Another newbie getting to grips and with CSR concerns

[GolfGardener]

Hi everybody,

New CPAP user here, just one week in and learning a great deal.

First some history: I'm in my mid 50s. I have a long history of very loud snoring which I did nothing about other than trying to sleep on my side, which certainly helped but didn't fix it. Friends/partners have pointed out in the past that I appear to have sleep apnea, but I just shrugged it off. BMI of 25. Reasonably fit. Diagnosed as pre-diabetic around 10 years ago, characterised by high blood sugar first thing in the morning but with an otherwise normal response to food during the daytime.

In the last 3 or 4 years I have noticed a few changes taking place:
- Significant deterioration in quality of sleep. I can get to sleep very quickly, but wake up frequently throughout the night
- frequent nighttime bathroom visits
- persistently high blood pressure
- slightly reduced ability to exercise, i.e. I have to run a little more slowly than before to maintain the same target heart rate.

In a recent diabetes check, my doc mentioned "brachycardia" for the first time. After researching this I saw the potential link with sleep apnea and decided to get checked out for SA.

Went to sleep doc, who took my history, said that I don't look like a typical SA sufferer based on my body type, but then saw that I have an overbite and said that this could be the culprit.

I had a sleep study in September which diagnosed severe complex sleep apnea with AHI of 64.1, of which CAI was 20.6. Mean SP02 was 94%, minimum 79%. Cheyne Stokes breathing not seen. The average apnea duration was 31.6 seconds with a maximum of 59 seconds. That average, combined with an AHI of 64%, seems to suggest that I was in a state of apnea for more than half the night in total. Can that be right?

I spent another night in the sleep clinic for titration a few weeks ago. The experience wasn't great. I was using a nose mask, which was when I first discovered the significance of my being a mouth-breather. I seemed to be waking a lot during the night with lots of leakage and noise from the machine, but in the morning the sleep tech assured me that the settings they had used (9cm pressure) had removed all the events. I've asked for a copy of the results from that night but haven't got that yet.

I started on CPAP with my Resmed 10 a week ago and am still getting used to it. Based on the bad experience with the nose mask I started with a full face mask. It seemed better than the clinic experience, but I was still getting a lot of leakages etc. After a few days I decided to try the nose mask with mouth tape, and had a much better experience than either in the sleep clinic or at home with full face.

Now the results:

The most noticeable impact of all this was that the nighttime bathroom visits immediately stopped, which is great news. I also feel a little bit brighter when I wake in the mornings and a couple of times have actually got up earlier than I have to for the first time that I can remember. In fact overall, the immediacy of these impacts is quite startling. I'm hoping that I'm going to start to see a reduction in both morning blood sugar and BP as a result of my body being under less night-time stress, but haven't tested those yet.

I started off with the settings on APAP mode, min:4 max:9, EPR:1 (ramp only)

With the face mask I was getting AHIs in the region of 15-20 with a pretty even split of CAs and OAs, which was disappointing. The pressure kept maxing out at 9cm, so I increased the max to 12. The results didn't improve and this seemed to just make the leaks worse.

At that point I switched to the nose mask and decided to try to address the mouth breathing with tape. This gave me better results in terms of comfort, leakage and reduced AHIs: each of the three days I've used it the AHI have been below 10.

One thing that concerned me is that most nights showed periods of 30 minutes or so marked as CSR. I understand from reading here that lots of things marked as CSR by Resmed are just normal periodic breathing, but the flow rate patterns certainly looked like the real thing to me.

For last night I turned off the EPR to see if that removed the CAs and CSR, based on some reading here. I don't really see how it can do that given that it EPR was set to ramp only, but last night I had the best night so far in terms of the numbers (AHI 1.39) and no sign of any CSR. Even though I only got about 5.5 hours of sleep and was consciously awake twice, I woke in the morning feeling like I'd had the best night's sleep I'd experienced in years.

I've provided a link to my first week's worth of data here (sorry, IMGUR doesn't work where I am located):
https://sleephq.com/public/31e1dbee-ba9 ... 818c5a5de7

So, some questions for the wonderful forum members:
- is there anything else I might want to tweak based on what I've described above, last night's experience and the SleepHQ data?
- do I need to worry about the CSR-flags? Examples of these can be seen on the data from 05.30-05.45 on 9th Dec and 03.20-03.40 on the 8th. Note that I have no previous history of heart problems.
- Is there anything else that I should raise with my sleep doc based on the experience so far when I see him in a few weeks?

Thanks for all your help. I've learned so much already from this group, and I know I still have a long way to go, but the initial results have been really encouraging and the whole experience has been a lot easier than I expected.

[Pugsy]

Please include the image/report that actually shows the CSR flagging. So upload a report with CSR being flagged for us to see.
Real CSR has a definite pattern to it and usually the worrisome CSR will also have a bunch of central apneas flagged with it.
These machines actually flag periodic breathing which isn't always real CSR.
CSR is just one of the many forms of periodic breathing so not everything flagged as CSR is really a problem.

Here's an old one of mine....it got flagged but it isn't CSR.
It's just plain old periodic breathing ...which is just a waxing and waning of the flow rate that lasts at least 2 minutes.



Now this person...real CSR and a truckload of centrals and he definitely had a known heart function issue.



Not all CSR (even if it appears to be real) means a person automatically has some sort of heart issue but I know that when people see flagged CSR it scares the bejesus out of them. There can also be something called idiopathic centrals where there is no known cause.

Also...awake breathing can sometimes be irregular and the machine will sometimes flag awake breathing as periodic or CSR.

We need to see your flagged CSR breathing to have any idea if it is a real problem for you especially since you did have enough centrals during the diagnostic sleep study to earn the complex sleep apnea.

[GolfGardener]

Thanks for the quick reply Pugsy.

Sorry, I thought it would be possible to zoom in onto the relevant bits of the previous link.

Please try this one:
https://sleephq.com/public/33a45565-cf2 ... 8acd100305

Or this one:
https://sleephq.com/public/d10e8eb4-cb ... a9505b2e78

Which should show the periods that I’m talking about.

[Pugsy]

I can only see the one image you post and can't go into other images using sleephq....or at least I have never figured out how to go to other nights from the links people post.

So I zoomed in on the flagged CSR on the 2 nights you posted.
Some of the time the breaths look sort of like CSR and other times obviously not real CSR.
Odd the way SleepHQ only shows the green part at the flagged central cessation of breathing and not the entire segment. That's not normal and may have to do with the way SleepHQ is calculating and presenting the data.
This makes for evaluating just how much of a worry the centrals are (or aren't) extremely difficult. This is not how we normally see flagged CSR breaths.

Where are you located that you can't use imgur for OSCAR reports?
You've just been on cpap about a week...so not a lot of data on the SD card yet.
I would really like to see what OSCAR shows since that is how ResScan would also show things.

You obviously have nights without CSR flagging and with a nice low AHI....so it's not like all the nights are questionable.
So I don't think it is something that is critical at this point anyway but I would keep one eye on things.

[GolfGardener]

OK, I managed to find a workaround to the IMGUR issues. So here we have:
The night before last, AHI getting better, still some CSR flagging
https://i.imgur.com/L1vwuIW.png

Zoomed into the CSR:
https://i.imgur.com/Qww1fsF.png

Last night, much better:
https://i.imgur.com/7w74pPD.png

Thanks again!

[Pugsy]

The zoomed in section with CSR flagged looks like real asleep CSR but if you look at the CSR section flagged prior to it there are OAs and not centrals flagged and your pressure was pegged out at the max limit of 9.
The machine wanted to go higher but couldn't.
Were these real OAs or maybe centrals mislabeled??? Dunno and it's really hard to tell just by eyeballing the data graphs we are given.

You know at this point since you are so new to this therapy AND you are having some good nights in terms of the reports...I think I would just adopt a wait and see approach. See if you end up with more "good" nights than "bad" nights.
Doctors look for trends and patterns over the long term and don't often worry about a small segment of one not so great night.
If you ask your doctor about them he/she would probably say "don't worry right now...let's see how it goes over the long term".

Do you wake up very often with those leaks? While probably not bad enough to impact therapy effectiveness itself they sure could be impacting sleep itself and causing wake ups. If they aren't waking you up...don't worry about them.

[GolfGardener]

Ok, thanks for the tips.

I’ll try to stop worrying and just keep an eye on the trends for now until I properly get used to this new way of sleep.

In the meantime maybe I’ll increase the max pressure to stop it maxing out at 9. Then I’ll see what the doc says when I next visit.

On the waking up thing, I really have very little awareness of exactly what is waking me, but I will try to be a bit more conscious of that over the next few nights and see if it tells me anything. This last week I have probably woken twice, briefly, most nights. Not too bad compared to before treatment.

[Miss Emerita]

About the pressure maxing out at 9: the pressure increases seem to be largely driven by your flow limitations. Increased pressure doesn't actually do much to address flow limitations, so as long as your OA and H indexes are low, you might not want to worry too much about increasing your max.

(Flow limitations can originate in the nose or further down, in the pharynx. FLs from nose problems can't really be addressed with pressure at all. FLs in the pharynx can be. FLs may or may not interfere with sound sleep. Usually when they seem to be a problem, EPR is the best solution. For you, though, EPR could be counterproductive, since it sometimes increases CAs.)

All in all, if you're having good results with your current settings, I'd be inclined to leave them alone for a while, as you continue to acclimate and watch the CSR trends. You're doing SO much better than I did, and with your interest in data and understanding what lies behind them, I'm betting you'll do very well going forward.

One quick question: do you live at a high altitude or use any narcotic-type medications?

[Pugsy]

If you are seeing clustering of OAs or hyponeas and the max pressure is pegged out...you might also be on your back when that is happening.
It's common for people to have their OSA worsen and require more pressure when supine than they might be needing when on their side.
REM stage sleep can worsen OSA as well. My own OSA is about 5 times worse in REM and sometimes I might need 6 or 8 cm more pressure to break up the clusters.

[GolfGardener]

About the pressure maxing out at 9: the pressure increases seem to be largely driven by your flow limitations. Increased pressure doesn't actually do much to address flow limitations, so as long as your OA and H indexes are low, you might not want to worry too much about increasing your max.

(Flow limitations can originate in the nose or further down, in the pharynx. FLs from nose problems can't really be addressed with pressure at all. FLs in the pharynx can be. FLs may or may not interfere with sound sleep. Usually when they seem to be a problem, EPR is the best solution. For you, though, EPR could be counterproductive, since it sometimes increases CAs.)

OK, this is a new one for me. So "flow limitations" is another concept I need to add to my vocabulary!

I have a long history of sinus troubles, and when I last had this looked at as a result of a month-long headache, they found multiple nasal polyps as well. It was suggested that I might need to have FESS surgery at the time, but when the headaches went away the doc suggested I wait and see. I still often seem to have a blocked nose though, hence the mouth breathing. Is this a possible root cause for "flow limitations"?

All in all, if you're having good results with your current settings, I'd be inclined to leave them alone for a while, as you continue to acclimate and watch the CSR trends. You're doing SO much better than I did, and with your interest in data and understanding what lies behind them, I'm betting you'll do very well going forward.

Yep, I can turn pretty much any problem where I get data to look at into an interesting puzzle!

One quick question: do you live at a high altitude or use any narcotic-type medications?

No, I'm based in the Arabian Gulf, at sea level and am not on any meds.

[GolfGardener]

If you are seeing clustering of OAs or hyponeas and the max pressure is pegged out...you might also be on your back when that is happening.
It's common for people to have their OSA worsen and require more pressure when supine than they might be needing when on their side.
REM stage sleep can worsen OSA as well. My own OSA is about 5 times worse in REM and sometimes I might need 6 or 8 cm more pressure to break up the clusters.

Yes, I have been mostly on my back this last week.

I tried one night on my side with good results, but then another night was disastrous due to leaks etc. and I just went back on my back.

I think I need to find a more firm pillow and then I will be giving side sleeping another go with the nose mask, for sure.

Out of interest, how do you know when you are in REM sleep to determine that it is 5 times worse?

[Pugsy]

Out of interest, how do you know when you are in REM sleep to determine that it is 5 times worse?

Documented when I had an in lab diagnostic sleep study.
Overall diagnostic AHI when not in REM was around 12 but in REM (what little REM I got) it was documented at 53 per hour.
Supine sleeping has never been that big of a deal for me but REM sure is. It's fairly common and some people have OSA only during REM.

A lot of home sleep studies don't measure sleep status though so there is no way to know if REM is worse or not because some sleep studies don't do the EEG leads to measure sleep stages or even whether someone is actually asleep or not.

As for determining REM when on cpap...I can watch the pressures change during the probable REM cycles. REM is fairly predictable when someone is sleeping fairly soundly....first REM will occur approx 90 minutes after sleep onset and as the night goes by we have longer durations of REM and they come on faster.
Google "sleep stages" and look at the normal hypnograms and you will see what I mean.
Most REM will occur in the wee hours of the morning and your cluster with the max pegged out...could also maybe have some REM factoring into what is going on. Maybe a combination of supine sleeping and REM got together in your case. I don't dwell on REM so much because there's nothing we can do about it and we need REM and the treatment is still cpap. For myself I just let the machine sort it out.
As long as my minimum pressure takes care of the bulk of any events I just let it do its increases as it needs...and I don't really worry about supine sleeping so much because again I just let the machine sort it out....but my OSA isn't all that worse supine but if it was I would still let the machine sort it out.

Now I know one person who needs 19 cm when on their back...and only 9 cm when on their side. Don't blame them at all for going to extraordinary measures to stay off their back when faced with 19 cm...man that's a hurricane like wind for sure.
I have never seen a pressure change of any significance with supine sleeping though. REM yes but supine sleeping no.

[palerider]

Ok, thanks for the tips.

I’ll try to stop worrying and just keep an eye on the trends for now until I properly get used to this new way of sleep.

Yes, stop worrying, now if you had *hours* of breathing like this:

Then you should be worried, but a few minutes here and there, especially towards the end of the night, no, that's NOT something to worry about.

(the above image was the first sign of my late brothers severe heart failure. and that's classic CSR)

[palerider]

About the pressure maxing out at 9: the pressure increases seem to be largely driven by your flow limitations. Increased pressure doesn't actually do much to address flow limitations,

Um, yes, yes it can, and usually does. that's WHY the machines increase pressure for flow limitations.

[lynninnj]

I’m looking at the ramp on auto and thinking that makes it tougher. I like my 5 minute ramp. Minimum setting may need upward tweak, if I’m reading it right.

maybe a veteran will concur.