Another question about Centrals

[Underdog]

Any thoughts on charts that look like this one? I get quite a few of these nights with tons of centrals during the last hour. I only ask because I look at the frequency and they are clustered so close, I wonder if I could this could be bad for me. The chart used to show the same frequency/number during the first hour of sleep but I take Lorazepan before going to be an those centrals from the first hour of sleep completely disappeared. I don't want to be worrying unneccessarily about something that is no big deal but I have little to go on to make that assessment.

[robysue]

Did your titration study have any centrals in it? Any clustering of centrals like this chart? If so, what did the sleep doc say?

If not, have you called the sleep doc's office to ask if you could speak with either the doctor or his/her nurse or PA about the fact that your machine's data is showing an extraordinary number of apneas that it marks as "centrals" and that Encore Viewer is showing that they are clustered in the last hour before you wake up?

Finally, how do you feel when you wake up? And how do feel all day long?

[Underdog]

Did your titration study have any centrals in it? Any clustering of centrals like this chart? If so, what did the sleep doc say?

If not, have you called the sleep doc's office to ask if you could speak with either the doctor or his/her nurse or PA about the fact that your machine's data is showing an extraordinary number of apneas that it marks as "centrals" and that Encore Viewer is showing that they are clustered in the last hour before you wake up?

Finally, how do you feel when you wake up? And how do feel all day long?

I don't often get to see the doctor, but the Physician's Assistant is aware of this issue. The PA requested the Lorazepan that I have to say helps just a bit. Generally I feel terrible. I dread going to sleep at night.
When I ask I get PA I get responses like "what do you think?"
There so much information and knowledge here on this forum that I thought I would bring my question to the "pros"

[kempo]

Underdog, I am no pro, but your chart is similar to many of my charts over the past 7 months. A bunch of ugly centrals at the beginning of the night and during the time I am waking in the morning. I am not having near as many now as I was when I first started xpap. My sleep doc said not to worry about them. When I quit taking the ambien the central numbers went up during the time I was going to sleep and the number of central went down during the last hour of sleep. For the past month the number of centrals have gone way down on both ends. I'm thinking once you become comfortable with the machine, mask and your completely off sleep meds the number of centrals will go down.

It wouldn't hurt to show your doc the chart.

rested gal put these links together on centrals: viewtopic.php?p=22702

[greg-g]

Just my thoughts

I don't know how accurately these machines detect centrals, and if they really are centrals the last thing you would normally do is increase your pressure, but with the ResMed S9 AutoSet even when it detects a central it will increase the pressure up to 10.

Your pressure of 5 is very low by most standards, and below the minimum pressure that most people set their APAP machines to. Unless your intolerant of higher pressures I'd be inclined to try a slight increase and see what happens. Start at 5.5, or 6 and follow the charts. Anything below 10 is still reasonably low.

[JohnBFisher]

Folks, centrals when you fall asleep or wake up are completely normal ... up to a point. If they interfere with sleep, or are profound enough (last long enough), then they must be addressed. And I sure would raise a stink about those centrals. Remember, untreated centrals are just like obstructive apneas - in that they impact your body. It can lead to unctrolled high blood pressure, increased risk of stroke and heart disease.

A few centrals is fine. But you have a LOT of centrals. I would certainly want them addressed if I were in your situation.

[Underdog]

Thanks for these helpful perspectives. Still learning about these events and I'm never sure what should concern me and what should not. When I look at that hour long cluster of centrals my interpretation is that it looks like I am hardly breathing during that last hour. Similiar to someone taking a pillow and holding it down over my face.

Perhaps I'm being an alarmist? I don't have anything to gauge what is acceptable except the reaction from the staff at the sleep clinic which is, " this is interesting." When I hear comments such a these I assume that clustered centrals are nothing to be concerned about. But then I think to myself "why woundn't they be a concern." At what concentration to these events become a health threat? If you just look at the AHI for this one night its below 10 however from my perspective the central are clustered in such a way to be dangerous. Am I not looking at this correctly?

[robysue]

Perhaps I'm being an alarmist? I don't have anything to gauge what is acceptable except the reaction from the staff at the sleep clinic which is, " this is interesting."

I don't think you're being an alarmist. When medical types find something "interesting" that's a sure sign that what ever it is is not "normal" in the sense of "yawn, we see a lot of this, we don't need to worry at all about about it" in my humble opinion. Now it could well turn out that on further investigation that "interesting" doesn't turn out to be anything serious or warrant any medical intervention or treatment---but the very fact that it's "interesting" means there's something that needs further investigation---at least in my opinion.

And I still think critical questions are:

How do you feel upon waking after one of these nights? Rested? Refreshed? Or lousy?

How do you function during the day after one of these nights?

[JohnBFisher]

First, let me tackle the info about centrals and sleep onset (and also when awakening). Here is an article which explains more about the fact that SOME central apneas are perfectly normal during the transition to and from sleep.

Ventilation is unstable during drowsiness before sleep onset
http://jap.physiology.org/cgi/reprint/99/5/2036

Now, that being said, SOME is the operative word. An hour of central apneas is NOT normal.

Second, let me tackle the idea that you are an alarmist. Rather than worry about the central apneas, let's focus on how you feel? Do you feel rested? Or do you feel really beat? Do you still feel you could fall asleep at the drop of a hat? Do you wake up with headaches? Are you struggling with high blood pressure?

In other words, besides the fact that they are on the report - WHY are you looking at the central apneas? Do you feel as if you are rested when you awaken?

Communicate THAT (not your worry about the central apneas) with your doctors. Stress what you mention to us:

Generally I feel terrible. I dread going to sleep at night.

Speaking as someone who used to fight going to sleep (and still sometimes does), I can assure you that is NOT NORMAL. Stress that to your doctor. Explain that you don't just feel poorly. You feel terrible. DEMAND they focus on the problem. If they waffle on it, THEN note the centrals and ask if it is normal. Ask if stopping breathing over and over and over again might be bad for your body. Ask if you might be dreading that experience. (I know I did).

And don't take "I don't know" for an answer. Untreated, central sleep apnea is just as bad as obstructive sleep apnea.

Let me offer my own It caused me to gain weight. I would eat to stay awake. I would eat to avoid sleep. I would eat to go to sleep. Those behaviors hastened my Type 2 Diabetes. I complained about the morning headaches. My doctors did nothing. I had high blood pressure, that medication did not control. To handle the headaches, I took Ibuprofen. That and the high blood pressure led to kidney damage.

In other words, you do need to address this. You are not being an alarmist. But remember that central sleep apnea is VERY rare. That is why most doctors are reluctant to do anything about it. They don't know what to do.

Hope that helps.

[jbn3boys]

And don't take "I don't know" for an answer. Untreated, central sleep apnea is just as bad as obstructive sleep apnea.
...In other words, you do need to address this. You are not being an alarmist. But remember that central sleep apnea is VERY rare. That is why most doctors are reluctant to do anything about it. They don't know what to do.

Hope that helps.

Okay, John. It's not even my thread, but you have encouraged me to call my doctor. Right now. We'll see if I get anywhere on a Friday afternoon or not.

[Underdog]

Do you feel rested? Or do you feel really beat? Do you still feel you could fall asleep at the drop of a hat? Do you wake up with headaches? Are you struggling with high blood pressure? In other words, besides the fact that they are on the report - WHY are you looking at the central apneas? Do you feel as if you are rested when you awaken?
And don't take "I don't know" for an answer. Untreated, central sleep apnea is just as bad as obstructive sleep apnea.

Let me offer my own It caused me to gain weight. I would eat to stay awake. I would eat to avoid sleep. I would eat to go to sleep. Those behaviors hastened my Type 2 Diabetes. I complained about the morning headaches. My doctors did nothing. I had high blood pressure, that medication did not control. To handle the headaches, I took Ibuprofen. That and the high blood pressure led to kidney damage.
In other words, you do need to address this. You are not being an alarmist. But remember that central sleep apnea is VERY rare. That is why most doctors are reluctant to do anything about it. They don't know what to do.
Hope that helps.

Wow, I don't know what to say.. I have yet to read the material in the link but without hesitation I can answer yes to.... feel really beat, could fall asleep at the drop of a hat, wake up with headaches, struggling with high blood pressure (that does not respond to medication), would do anything to avoid going to sleep (including eat everything in the pantry). I can add short term memory loss to the list.

Previously I had been given the sense from my doctors/physician's assistant that "centrals" were an erroneous category of events that did not really count. The treatment and diagnosis of obstructive events was explained in great detail. Ther examining room has anatomicly correct transparent plastic body parts to describe possible obstructions, posters on the wall and a folded handout. .
But centrals, these are described as "technically clear airway events that may be eroneous or otherwise misinterpretted responses to the CPAP therapy."
I will read the link this weekend to bring me up to speed. Maybe I can get my foot in the door to some help. Everything really is a fight or battle. I never expect that.

[JohnBFisher]

... Wow, I don't know what to say.. I have yet to read the material in the link but without hesitation I can answer yes to.... feel really beat, could fall asleep at the drop of a hat, wake up with headaches, struggling with high blood pressure (that does not respond to medication), would do anything to avoid going to sleep (including eat everything in the pantry). I can add short term memory loss to the list. ...

Yup. A classic list of untreated apnea. Central apnea is just as bad - and in some ways worse - than obstructive apneas. But it is just as deadly.

... Previously I had been given the sense from my doctors/physician's assistant that "centrals" were an erroneous category of events that did not really count. The treatment and diagnosis of obstructive events was explained in great detail. Ther examining room has anatomicly correct transparent plastic body parts to describe possible obstructions, posters on the wall and a folded handout. .
But centrals, these are described as "technically clear airway events that may be eroneous or otherwise misinterpretted responses to the CPAP therapy."
I will read the link this weekend to bring me up to speed. Maybe I can get my foot in the door to some help. Everything really is a fight or battle. I never expect that. ...

You've probably seen me chide folks for getting worried about "CA" events being central apneas - and they have just a few. Your physician's assistant (and even your doctors) are right that most of the time and for most of the cases, those CA events are erroneous. But not when there are that many for more than an hour at a time. That is NOT normal. And that will continue to stress your body, until it kills you.

As I mentioned, without treatment for my central apneas, I was a wreck. My blood pressure was often in the 160/110 range! I went to my sleep doctor and said I was not getting relief with my BiPAP. We did a sleep study - that I failed miserably. He wanted me to try again - on BiPAP. I refused and said I needed to see him. Then - almost in tears - I asked what the heck would change by trying the BiPAP again. I explained as clearly as I could that I had very similar symptoms (to yours) and was DESPERATE for some sleep. But every time I went to sleep, I would stop breathing ... for so long that my machine would turn off. The Auto-Off feature was not detecting any breathing for more than a minute at a time.

Finally, he got it. But a lot of damage had already been done. I should have been more forceful about this YEARS ago.

Central Sleep Apnea is VERY rare. But they should NOT ignore it.

Ultimately, you may need to move from your current sleep doctor to one who has a neurological background. They are a little more receptive to working with and helping someone who might have central sleep apnea.

[rested gal]

Just my thoughts

I don't know how accurately these machines detect centrals, and if they really are centrals the last thing you would normally do is increase your pressure

I was thinking the same thing, essentially. Looking at Underdog's chart, I'm struck by the fact that soooo many centrals are all clustered toward the end of the sleep session. The end of the sleep session is when most people are having their longest period of REM sleep. And it's in REM that obstructive apneas are most likely to hit most people. So...I wonder if what the machine is reporting in those clusters really are "central" apneas, or if they are actually obstructive apneas being mistakenly noted as "centrals."

Your pressure of 5 is very low by most standards

Sure is.

Unless your intolerant of higher pressures I'd be inclined to try a slight increase and see what happens.

That's what I'd do, too, if it were me. With the software, Underdog will be able to "follow the charts", as you said, Greg, and can see if more pressure helps the situation, makes it worse, or doesn't make a significant difference in the data at all. I'd use full cm increases, giving each full cm several nights unless there is an extremely drastic increase in the number of "centrals" reported.

I'd think if you had true "Central Apnea", Underdog, "centrals" would be appearing all over the night -- not clustered just during the last couple of hours. I'd also think that if a person had Central Apnea to the degree it could produce such a heavy cluster of them near the end of the night, they would also be appearing throughout the night.

I suppose it's also possible that there are tons of centrals throughout the earlier hours of the night, but if they were short enough in duration, perhaps they don't get marked at all? Dunno.

Anyway, I'd want to try some more pressure just in case those clusters are misidentified obstructives slamming you during the final longest REM period of the night. You'll see quickly enough on the data whether more pressure is a good or bad idea.

[rested gal]

Well, I just now went to look at some of your previous topics, Underdog. Looks like your sleep doctor and you had already tried more pressure to no avail:

viewtopic.php?p=501216#p501216

I had my first meeting with my sleep Dr. to go over my progress. The good news is that I've used the cpap for over a month and never missed a single day (100%). I average 6hrs and 37min per night. The other good news is that the raised pressure "8" did not show any improvement and I can go back to (the much more comfortable) "6" cmH2O pressure setting.
The average time in Large Leek Per Day is 5 minutes 4 seconds.

On the down side the average a AHI is 19.0

Was that the average AHI just during the time you were using pressure of 8 ?

Or did that average AHI of 19.0 include all the previous extremely high AHIs you had been having before you raised the pressure?

[Underdog]

Well, I just now went to look at some of your previous topics, Underdog. Looks like your sleep doctor and you had already tried more pressure to no avail:

viewtopic.php?p=501216#p501216

I had my first meeting with my sleep Dr. to go over my progress. The good news is that I've used the cpap for over a month and never missed a single day (100%). I average 6hrs and 37min per night. The other good news is that the raised pressure "8" did not show any improvement and I can go back to (the much more comfortable) "6" cmH2O pressure setting.
The average time in Large Leek Per Day is 5 minutes 4 seconds.

On the down side the average a AHI is 19.0

Was that the average AHI just during the time you were using pressure of 8 ?

Or did that average AHI of 19.0 include all the previous extremely high AHIs you had been having before you raised the pressure?

I'll try to answer the best I can. I would like to qualify my statements with the fact that I have zip (almost nil) short term memory brain cells left so I screw up things regularly. We (sleep clinic staff and I) were finally able to get my AHI to drop down into the 10-12 (occasionally 15) range by dropping the pressure. I would drop the pressure (Dr said it was ok to do it on my own) and wait and watch for a week, then do this again and each time the pressure dropped the centrals dropped. I was running at 4.5 for months and staying down in the 10-12 range. But I still felt (feel) terrible and the centrals clustered just after going to sleep and just before wakein up. in the a.m Then I was given a prescription for Larazepan and that eliminated all of the centrals during the first hour of sleep. But I was left with the last hour. I dont have that situation figured out.