Cheyne Stokes Respiration after new mask

[Frogler]

My friend recently switched to a N20 mask and instantly got a very high number of events. He switched back and the high events continued. I've tried adjusting his pressure a little bit as the AHI seems to be related to central apnea.

I'm most concerned that it's reporting it as Cheyne Stokes Respiration. This is on a Resmed 10. It's been a few weeks and I'm out of ideas and am hoping someone here might have some ideas.

I have two Oscar readings. The first one is for the whole day (there's a nap in the middle of the day which is why the events look odd). The second one is a zoom in on the CSR which appears to be what I've read online.





I will try to follow tomorrow with a normal night's sleep. He has an appointment with his doctor later this month but his AHI being >50 (when it was <4 for years) is really concerning.

So far what I've lowered his Min from 9 to 6 and his max from 12 to 10.8 and increased his EPAP from 2 to 3 with the only affect being he's sleeping more comfortably with a lower leak rate but not change to his AHI.

[palerider]

You didn't post any images.

[Respirator99]

Frogler, your images didn't show up - here are the links:

https://ibb.co/T0gnY4G

https://ibb.co/BLtvrzR

That is Cheyne Stokes respiration, which is a form of central apnea. The central index is 38.56, which is severe. For CA to start suddenly like that, there must have been some substantial change in his circumstances, such as a head injury, new medication (especially painkllers) or a move to high altitude. Your friend did not get this level of CA just by changing masks - there is a back story here which we are not seeing. Please get your friend to post for himself and pay attention to the sticky titled Sticky: Newbies PLEASE READ BEFORE POSTING. viewtopic/t172378/Sticky--Newbies-PLEAS ... STING.html

[palerider]

Step 1, turn *OFF*EPR.

[Rubicon]

Fix the leaks. Based on what's happening at the beginning of the night you've got major CO2 Washout as a contributor, if not the cause of the whole mess.

[Frogler]

With regard to the suddenness of this. Here is the CPAP results from when he was still using the P30:

P30:



Changed to N20:


I don't think the mask changed caused it. I provide it as just additional information.

As you can see, even when he had a lower AHI he had a decent amount of leakage with the P30 mask before. His leak rate before when he has a good AHI was actually higher than it is now. (compare the first image here with the image in the first post to see what I mean).

When he brought up the issue, I suggested he switch back to the P30 to try to get back to where he was but the high AHI and CSR continued which is what brought me here and the first post in this thread.

One data point, when he first switched to the N20, he had higher leakage because he had two necks attached to his hose (both ends -- the P30 and the N20 so he had two vents) which I fixed once he asked me to take a look.

I've told him to talk to his doctor first thing Monday as I'm out of ideas on what I can do as a lay person (I've been lurking here for 10+ years and use a F20 myself and was using Sleepyhead before Oscar).

But obviously such severe apnea, particularly central, and so sudden, is very concerning.

I'll have another update based on last night's data.

[Rubicon]

I'm out of ideas on what I can do

You've been given 2 good ideas (3 if you consider Paul's comments). Not all leaks are the same (a mouth leak with a nasal mask will create washout whereas a nasal leak may not). There could be a ton of central stuff in the "good" DL that simply isn't scored and needs breath by breath analysis.

Fix leaks trash EPR.

[Frogler]

If I knew how to get his leaks lower I would. When he first switched to the N20 he had a very high leak rate because he had connected two necks to his hose. Once we switched him back his leak rate went back to around 10 and I adjusted it further to get it down to 7. His seal is good but his AHI is still very high.

His EPR was set to 2 before and has been at 2 for half a decade without issue. When he switched back to the P30 he complained that he was having trouble breathing out so I raised it to 3. I can try disabling it entirely but I fear he will end up pulling off the mask entirely.

I talked to his wife today and she described what his breathing I like when he's not wearing the mask and it sounds like textbook Cheyenne Strokes (normal breathing that slowly gets weaker, then stops for a bit and then returns after 20 seconds or so). Obviously if it's genuine central apnea there's not a lot that CPAP can do but it seems so odd that it would occur the day he switched masks.

[Rubicon]

I talked to his wife today and she described what his breathing I like when he's not wearing the mask and it sounds like textbook Cheyenne Strokes (normal breathing that slowly gets weaker, then stops for a bit and then returns after 20 seconds or so).

Sounds like Paul hit the nail on the head with there being a "back story".

IMO he'd be better off in the ED rather than a CPAP Forum.

[Miss Emerita]

Bystander here: yes, please urge your friend to see a doctor as soon as possible. The change in masks may well be a red herring, and you don't want your friend to delay getting what may be urgently needed medical attention.

He should be sure to take a printout of an Oscar chart with him, along with the zoomed-in view that shows that C-S pattern in the flow rate. In case it helps, here's some information from the NIH about the pattern:

Cheyne-Stokes respiration is a specific form of periodic breathing (waxing and waning amplitude of flow or tidal volume) characterized by a crescendo-decrescendo pattern of respiration between central apneas or central hypopneas. The American Academy of Sleep Medicine (AASM) recommends to score a respiratory event as Cheyne-Stokes breathing if both of the following criteria are met:

There are episodes of at least three consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds).
There are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of two hours of monitoring.

[Frogler]

I took him into Emergency where he was diagnosed with Pulmonary Hypertension which can contribute to that.

But it does remain very odd that there was no indication of this until he switched masks (I want to emphasize I don't think the mask caused it). I am more concerned that perhaps because he had so much leaking (had had hooked a neck up to both ends of the tubes so he had very high pressure due to the leaks) that first night that it somehow aggravated an underlying condition? It just seem like such a coincidence.

They gave him some medication an an appointment for a right-heart catheter to get a better idea of what's going on.

[palerider]

I am more concerned that perhaps because he had so much leaking (had had hooked a neck up to both ends of the tubes so he had very high pressure due to the leaks)

No, this is not the issue, leaks absolutely DO NOT cause pressure increases.
If leaks are bad enough, auto machines will REDUCE pressure in an effort to get the mask to seal better, before raising pressure up again.

[ozij]

And why did he change the mask and the mask type?
Could he have been attempting to relieve some kind of breathing discomfort by changing the mask?

I'm glad you took him to the ER.

[Miss Emerita]

Frogler, you're a good friend. I'm so glad you took your friend to the ER.

I'm curious: did he take any Oscar print-outs with him? Or did he (or you) just describe the increase in central apneas and/or the pattern of the flow rate?

[Frogler]

And why did he change the mask and the mask type?
Could he have been attempting to relieve some kind of breathing discomfort by changing the mask?

I'm glad you took him to the ER.

He doesn't like the feel of the P30 (the silicon). I suggested the N20 touch because of the memory foam.