Perodic breathing with CAs & HAs

[Scott123]

I was asked to do a new thread for this / my issues. Here is is.

I am here to figure out more about my periodic breathing as that seems to happen when I get a high AHI night.

From other posts I have read, it looks like maybe Cheyne Stokes Respiration going on, connected to the periodic breathing. My chart posted below.

Short History:
I have been using an APAP for over 10 years now, always respironics, upgraded to the dreamstation in June 2018.
APAP originally set up for 4-15, once I had access to sleepytime (upgrade to cpap around 2012) I changed it to 8-15 as 8 was the lowest pressure showing typically. This has worked well. I was around 90 AHI in the sleep study and most of my nights are good - in the low/mid 2s, sometimes in the 1s, sometimes in the 3s. Rarely I would get a high reading 10 ish (3-4 times a year), typically adjusting my mask lowered things back down.

Higher AHIs more often recently...
Last half of Nov 2020, I got a higher AHIs about once a week and the last 8 days I have gotten higher numbers 4 days.
Nothing correlates to this increased number of higher AHIs (no equipment changes of any kind).
I am losing some weight but I only dropped below my typical weight +- a few lbs after the end of Nov, however maybe that is affecting things.
I have a Dreem 2, and the higher AHIs do not correlate to REM sleep or position or anything else noticeable.

There is a correlation between CAs HAs and the PBs

Note, Dreem 2 (shows brain waves same as sleep study, so an accurate wearable for home), showed:
REM sleep from 5:50 to 6:30 when the first chunk of CAs & PB were happening.
It showed Rem then a short awakening at the beginning of the 2nd chunk of CAs & PBs, followed by light sleep 8:13-9:30.
The first general picture attached - the 4th chart down is the Dreem sleep stages chart.
-1 is awake,
-2 is REM sleep
-3 is light sleep
-4 is deep sleep

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More charts in the next post.

[Scott123]

More charts attached.

This shows the patterns - zoomed in - of the PB & CAs.
NOTE: Next post I will include a couple charts that shows what happens right before the Periodic breathing starts.

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[Scott123]

Here is one more of the periodic breathing zoomed in.

The last 2 are showing the time just before a periodic period appears.

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[Scott123]

FYI, OSCAR can import the Dreem 2 CSV files, and display the hypnogram.

Slowwriter, I included the hypnogram from Dreem - in the top general picture of the chats.
I wish the positions were also imported, but Dreem does not export that.
I thought about putting in a screen shot of my phone, but that is difficult to read. Maybe a video while I slowly move the bar across the night but it could be hard to see if someone didn't know what they were looking at / could not make it larger.

[Pugsy]

Couple of questions you can answer in that thread...
Do you take any medications of any kind? If so, what?
Do you think you were asleep or awake when some of that CSR looking flow rate is happening? Sleeping soundly for the most part or lots of wake ups going on?

[Scott123]

Pugsy, thanks for looking at this.

Here is my own thread.
Medications... They have not changed in years. I take low doses of:
Metrolopol (blood pressure), atorvastatin, enalapril, warfarin, allopurinol.
I take supplements, again they have not changed in years.
I have mild afib and trace Mitral valve regurgitation. My blood sugars have recently (in the last 2 months) become much better controlled and in the normal range, as is most of my lipids and this resulted in the weight loss (along with eating healthy and exercising). Afib and valve issues drastically improved over the last 2 years.

I don't think..... that I am awake and Dreem seems to support that overall.
Here is what I put in the first big entry...
Dreem 2 (shows brain waves same as sleep study, so an accurate wearable for home), showed:
REM sleep from 5:50 to 6:30 when the first chunk of CAs & PB were happening.
It showed Rem then a short awakening at the beginning of the 2nd chunk of CAs & PBs, followed by light sleep 8:13-9:30.

I will try to make a Dreem video that can be seen.

[Scott123]

Here are dreem 2 videos of the night. They actually turned out pretty good.

Starting just before the periodic breathing started:
https://www.dropbox.com/s/q43u4ac0phlw2 ... 9.MP4?dl=0

The entire night:
https://www.dropbox.com/s/ztngogfrbdnzj ... 9.MP4?dl=0

I will grab pics of good nights, just to show the difference.

[Scott123]

Here is a good night.

Note: The 4th chart down is the Dreem sleep stages chart. (Same for the general chart pic in the first post).
-1 is awake,
-2 is REM sleep
-3 is light sleep
-4 is deep sleep

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[Pugsy]

http://freecpapadvice.com/sleepyhead-free-software
Go to the above website and watch the videos...then go through your bad nights and see how many of the centrals/CAs could maybe be awake breathing false positives.
For the bad nights...try see if you can correlate just a crappy night's sleep for some reason or other.

In the meantime....

Try turning off your Flex exhale relief if you can and lets see if the centrals reduce or not.

[Scott123]

I did watch the last video on that link you listed (I saw you posted it on another thread).

I will try and go back and look at other days to see if I am awake, but last night I only was for a couple minutes during the periodic breathing. It started at the end of REM sleep, it could be I had a disturbing dream that set things off (I didn't wake from a bad dream like I do sometime and did the night before which was a low AHI night).

When Dreem showed I was awake, I was actually drifting much of that time (not quite awake, not quite asleep).

When I was awake in the middle of the night, I did feel a little agitated, just fretting over concerns of the day and all that is going on these days. So that restlessness might have flowed into my sleeping also....
I will try to track that.

I just brainstormed with my wife about what had changed.
I upped my testosterone around middle of Nov so that fits the timeframe when PB & CAs got worse. That might have made the difference.
I take it twice a day (to spread out the peaks and valleys).
I am going to try the new dose in the mornings and the old smaller dose at night and see if that changes things.
I will come back and post after a week or so if thing have changed or I figure something else out.

[Scott123]

Ok, that was the solution.
I have lowered my testosterone at night only (I need the higher dosage but day time only is working well).
Immediately that first night I got less CAs, 1 all night long vs a big block plus some other ones. My AHI dropped to low 3s. I still had a fair amount of periodic breathing, but not a CA/HA in each valley.
Subsequent nights (5 total since lowering nighttime testosterone) had AHIs in the 2s to low 3s. I still have some nights with periodic breathing, but not the HA/CA between each one.

So I am considering this solved.
I am attaching some graphs.

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[Scott123]

Ok, my last "consider it solved" post was not accurate.

The same PB and CA pattern came back a couple of days later just as strong.
I used a Dreem 2 and could not figure out any patterns that matched sleep stage or sleep position.

Next I tried a chin strap (I had used a nasal mask forever).
It gave some improvement, AHIs improved some but still APIs were too high many nights.

So then I tried a full face mask (I had to go get a new one, my old one didn't fit well anymore) without the chin strap.
That didn't help, but I continued to help it (and didn't use the chin strap).

So I started upping the pressure (so that EPAP would be higher).
I have a dreamstation autopap.
Previous to any pressure adjustments, I had the settings at
Pressure min 8, epap was about 6 min.
I increased the pressure min to 8.5. My epap was around 6.7. I still got very high readings (mid teens) some days.
I increased the pressure min to 9, an improvement but still some problems.

Having figured out a data problem, I will repost information soon.

[Scott123]

Ok. Looking generally at Oscar data:

March 1st thru 22nd, 13 days over 3 (59%). Of those 13, 8 were 4s or 5s, one was 10.72.
Got new mask, had a 16.38 and a 1.42 so considered that not any improvement.
Changed min pressure setting to 8.5. AHIs 5 one night, 17 another (taken as no change).
Changed min pressure setting to 9.0. AHIs below 3 = 4, 1 above 10, so much better (25% over a 3 vs 59%). PB also decreased significantly, and when there was a higher AHI night the AHIs were when the pressure was lower.

However, after the pressure was changed to 9 minimum, without any further pressure changes, the min pressure setting showed as 8 some nights (yes, the AHI was worse, these nights were not included in the numbers above). I know there are settings that say let the machine set the pressure to what the machine thought was best in the last few days. I will do look more carefully at all the settings to make sure it is staying at a 9 minimum at all times.

[BlueDragon]

1) My oscar charts now doesn't report the same event flags. So I have no idea if I am hitting lots of PB intermingled with CAs/HAs like before. Is there something with the dream station that it reports less event flags if you go above certain pressures? Pictures are below.
Is this an Oscar 1.1.1 problem? I did the upgrade but I didn't write down which day it was done. I just did an upgrade to Oscar 1.2 and the same problems exist.

The first screenshot shows a Dreamstation and the next two show a ResMed AirCurve 10 VAuto. There are differences in the way the data is reported and which events are reported by different manufacturers and thus differences in how the OSCAR screen looks. One thing to note is how OSCAR handles the event indexes in the left sidebar. A type of event is shown in that list of events only if OSCAR has seen an incident of that event for the current machine. If the event has not been seen, then the line will not be seen. Manufacturers differ in what they report. For example, the Dreamstation report shows Periodic Breathing. ResMed machines evaluate this issue differently and call it (incorrectly) Cheyes-Stokes Respiration (it is usually just periodic breathing). A Dreamstation and a VAuto should not be expected to show the same results even for the same breathing pattern because they have different internal algorithms.

2) The AHI numbers in Oscar no longer match the front of my machine in the morning (which I write down each morning, note they do seem to be rounded). The 7 day average shown right now in the therapy mode, info screen matches closer to the numbers I wrote down and are way off from what Oscar is giving. Again, maybe this is an Oscar 1.1.1/1.2 problem? The 7 day average - reported in the therapy info screen seems a lot closer to what I wrote down and does not match what Oscar is saying at all.

I can speak to the difference in AHI and other indices between ResMed machine display and OSCAR display but am not so versed on Dreamstation machines. The AHI and index numbers disagree because the ResMed machine computes more coarsely than OSCAR does. There may be multiple sessions during the night. ResMed CPAP machines round each session's duration to the nearest minute, adds them all together, and divides by total time, again in minutes. OSCAR doesn't round the session duration but uses the raw data provided by the CPAP machine, which is precise to the second, and doesn't round anything until the final display when it will show only two decimal digits. Suppose you have a session that lasts 10.4 minutes and has one event. The CPAP machine will report 1/(round(10.4), or an index of 0.1. OSCAR, since it doesn't round, will report an index of 0.09. The difference between the two index computations can get much larger when there are multiple sessions with the multiple roundings resulting in a greater discrepancy.

3) I am now getting mostly CAs. Is that a problem? Again, I am not sure I am getting good Oscar information.

I generally don't get involved in therapy efficacy discussions, and I have not read the rest of your thread, so won't address whether that is a problem for you. OAs are generally treated first by increasing EPAP. I also use a VAuto and have found that the number of CAs I see was greatly reduced by increasing the Trigger value to High.

P.S., I recommend you use OSCAR 1.2.0 which includes lots of fixes.

[Scott123]

BlueDragon,
I read your other reply and scanned this one.
Yes my wife and I have two very different machines.
Great care is taken each time we load data into Oscar to confirm what profile we are under as well as what machine the SD card says it was from (and the SD cards are different). Because we both have a background in software we expected different formats (though we didn’t know for sure).

I will check file structures on both SD cards in the morning.
Scott