickly deteriorate. I think you can ignore that last central at 8AM, I see those too at the end of my sleep also. I need to get up by then anyway so those are
no big deal, I call them my built-in alarm clock. It is important to note that you have NO "obstructive" events on CPAP, that is half the battle, unfortunately I think the obstructive part is the EASY part to deal with. CPAP will keep your oxygen levels up to near normal levels at almost any pressure. It is going to force some oxygen into you weather you want it or not. I see that as a good thing.

Body Position: Again, I see no correlation in sleep position as it relates to arousals. Most people are more severe on their back or supine position. But if you sit back and look at that graph as a picture and compare to the first chart for Body Position, It says to me you spent a lot more time tossing and turning in the Titration study than you did in the first study. To me that says your sleep wasn't as good in the 2nd study. If you are sleeping better you should toss and turn less. It could very well be that you were not in your own home comfort zone and in a strange place trying to sleep or from the mask/machine which during the first study you didn't have.

Heart Rate Trend: Hey I'm no Cardiologist, but it sure looks to me your heart is under a lot more duress with treatment than it was without. Granted heart rate can climb while in REM and that may be normal, it can also climb while in an apnea including central apnea. The brain usually controls heart rate, if it doesn't get enough oxygenated blood it tells the heart to beat faster. Usually you see a increase in heart rate as it correlates to a drop in SaO2 which may also correlate to a obstructive apnea/hypopnea. Without that correlation, it could be the hypoxic condition that may have existed as a result of no treatment and it will take your brain/heart a while to catch up to where it knows the events causing the condition are now under control. If you take your BP regularly
you might find you have a higher than normal resting pulse rate. It is pretty common for hypertension and OSA to coexist together.

Treatment (Pressure): Obviously on CPAP treatment. You started at 5cm which eliminated ALL your mixed apnea (leaving centrals behind). That is important to note. Very LOW pressure clears all your "obstructive" events. You then went up to 6cm, 7cm, 8cm finally resting on 9cm and ending with a Central Apnea. I don't know if that very last central apnea was a result of the sleep tech attempting to increase pressure to 10cm or not. As mentioned I sometimes get a central when it is time for me to wake up anyway, in fact I think it is actually what wakes me since I don't use an alarm clock. It is possible the higher pressure of 8 or 9cm allowed you to get to REM sleep, but that is the only benefit I can see from that higher pressure. It certainly wasn't obstructive events that prevented you from reaching REM earlier in the night.

Oximetry: the import thing about them little squiggly lines is they stayed above 90%, pretty easy to see. Even 5cm CPAP should keep you above that mark.

SaO2 Histogram: Looks like you stayed above 91% most of the time.

Summary:

Again, I'm not a doctor but in my opinion: Your sleep fragmentation is no better in the titration study than it is in the first study. Lots of interrupted sleep is all I see. You only had 1 period of REM sleep. Most people have many more periods of REM every 90 minutes. These interruptions (in my opinion) are what leave you fatigued during the day. Just keep in mind, No drug is going to make up for that lost sleep.

But as SAG mentioned the arousals are the cause of that interrupted sleep (and possibly the centrals), the hard part is finding the "root" cause of the arousals. Your goal should be to reduce/eliminate those "Wake" periods, to do that you have to address those arousals. . Once you do you will feel better during the day.

We know that 5cm pressure eliminates nearly all your obstructive events (mixed apnea completely gone). The PSG tech continued increasing pressure to 6cm, 7cm, 8cm & finally 9cm before seeing the final central where the study was then over because you are now awake at that point. That last central at 8AM may have also been your body telling you to get out of bed (in my opinion). I would ignore the last one.

Keep in mind that 2nd study was only a 1-night snapshot of how you sleep. The next night you could very well have double the events not seen on the PSG.

Unfortunately you don't have a sleep lab to take home with you so you NO longer know:

if you continue to have those mixed events?
if you continue to have those central apnea?
if you continue to have micro/spontaneous arousals?
if your sleep continues to be fragmented?

One thing I can guarantee you will be tired the next day. So now you go back to your Sleep doc and he sees where your "obstructive" sleep apnea is all under control. Ah he says, CPAP is working just fine here, no hypopnea, no apnea, oxygen levels are up, yes CPAP therapy is working just fine. Then a month later you feel like the walking dead. You go back and he doesn't have a clue as to what’s up. Well let's order up another PSG he says, it comes back looking the same as your 2nd study. If yours is typical he didn't take the time to look at your PSG carefully and see all those spontaneous arousals, the arousals that did NOT go away with therapy. He sees a few centrals like in your Titration study and says ah "those are insignificant" or "normal" don't worry about those. He has absolutely NO idea about the spontaneous arousals behind it all.

At that point he says well, I got a golf game, jumps in his Mercedes, see ya in 6 months. By then you say screw that guy and you are then out on your own seeking your own answers as to why you are so tired during the day and then you end up here.

If there are any suggestions I could offer (based upon your results), they would be:

1. Take an inventory of ALL the medications you may be on. Write them down on a list along with their dosages and give that list to your doctor and ask him about it. Do your own research on these medications finding the Prescribing information then consult the "adverse" reaction list. There is a lot of doctor-bable in it but you can still make
out what they are saying. Pay special attention to side effects that contribute to fatigue, muscle pains, etc.. You may be surprised after compiling that list what you find. If taking more than 1 medication, look for drug interactions. I used to take DivovanHCT. That stuff gave me leg cramps like you would not believe. I went back to my doctor and complained about the leg cramps, well we have this Vioxx like medication you can take for those. No thanks, lets try something like Lisinopril, sure enough leg cramps in the thighs went away, so don’t overlook any medication even if you have taken it for some time.

2. Pay special attention to any muscle-skeletal pains. This can include arm or back pain or even arthritis. If you have any of these conditions pay special attention to the medication you may be taking for them. For example I have a bad lower back L4 along with Sciatica I've had for 20years. Every once in a while I have to hang upside down in an inversion table to relieve the pain where it is bearable again.

If you have Sciatica, you know the pain can be near constant. I take no medications for that pain, I've just learned to live with it. For the past 6 years I have been taking a 325mg Ecotrin aspirin every day for stroke prevention as part of regular aspirin therapy. They used to have me on Plavix, I stopped taking that a couple years ago, haven't noticed any difference, not even a single TIA. I tried about a month ago to lower the dose of aspirin I was taking from 325mg to 81mg, but after about a week in the morning on 81mg I felt every muscle and joint in my body now aching. I was stiff as a board. I must have developed arthritus over the past 6 years and since I started taking the aspirin and never knew it. My Mom has it so that is what I suspect. I went back to 325mg/day of Ecotrin and those pains subsided. I still have a strong suspicion that my Sciatica is a contributing factor to my spontaneous arousals, but that is only a theory, very hard to confirm. Pain sensory is one of the receptors that can impact your chemoreceptors which in turn control central respiratory rate.

3. CPAP therapy. Your Titration study shows a low pressure of 5cm takes care of your mixed apnea (or obstructive events). If you are wondering why they went higher, the higher pressures used during your titration taking you up to 9cm was an attempt to IMPROVE the quality of your sleep (even if No obstructive events where seen). It could very well be that had that pressure NOT been applied you would have had many more obstructive events than what was seen. As mentioned CPAP even at low pressure of 5cm can keep your blood oxygen levels up to near normal, so that is good for your brain, heart and other major organs. So if there is any benefit from it at all, that would be it. CPAP may keep you from having a stroke or heart attack down the road.

It is important to also understand from your PSG that other alternative therapies may/may NOT help your condition at all and should be considered carefully. For example a Dental Mandibular Advancement Device (MAD) is popular. But for your condition it may NOT do anything towards your particular treatment. If it eliminated your mixed apnea it will still may leave behind the Central apnea and most likely that spontaneous arousals. Since it doesn't force any oxygen into your system like cpap, you can very well have a drop below 89% and never know it until it is way too late and you are in Cardiac care ward. So keep that in mind as you explore other options.

As for autopap machine: that may be difficult until you actually try one. Based upon your residual central apnea, you need a machine that avoids any confusion or pressure response to those centrals. Most autopaps on the market today do a lousy job at differentiating those central/mixed apnea from obstructive ones. A 40-second central apnea looks identical to a 40-second obstructive apnea to most autopap machines on the market as there is no airflow in either case. So if the machine confuses that central for obstructive it may apply more pressure, this only makes centrals show up in greater frequency (under most circumstances). The hope is always in applying CPAP pressure is that your Centrals will completely disappear. From your titration study they did go down dramatically which is what you want to see. But that pressure did very little (in my opinion) to improve the quality of your sleep. Too many interruptions to sleep still exist in the Sleep Stage graph to call that a complete success.

So based upon your results, seeing your pressure, seeing the events you are having the only machine I can suggest at this time is the PB-420e based upon my experience. Your pressure requirement is low enough to where the lack of Cflex feature found on the Remstar is not of any real concern. The more important feature is avoiding any response to those central/mixed apnea seen on your PSG. The 420e also does a better job at that because of its more sophisticated sensor in differentiating the difference between a central and obstructive apnea. It does this by monitoring for an open airway and listening for cardiac oscillations. It is superior than even the Remstar at avoiding any response to those central events (in my opinion). It also has some special parameters that are changeable where they are hard-coded and unchangeable in all the others. Sometimes being able to tweak these parameters specifically towards your needs can make/break your cpap therapy. Also this machine has excellent reporting capabilities compared to all others and it does a much better job at tracking those central apnea showing up on your PSG. It can show you both types of events or just the centrals. It offers you a way to see some improvement since you no longer have the EEG info from the lab. In your case you can at least see the centrals, where on the others you cannot.

Now, getting your doctor to go along with that 420e autopap idea may be an uphill battle. Conventional sleep medicine has decided autopaps are bad in general for central apnea. I disagree and feel it is that way for the lack of machine knowledge. Also know that before insurance will pay for any autopap you have to first try straight cpap therapy. Based upon your Titration why bother? If you try straight cpap for a week you have met that requirement with insurance. Next the battle comes down with your DME supplier in getting the right machine. Most DME's will lie through their teeth and tell you insurance won't pay for it. If your doctor is machine ignorant they may even agree with them and won't support you. When that happens you dump the doctor as well as the DME. So you have to go in this armed with knowledge about your own sleep condition. If you don't get the satisfaction from your sleep doc say seeya and go back to your GP. My GP
handles all my care, I haven't seen my sleep doc in probably 3-4 years, from what I can tell I'm not really missing anything. Good Luck. Oh did I mention this was long?

[WearyOne]

Snoredog, yes it was long--and I'm glad it was! I need all the help and suggestions I can get!

I figured all the arrousals on the titration were because of being on cpap for the first time. Even though I was excited and wanted the therapy, I really panicked when she put the mask on me. She tried seveal before settling on the NA II. I was surprised I slept at all. I remember waking up a bunch of times very uncomfortable with those "chipmunk cheeks." Then I didn't know what was going on, but I do now. And a couple of times she had to come in and adjust a lead, which woke me up.

Although they didn't note snores on the first sleep study, in his report, he mentioned the techs could hear my snoring. Don't know why that's not on there.

I'm about 70 pounds overweight, have Graves' Disease (which is autoimmune hyperthyroid). Thyroid was ablated and I take Synthroid in the morning. I also started Toprol, (a BP med that lowers heart rate) last summer when my heart went speeding away at the beginning of the hyperthroid chaos. I was taking a low dose of another HP med before that, but stopped when starting the Toprol. My heart rate during the day runs from 60 to 85, depending on what I'm doing. I also have suffered for many years from anxiety and depression, (lots of personal issues) which can mess with your sleep as well. They put me back on a SSRI right before my first sleep study. (Take it in the a.m.)

And I've also suffered from just regular ole sleep-onset insomnia for years. Took Ambien last night and did much better.

This could be good--sleep doc is leaving as of tomorrow. He was a certified sleep doc with a degree in psychiatry. The next guy they're getting interim will have a neurology background, which may be more helpful when I go in for my follow-up next month. I'll take these charts and really point out all those arousals.

I'm a mess, really, and doubt I'll ever figure all that's going on with my sleep. But I want to make as much improvement as I can. I have a copy of my script, so cpap.com may just see me purchasing that PB 420e. I've had excellent service from them with the Hybride and some supplies I've already purchased.

Thanks again, Snoredog, for you very-much-appreciated post!

Pam

[bgalb]

I had only two apneas last night. One at 3AM and one at 5AM. I noticed my clock in both cases because both woke me up to a wide awake condition instantly. This is not my norm, even with untreated severe sleep apnea, I only woke completely when the need to urinate compelled. It took 30 or 40 minutes to go back to sleep in both of last nights events.

I checked my chart the next day and both apneas were at the precise times that I woke up during the night. This resulted in a sleepy day for me with the need for an hour or two more sleep. This is such a mild experience compared to many on the forum, I hesitate to mention it, but just wonder if these were central apneas. My pressure is only 9in H2O with EPR of 3
My AHI was only 2.3. Overall, much improved energy and blood pressure since going on CPAP about 6 weeks ago. Just trying to understand all the mechanics of the system.

[WearyOne]

Snoredog, forgot to mention this. I was going to look into a dental appliance--in fact, had an appointment today with a dentist who specializes in them, but had to cancel because of car trouble. Glad you mentioned what you did about them in your post.

Pam

[Snoredog]

I should mention that during your titration study the residual centrals seen did go away at 7cm pressure, and the arousals reduced so that is a good thing, that is what you want to see. But your sleep remains fragmented.

So if you get any autopap, I would set the minimum to 7cm so those mixed and centrals are eliminated.

[StillAnotherGuest]

Very thorough analysis there, snoredog, looks like I'll have to scrounge to find some leftovers.

Does a mixed apnea look similar to that post arousal-central?

Here's an example of a mixed apnea I posted elsewhere. I had taken out the EEG channels, but you can infer arousal by activity in the chin EEG:



Since the latter part of the MA is obstructive, it would pretty much always need an arousal to terminate it. The initial central component could very well be post-arousal in nature. But true mixed apneas are quite rare, so I'm looking at all those mixed events in WearyOne's diagnostic and right now being a little skeptical. Especially since someone like that would normally be a shoo-in for CSDB, but in titration, low level CPAP clears everything up almost instantly. The central component would still remain, so you should have been left with a heckuva lot more centrals that you are. That plus snoring (I'd like to see exactly where that starts and stops) suggests this a little more obstructive in nature. This chart lumps apneas and hypopneas together, do you have the test report that breaks this out? If they're calling "mixed hypopneas" we may have some words. (Note to self: Redefine events, reassign arousals, hyperarousal)

But we must also look at the role of the severe sleep fragmentation. If that is the cause of the centrals (they're post-arousal) then once you return to sleep the obstructive component occurs, and the respiratory event now has a "mixed" appearance. I think it's important to dwell on that a little bit to figure out if you're a CSDB candidate or not. If you feel ambitious, get a few 5-minute epochs of the area between 0100 and 0130, tell 'em its for a science project, you need some examples of mixed events because they're so hard to find. On the other hand, this might be an entirely academic argument, cause respiratory-wise your titration looks fabulous. As snoredog notes, however, architecture-wise it's still a wreck.

There are no arousals from 0245 to 0445 because that looks like straight wake.

Yeah, the REM thing. No REM in diagnostic (undoubtedly thanks to the SSRI), it's important to know how bad the OSA gets there, and REM is helpful to identify CSDB.

Heart rate of 100 during sleep is is noteworthy high, especially if you're on a beta-blocker. The synthroid dosing OK? By any slim chance, do you have a current Resting Metabolic Rate (RER or BMR)?

I do note some positional dependency. The respiratory events are more severe while supine, this is seen more clearly in the oximetry channel. The part from about 2330 to 0230 or so are all desaturations.

Is the reason you want an APAP that you're thinking you'll feel better? Your titration sleep efficiency looks to be about 75% (depending on where they called "lights out"), so the most bang for the buck would be attacking the insomnia. BTW, which SSRI are you on? Some of those really destroy sleep architecture.
SAG

[WearyOne]

SAG, good morning!

So, is this centra/arousal thing kinda like which comes first, the chicken or the egg?

The SSRI my GP origianlly put me on was Lexapro (with a load of samples), which the sleep doc approved. I just asked to be switched to Prozac for several reasons, including it's not covered by my insurance! But, I remember my now-retired GP giving Prozac to me years ago when I was waking up every 20 minutes, to help with sleep (and depression). (A sleep study then showed nothing significant, a few centrals but nothing obstructive, little if no snoring. And also 70 pounds lighter!) A couple of friends took it for sleep issues and it helped them, and it is listed as a reason it is sometimes prescribed. Yeah, it's mainly for the anxiety/depression, but if helps the sleep some, that certainly couldn't hurt.

I went online and figured my Resting Metabolic Rate. Filling in the little chart, it said mine is 1640.

Yeah, I'm bothered by the higher heart rate during sleep as well. Now, I used to check it by taking my pulse (pre-cpap) right when I woke up in the middle of the night, and it was almost always under 80. (Why I did this was because several times pre-cpap, I would wake up in a panic with my heart racing over 150 beats a minute. I know, symptom of OSA. ) I do the same thing now with that litte finger pulse oximeter thing, and it's under 80, usually in the 60's, actually. And during the day, my resting pulse seems to have dropped since starting cpap.

My last blood workup on the thyroid was, as the endo put it, 100% perfect. I have the labs on all my blood work and am hooked into a great thryoid board and all seems well there.

Why am I looking at an auto? Maybe just grabbing at straws. Originally, it was because I like the idea of it changing pressure during the night to meet my needs as I sleep and thought it would help me stay asleep better. Also, looking at all those centrals on the tirtration, I thought even though 8 isn't a high pressure, maybe that's having something to do with CA's now and apap might keep me lower than that for part of the night. That's before I learned all about apap's misreading CA's as OSA's and raising the pressure. I don't know. Again, grabbing at straws, I guess.

Oh, on the first sleep study report: "Total of 24 obstructive hypopneas and 74 mixed hypopneas were observed with respiratory disturbance index calculated at 19. Average duration of hypopneas was recorded at 20 seconds, with the longest hypopnea lasting 31.9 seconds....Total arousal index (average number of arousals per hour of sleep) was calcualted at 31.6. Respiratory arounsal index was 18.6." That leaves a lot of arousals "unaccounted for," doesn't it? Doesn't mention anything on the titration report about the "other" arousals. I can see now he must have been only concentrating on the respiratory part and ignoring the other stuff.

Think I'll have a good talking-to at my next appointment with the new sleep doc that's starting to work there next week.

Thanks SAG and Snoredog!

Pam

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, Arousal, CPAP, Hypopnea, auto, APAP

[StillAnotherGuest]

So, is this central/arousal thing kinda like which comes first, the chicken or the egg?

Absolutely, there's a bunch of different causes for centrals, and you really have to figure that out before you can do a good job of attacking that.

The SSRI my GP origianlly put me on was Lexapro (with a load of samples), which the sleep doc approved. I just asked to be switched to Prozac for several reasons, including it's not covered by my insurance! But, I remember my now-retired GP giving Prozac to me years ago when I was waking up every 20 minutes, to help with sleep (and depression). (A sleep study then showed nothing significant, a few centrals but nothing obstructive, little if no snoring. And also 70 pounds lighter!) A couple of friends took it for sleep issues and it helped them, and it is listed as a reason it is sometimes prescribed. Yeah, it's mainly for the anxiety/depression, but if helps the sleep some, that certainly couldn't hurt.

I think that's a good move. Also, there's been a lot of recent talk about using eszopiclone in combination with fluoxetine to treat depression and insomnia. Fava has done a lot of work in this area, check out the Sepracor list

Eszopiclone/Fluoxetine Co-Therapy

Got that other study? It would be interesting to compare sleep quality. If you were on Lexapro for these last 2, we can see how much of the sleep architecture disturbance is due to the Lexapro fingerprint.

I went online and figured my Resting Metabolic Rate. Filling in the little chart, it said mine is 1640.

During metabolic workups, people will sometimes get a direct measurement of that. If your direct measurement was significantly elevated over your predicted, that might explain a state of hyperarousal, and consequently, another contribution to insomnia and poor sleep architecture.

Maybe we can try a different approach. Fill this thing out:

My last blood workup on the thyroid was, as the endo put it, 100% perfect.

I'd still be looking at thyroid control as a cause of the high baseline heart rate. Interestingly, the CPAP titration showed a much more normal baseline. Yeah, I can hear your next question, and I would say probably not. Also, you might want to get them to print out the diagnostic heart rate graphic using 150 as the high limit to see if anything drifted into there. And ask about this abrupt baseline increase during titration, towards the end of the study



Anything of interest on the EKG text report?

Oh, on the first sleep study report: "Total of 24 obstructive hypopneas and 74 mixed hypopneas were observed with respiratory disturbance index calculated at 19. Average duration of hypopneas was recorded at 20 seconds, with the longest hypopnea lasting 31.9 seconds....Total arousal index (average number of arousals per hour of sleep) was calcualted at 31.6. Respiratory arounsal index was 18.6." That leaves a lot of arousals "unaccounted for," doesn't it? Doesn't mention anything on the titration report about the "other" arousals. I can see now he must have been only concentrating on the respiratory part and ignoring the other stuff.

A "mixed hypopnea", huh? OK, there are all those desats, so there's absolutely a respiratory component. But there's also still a lot of chicken to be explained.

Or egg.

Try to get those epoch printouts, or at least get your guy to more closely scrutinize them.

I don't think you're going to feel much better till you attack that sleep architecture in a big way.
SAG

[WearyOne]

SAG, Interesting HAS table. My score is 51.

Unfortunately, I didn't start the Prozac until right after the sleep study in 1998, so that won't help comparing the Prozac to Lexapro. My GP back then wouldn't give me any medication until after the results of the sleep study. After OSA was ruled out, he gave me a couple weeks of Ambien and started me on Prozac.

Back then, I didn't ask for records of anything, so I never even saw this report until I called the other sleep center about four months ago and ask them to send it to me. Just pulled it out again--now that I know so much more about this stuff--and am wondering why the doc back then didn't follow up on his statement, "Moderately severe sleep fragmentation"? (Back then, I left everything to the doctors and didn't question stuff. When he said I didn't have enough respiratory disturbances to be classified OSA, I thought "good" and went on my way. Naive. Respiratory index then was 1.4.)

I can scan in this old one, if you'd be interested. Notations typed with the graph were:

0:05:00 a lot of movement.
0:14:00 alpha intrustion in sleep
2:15:00 a lot of movement
3:19:00 hyperventilation
3:38:00 a lot of mouth and head movement
4:29:00 a lot of movement
5:08:30 mild snoring
6:11:30 lights on

There's something on this graph "Ars1." What is that? Ars1 and leg movements, there seemed to be a lot of these. Again, on the 1998 study. And it doesn't look like I ever went into stage 4.

The doc that did my recent sleep studies has left the Center as of yesterday. I am going to call the assistant and talk to her Monday. Are PSnores just regular snoring? If so, I wonder why that wasn't noted on the the current "first" sleep study graph, seeing as though on the first study, the comment was made, "Loud snoring was observed by the recording technicians."

Could shallow breathing be picked up as a CSA?

Just knock me out with a hammer each night--maybe that will work. LOL

Thanks for spending so much time on this, SAG.

Pam