Wigged out about central apneas

[DreamStalker]

You need to get your leaks under control. Your report data cannot be trusted unless you steady and smooth out that leak curve.

An APAP requires that you have relatively few leaks in order to work correctly.

[pjwalman]

You are absolutely right, DreamStalker! I'm still trying to find a mask that will not beat up my face AND will not leak so much! This one is more comfortable than the Quattro but leaks more. I've got a ZZZ on its way, and the DME has a gel mask coming in soon that I will be able to try. I'm still in the search!

Peggy

[pjwalman]

Latest update, if I haven't driven you guys batty with it yet.

Used ZZZ mask last night, had the lowest leak rate I've had with any of my masks and coincidentally was the most comfortable with it. Is this leak graph looking more like a normal one should look now?

Had another pesky NR show up again last night, and I'm thinking it wasn't during ramp. Still new at reading these, but doesn't it look like it's just in the middle of things, not at the start of a ramp? So that's two potential centrals in a week, one a "normal" one when just falling asleep, one not. At what point do I decide to do some personal experiment with more precise equipment to see if I want to piss off my doctor again by bringing it up? Do you all have NRs in those numbers in a week? Is that pretty normal?

Enough of my chatting. Here's my chart from this morning and then the summary of what has happened at each pressure for the last week. Just wondering if there is enough activity up in 14% that we should reanalyze the range or if we go by the AHI and say it's good right now. They have ranged from 1.3 to 6.6 this week at 10-14 range.





Thanks for glancing over these!

Peggy

[NightHawkeye]

Latest update, if I haven't driven you guys batty with it yet.

Nope, not batty at all. Actually, I don't think it's possible to drive someone batty with this stuff here. Anyone who isn't interested can move on to another post.

Had another pesky NR show up again last night, and I'm thinking it wasn't during ramp. Still new at reading these, but doesn't it look like it's just in the middle of things, not at the start of a ramp?

Exactly right, Peggy. I put crosshairs on your NR and verified that as soon as the NR occurred, the machine immediately backed down pressure and that string of apneas stopped. That suggests to me that particular string of apneas was "central" in nature, at least just prior to when the pressure was reduced. Can't say how it started though, whether obstructive or central. Can't determine much about the other string of apneas either.

You asked earlier if the 420E would provide additional info. This is an instance where the Puritan Bennett 420E "might" be able to shed additional light into the nature of the apnea. Then, again, the 420E might not provide much better info. It's central apnea detector is the best of any APAP and it's definitive of "centrals", but only characterizes two-thirds of the central apneas it sees as centrals. Also, the 420E can't guarantee any better results for you, because your results now look pretty good really, Peggy. .

So that's two potential centrals in a week, one a "normal" one when just falling asleep, one not. At what point do I decide to do some personal experiment with more precise equipment to see if I want to piss off my doctor again by bringing it up? Do you all have NRs in those numbers in a week? Is that pretty normal?

I really never saw NR's in my data with the Remstar-auto, whereas with the 420E I see "centrals" frequently, but they aren't dominant. If that comparison is any indication, then it's fair to say that your current situation may not be greatly different from what you experienced during your titration study. As for adjustments, you have only a little room to lower your pressure. The previous chart you presented looked liked a pressure increase over 12 cm was warranted. Looks like your machine last night backed down when it reached 13 cm, so kinda looks like your choices are in the 12 cm to 13 cm range if you continue with the Remstar-auto. You could play around within that range a little to see if the data shows, or you "feel", any improvements.

Enough of my chatting. Here's my chart from this morning and then the summary of what has happened at each pressure for the last week. Just wondering if there is enough activity up in 14% that we should reanalyze the range or if we go by the AHI and say it's good right now. They have ranged from 1.3 to 6.6 this week at 10-14 range.

I'd go with "good" for the time being.

Regards,
Bill

[Snoredog]

[quote="pjwalman"]Latest update, if I haven't driven you guys batty with it yet.

Used ZZZ mask last night, had the lowest leak rate I've had with any of my masks and coincidentally was the most comfortable with it. Is this leak graph looking more like a normal one should look now?

Had another pesky NR show up again last night, and I'm thinking it wasn't during ramp. Still new at reading these, but doesn't it look like it's just in the middle of things, not at the start of a ramp? So that's two potential centrals in a week, one a "normal" one when just falling asleep, one not. At what point do I decide to do some personal experiment with more precise equipment to see if I want to piss off my doctor again by bringing it up? Do you all have NRs in those numbers in a week? Is that pretty normal?

Enough of my chatting. Here's my chart from this morning and then the summary of what has happened at each pressure for the last week. Just wondering if there is enough activity up in 14% that we should reanalyze the range or if we go by the AHI and say it's good right now. They have ranged from 1.3 to 6.6 this week at 10-14 range.





Thanks for glancing over these!

Peggy

[pjwalman]

Oh, good God, this stuff is complicated!! My AHIs were way higher at lower pressures. I don't know how to beat this stupid game!

[RonS]

First off, don't sweat it!

An AHI of 2.8 or 3.6 is wonderful! It's way below the goal of < 5.0 and you're probably getting lots of great sleep!

Second, remember that whatever anyone tells you on here is opinion and not the Gospel. Including me.

_________________

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

[NightHawkeye]

Oh, good God, this stuff is complicated!!

LOL. Ummm ..., no, not so much, merely new to you.

My AHIs were way higher at lower pressures.

Sounds like progress to me. .

I don't know how to beat this stupid game!

Look at it this way, you're already way ahead. Enjoy!

BTW, the game is trial-and-error. Some things work, others don't. Find a prize here, find another prize over there. You've done well. Maybe you'll do better, maybe not. Over half the folks who start this therapy simply quit, so you're way ahead in this game already. Further improvement requires time, money and/or frustration with no assurances of real improvement. Kinda like life, which you'll probably have a few more years of now. That's my opinion, anyway.

Regards,
Bill (hardly ever lacking an opinion ... )

[rested gal]

Peggy, since you had a considerable number of central apneas show up in your PSG sleep study, it's possible that a lot of the "obstructive apneas" being marked on your Encore data are really centrals.

None of the regular autopaps, including the one you are using, even attempt to identify "centrals"...except one machine...the Puritan Bennett Goodknight 420E.

If some of those "obstructives" turning up on your overnight data are actually central apneas, the 420E autopap is the only regular autopap that is capable of telling you that. The 420E can't identify every central that happens, but when it does mark an event as a central apnea, it really is a central apnea. It identifies a central by picking up rythmic oscillations in the airflow from a beating heart. Oscillations delivered via an open throat..an unobstructed airway.

If the throat is open but the person is not breathing because the brain simply hasn't sent the signal to "Breathe now" it's a central. The 420E senses heart beats through an open throat. If throat is closed (obstructive) those oscillations don't come through to be picked up.

So, with your sleep study history of having centrals in addition to obstructives, unless you know you are no longer having centrals (and you can't know that from the recordings of the machine you're using now) you really don't know if the obstructives showing up on your data are obstructives... or ... are really centrals.

A regular autopap's pressure isn't going to do anything for centrals (throat is already open) so tweaking the pressure to try to get rid of the "obstructives" on the data (if all of them aren't obstructives after all) would be like a dog chasing its tail. Not getting anywhere.

I'd try a 420E the first chance you get. Just a few nights of data from that machine might give you an idea if centrals are still happening.

[jammin]

Hi Peggy,

I just wanted to drop in and say that centrals are not the end of the world. I've had several tests that confirm that I have both central and obstructive apneas, and more of the former than the latter. I am otherwise quite fit and healthy, so I don't fit anyone's profile for this. My doc let me go on a Resmed Adapt SV, which was the first machine that claimed to treat centrals and it lived up to it's promises. According to her, my results with this machine were very good. Currently my DME is letting me try out a Respironics Auto SV and my first impression is that it's more comfortable and natural feeling in operation. I like it, but I'd be shocked if my insurance was willing to buy another one after only a year. These run $5K or more, but I mean, it's your health and well being that's at stake. I'm not technical enough to talk numbers or stats on the level of the other people posting here, but I can tell you that these things work. You need a sharp and well informed doc just to appreciate the central thing.

Regarding the mask thing, I've had good luck with one that doesn't seem to work well for a lot of folks. I use the universal hybrid and have virtually no leaks, and no more bruises on the bridge of my nose.

Lots of luck. No need to be afraid of this.

[pjwalman]

Thank you, Jammin -- I appreciate hearing that! There's just something about the "forgetting to breathe" thing that bothers me, 'cause then the machine can't really help, can it? And of course you worry about the things you read about as causes. Ick! But sounds like you must have the idiopathic kind, thank goodness! I'm glad you have a doctor that is progressive! Mine doesn't think mine are real centrals, that they're just triggered by my apneas, so I probably don't have a darned thing to worry about, although my sleep study, like yours, I had more centrals than apneas, something the doc isn't in the least concerned about. It's good to hear your perspective on it, as someone who has real centrals, that it's not that bad providing you get a decent machine. Those are the machines that will breathe for you if you don't seem to be doing it by yourself in a timely manner. Right? Amazing what technology can do, isn't it?

Thank you again, Jammin, for taking the time to write and reassure.

Peggy

[jammin]

Yes, when you hit a threshold and the machine sees that you've stopped breathing or your breath volume has fallen a significant amount, it kicks in and starts acting as a ventilator. Sometimes I notice it doing this when I'm still not quite asleep, which is how I got to know what it feels like. It's not unpleasant, just a little surprising at first, and I'll think, Oh yeah, it's been quite a long time since I took a breath. Seems bizarre but we're all different.

Eight years ago I went through a few sleep studies and I eventually abandoned treatment because I couldn't stand what was available then - plain old CPAP with no C-Flex or anything like that, and the masks were tearing my nose up. And somehow I convinced myself I was over it - denial is such a useful thing. Last year I had to get a new primary care doc and he insisted that I be retested, and all the same results came up. Once the diagnosis was confirmed yet again I started reading everything I could find about central apnea, and that's how I discovered the Resmed Adapt SV. I talked my sleep doctor into letting me try it because the alternative at that time was a BiPAP with supplemental oxygen. if you've ever seen or heard an oxygen concentrator you wouldn't want one in your house if there was any way to avoid it, and I was thinking that it would end any possibilities of travel, which is something I like to do. Bottom line is that she prescribed one and when the first set of readings came off the machine, all my numbers were back within reasonable ranges.

Here's what I don't like about the Resmed. I'm an unusually slow breather, even when awake. The Resmed wants to see you breathing at least 12 BPM and it's default is 15. This is uncomfortably fast for me and it's always starting the next breath before I want to, so it feels "pushy" to me. I haven't heard of anyone else here having this experience. Last week was my one year check-up with the doc and I told her this. She had me bring in my machine to the lab manager and he called Resmed to see what adjustment could be made, and their reply was "none." It is what it is. The lab manager suggested that another approach that might work would be the newer Respironics Auto SV. I got a loaner from the DME and so far I'm pretty impressed with how much more comfortable this experience is. I'm sleeping straight through the night more than I did with the other machine and liking that a lot.

Clearly there is ongoing progress in both the understanding and treatment of this problem, and we'll benefit from both. It really is worthwhile to go for the latest and greatest if centrals are the real culprit for you.

[Snoredog]

Peggy, since you had a considerable number of central apneas show up in your PSG sleep study, it's possible that a lot of the "obstructive apneas" being marked on your Encore data are really centrals.

None of the regular autopaps, including the one you are using, even attempt to identify "centrals"...except one machine...the Puritan Bennett Goodknight 420E.

If some of those "obstructives" turning up on your overnight data are actually central apneas, the 420E autopap is the only regular autopap that is capable of telling you that. The 420E can't identify every central that happens, but when it does mark an event as a central apnea, it really is a central apnea. It identifies a central by picking up rythmic oscillations in the airflow from a beating heart. Oscillations delivered via an open throat..an unobstructed airway.

If the throat is open but the person is not breathing because the brain simply hasn't sent the signal to "Breathe now" it's a central. The 420E senses heart beats through an open throat. If throat is closed (obstructive) those oscillations don't come through to be picked up.

So, with your sleep study history of having centrals in addition to obstructives, unless you know you are no longer having centrals (and you can't know that from the recordings of the machine you're using now) you really don't know if the obstructives showing up on your data are obstructives... or ... are really centrals.

A regular autopap's pressure isn't going to do anything for centrals (throat is already open) so tweaking the pressure to try to get rid of the "obstructives" on the data (if all of them aren't obstructives after all) would be like a dog chasing its tail. Not getting anywhere.

I'd try a 420E the first chance you get. Just a few nights of data from that machine might give you an idea if centrals are still happening.

I agree, and it is all about "avoidance" that is, avoiding any response to central yet still being available to treat the obstructive.

Out of all the machines out there, the 420e is the best at that, then with use of other programmable features can avoid the conditions where the others fail.

Her current machine is totally "blind" in differentiating those two events, it is akin to putting braille instructions at a drive up window. If you look at the events it takes to fire off one of those NR it is a machine error and failure of the machines algorithm so they call it a feature and everyone thinks that is just great! LOL

about the only thing you can conclude from those reports is some of those tics are obstructive based and some are central being scored as obstructive, those in front of the NR's are definitely are.

They have to use the pressure that best stabilizes breathing and those centrals will go away. IF NR's are showing up at 11 or 13 cm pressure that is even the machine saying I screwed up in the past 6 responses, so you look in front of those NR's to see what the machine responded to. If you study the NRAH algorithm it takes a "lot" of events to fire just one of those off.

She clearly has the wrong machine, she can still use it if she "limits" how it can respond either by putting it in CPAP mode or setting Maximum limits on pressure.

That is the advantage the 420e has, you don't have to put limits on it, it uses its cardiac oscillation detection to more accurately avoid those centrals which means it is more readily available to respond to true obstructive events.

It is all about which machine does the better job in avoiding any response to centrals and yet is still available to respond to the frank obstructive events seen, respond the wrong way and you end up with clusters of events and a NR at the end.

of course that is just my opinion.

[pjwalman]

I am very happy to report that I am going to be able to get my hands on a 420E for a trial period (thank you, kind benefactor!!), and hopefully we will be able to get a clearer picture on this finally.

Plus it turns out most of the cost of my equipment is NOT going to be covered by insurance, so I am thinking maybe I should just return everything, as NightHawkeye suggested, and look instead at getting a 420E for my primary machine with a stand-alone humidifier.

I must admit, all the worry about this central stuff is making me tired (like I wasn't tired before; right?), so it will be good to have it figured out one way or the other. Then I can either chill out with my doc or prepare to confront. Ick!

Peggy

[Snoredog]

Oh, good God, this stuff is complicated!! My AHIs were way higher at lower pressures. I don't know how to beat this stupid game!

that "NR" showed up at 13 cm pressure, your machine found 90% pressure, if you look down at the raw data of Events per Hour, lower pressure actually had the better AHI per hour with 10 cm pressure reporting the lowest AHI per hour at 1.7 and spending 56% or more than half the time there.

You only spent 8.3% where the machine reports your 90% is, then that is where the machine screwed up responding to central events with pressure and had to suddenly back down.

So you need to toss out that pressure and any 90% found, if anything the pressure you were at that fired off that NR is the pressure you want to avoid in the future or it becomes your threshold for central apnea. That threshold can be confirmed if it happens again in future reports.

If 13 cm pressure triggers a cluster of centrals you need to avoid that threshold and stay below it OR use a machine that does a better job at avoiding those clusters so it doesn't aggrevate them further.

Your AHI (avg. events per hour) at 13 cm is 4.9 compared to 1.7 at 10.

with that machine, you have to understand that the AHI being shown can be made up of BOTH central and obstructive events. One you respond to with pressure and the other you normally don't. Get that wrong and AHI goes up.

They won't harm you if they continue, they just drive up your pressure and/or it may wake you up.

Looks like you were awaken or therapy stopped at session hour 1.25 and 4.5?

the NR showed up at session hour 5.5. If you look at therapy hour 5.5 where the NR is, you see a cluster of OA lined up, those are what fired off the NR, but since the NR fired off you have to conclude that cluster is centrals not obstructive.

If the machine confused those, what about the others seen at therapy hour 3? are those obstructive or central events?

Since there was NOT 6 events in a row, the machine didn't report any NR, maybe there was only 5 or 4 of the 6 needed to fire off a NR. The point is those "obstructive" events seen at therapy hour 3 (another cluster like the one at therapy hour 5.5) can easily be a cluster of central events just as well as the ones at 5.5 hr.

And that is the problem in my opinion, takes too many events before that machine "decides" it has screwed up and responded to the event with adverse pressure. It cannot undo what it has already done. Let's say those events last 30 seconds each, that is 30x6 or 180 seconds, that is a long time, that is like 3 minutes.

So instead of it taking 6 of those events (or 3 minutes) to determine the event may be central, a 420e can determine that with a single event (based upon presence of cardiac oscillations) indicating an open airway with no airflow.

What that means to you is it can; better avoid responding to any centrals yet remain available to respond to truly obstructive events (absence of cardiac oscillations).