An ugly night and signs of CSR/PB

[NotLazyJustTired]

I have been on the machine for exactly three weeks now. My average AHI has been below 2. I seem to be adjusting well with average usage of 9:10 per night (some of that is afternoon naps and weekend sleep ins). I woke up to an AHI of 6 this morning and I feel like crap...worst headache I have had since I started CPAP. I am prepared to write it off as just having a bad night, but I wanted to share some data and get some feedback. I only recall waking a few times, made a few minor mask adjustments, but really had no significant wake time to explain any of this. No alcohol or meds either (beyond my normal prescriptions).

There seems to be patterns of Cheyne-Stokes respiration and periodic breathing. My SleepyHead pie chart is always dominated with CAs but as I am new to treatment I have been ignoring them for the most part. However, last night I was visited by aliens or something. Instead of around 10 per night I saw 40. I rarely even have a hypopnea; one night I think I had 2. Last night I had 10. Weird.

Here are the high level SH charts to show the overall pattern. Most of the CA's and H's are clustered in the early evening and morning hours which I understand is pretty normal.




Here's a zoom on the flow rate graph on one of the clusters in the early evening. In the past, whenever I have a CA I see this breathing pattern, but there is usually no more than 2 CAs and never a Hypopnea and after that, the normal breathing pattern resumes. Here I can see it going on for minutes. Is this normal?



And here's one from early morning. I could show more, but basically anyplace you see a CA or H event, this pattern is present:



I've done some reading on the net and in the archives concerning CSR and, as I am not dying, I am not resigned to panic. It's just that this sort of came out of the blue without any warning. I haven't changed anything in over a week, so I can't correlate this to anything really. It seems there is no immediate need to make changes to therapy. Something I will keep an eye on and discuss with the doc on my follow up next month. Any thoughts or feedback from experienced vetrans?

[Pugsy]

Something I will keep an eye on and discuss with the doc on my follow up next month.

Out of the blue and no rhyme nor reason and not something you see all the time...just keep one eye on them.
I have had similar occurrences. One night I had 17 centrals in 17 minutes one right after another and the flow graph looked like yours.
Don't know why..just happened. Sometimes we just have bad nights that we can't explain away.
Obviously something went on but we don't know what or why.

[khauser]

The only scary thing I see about CSR in SDB patients is a relationship to Heart Failure. I don't think that's your case, because in http://www.atsjournals.org/doi/full/10. ... 0708-129MG I found:

In patients with HF and CSR, the periodic cycle duration averaged approximately 60 seconds, similar to that described by Cheyne, compared with only 35 seconds in patients with idiopathic CSA or high-altitude periodic breathing without HF (18, 28).

So it would seem this is one of many kinds of central apneas a patient can have. Given the occurrence of CAs and CSR breathing I think it's fair to say this isn't Sleep Wake Junk (or noise from being awake during the night). You should consult your sleep doctor ... an AutoSet may not be sufficient in your case. You might need a more advanced machine.

I'm curious what others will think...

[NotLazyJustTired]

Something I will keep an eye on and discuss with the doc on my follow up next month.

Out of the blue and no rhyme nor reason and not something you see all the time...just keep one eye on them.
I have had similar occurrences. One night I had 17 centrals in 17 minutes one right after another and the flow graph looked like yours.
Don't know why..just happened. Sometimes we just have bad nights that we can't explain away.
Obviously something went on but we don't know what or why.

Thanks, Dr. Pugsy, I was hoping you would chime in.

Here's the graph of my overview thus far. Visually, you can see my reason for posting. That AHI of 6 is twice my previous worst night and about thrice my "normal" night. I had two back to back awesome nights just prior too. Danged aliens! I just hope it doesn't become the new norm. I really feel like junk today

[NotLazyJustTired]

The only scary thing I see about CSR in SDB patients is a relationship to Heart Failure. I don't think that's your case, because in http://www.atsjournals.org/doi/full/10. ... 0708-129MG I found:

In patients with HF and CSR, the periodic cycle duration averaged approximately 60 seconds, similar to that described by Cheyne, compared with only 35 seconds in patients with idiopathic CSA or high-altitude periodic breathing without HF (18, 28).

So it would seem this is one of many kinds of central apneas a patient can have. Given the occurrence of CAs and CSR breathing I think it's fair to say this isn't Sleep Wake Junk (or noise from being awake during the night). You should consult your sleep doctor ... an AutoSet may not be sufficient in your case. You might need a more advanced machine.

I'm curious what others will think...

Thanks Kevin, I really appreciate that. Those thoughts had crossed my mind. I am content now just to keep an eye on things and see if this is an alien-attack-one-off or the beginning of a new trend. I have no real reason to suspect the latter; just reacting to a bad night's sleep, I guess. I am starting to keep a notebook of all these sorts of things to discuss with my doc on the follow up. Should make for an interesting appointment.

[Pugsy]

If this report was a nightly occurrence..yeah, get the doctor involved straight away.
If this is a report that you see once every blue moon...it's really doubtful that the doctor would get all excited.

Side note... I have noticed that when I have a bad night of sleep in general for whatever reason that my reports take on a totally different look to them. Usually when I have had a bad night from stomach distress (nausea and vomiting, etc) or just a bad night dealing with back pain. So I think that the overall crappy feeling is more from the general body stuff and not the centrals or PB.

Regarding the AHI over 6....I had that happen to me not long ago and the CA index was around 4.9 I think (would need to look back to see for sure) and it was an ugly, ugly looking night. So even after nearly 4 years I still have some ugly nights.
That night with the AHI over 6...was preceded by a night with AHI 0.56 and followed by a night with AHI 1.something....
Crap happens.

[Pugsy]

Here's the example of mine. I don't think I can get a closer zoomed in picture now but I think you can get the drift of how ugly it was. I have no idea what happened but this is/was an extremely rare occurrence for me. I have no other health issues that would cause me to worry or be alarmed by this very rare oddity.
Alien experimentation was my probable cause...

[-SWS]

I get flow graphs like that every once in a while as well. They tend to occur when I wake up from noise during a heavy sleep, and then go right back to sleep. Those nicely patterned amplitude oscillations are loop gain based.

As long as they're not overly prolific, those oscillations reflect ordinary homeostasis adjustments in CO2 levels that our bodies adjust when transitioning from wake to sleep:
http://jap.physiology.org/content/99/5/2036.abstract

[NotLazyJustTired]

I get flow graphs like that every once in a while as well. They tend to occur when I wake up from noise during a heavy sleep, and then go right back to sleep. Those nicely patterned amplitude oscillations are loop gain based.

As long as they're not overly prolific, those oscillations reflect ordinary homeostasis adjustments in CO2 levels that our bodies adjust when transitioning from wake to sleep:
http://jap.physiology.org/content/99/5/2036.abstract

Hmmm, interesting. My wife said she also had a rotten night's sleep due to some varmint in the walls. Occasionally, we get bats in our attic and once in a while they get "stuck" in a wall and make hellish racket. I, however, have no recollection of any of this, but perhaps that is what disturbed my sleep.

[khauser]

Those nicely patterned amplitude oscillations are loop gain based.

As long as they're not overly prolific, those oscillations reflect ordinary homeostasis adjustments in CO2 levels that our bodies adjust when transitioning from wake to sleep:
http://jap.physiology.org/content/99/5/2036.abstract

That reminded me of something else I read in the link I posted ... basically the same thing, that the CSR rhythm is simply a response to the body trying to home in on proper CO2 levels. In that case, when present for smaller amounts of time, I wouldn't even COUNT the CA's because the device doesn't really differentiate between a pause in breathing due to CSR from a pause because the brain forgot to say BREATHE!

[Pugsy]

That reminded me of something else I read in the link I posted ... basically the same thing, that the CSR rhythm is simply a response to the body trying to home in on proper CO2 levels. In that case, when present for smaller amounts of time, I wouldn't even COUNT the CA's because the device doesn't really differentiate between a pause in breathing due to CSR from a pause because the brain forgot to say BREATHE!

Yep, and that's why I don't get excited about random episodes of PB or PB like breathing or random ugly clusters of CAs.
It's normal to have a few now and then for normally healthy people.
It's when we see them a lot...consistently...and not random every now and then, that I start to worry.

Now of course if someone is really stressing out over them (even if random) then go see the doctor and get peace of mind one way or the other.

[NotLazyJustTired]

That reminded me of something else I read in the link I posted ... basically the same thing, that the CSR rhythm is simply a response to the body trying to home in on proper CO2 levels. In that case, when present for smaller amounts of time, I wouldn't even COUNT the CA's because the device doesn't really differentiate between a pause in breathing due to CSR from a pause because the brain forgot to say BREATHE!

Yep, and that's why I don't get excited about random episodes of PB or PB like breathing or random ugly clusters of CAs.
It's normal to have a few now and then for normally healthy people.
It's when we see them a lot...consistently...and not random every now and then, that I start to worry.

Now of course if someone is really stressing out over them (even if random) then go see the doctor and get peace of mind one way or the other.

I am not really stressing about this at all. I look at performance graphs all day long. It is my job to spot anomalies and dig in for the root cause. It's just the way my brain is wired from a life of software engineering and IT support. I really just like understanding things. Even before I had taken the mask off this morning and looked at the number on the machine I knew it was a bad night because my head was pounding so. If it hadn't been for that I doubt I would have even started this thread. I do intend to show this to my doc; if nothing else just to test his knowledge on the subject (am I evil ).

It is so very nice to hear an explanation that brings together what I see in the data and the way I am feeling. I can't express my gratitude enough for such prompt and encouraging responses from all of you! I only hope I can pay this forward in time. Perhaps the creation of this thread will do that for someone in some small way.

[Todzo]

Hi NotLazyJustTired!

It sounds like your time with Auto-PAP is going very well!

So things are healing up and changes are occurring in your body.

So I think there are three possibilities here:

1. Your breathing reflexes are changing due to healing.
2. Stress that particular night upset your breathing reflexes
3. A combination of the above

My own experience is that stress is the major factor to make breathing unstable. One way or the other it is a major player.

Familiarity with the machine can help reduce the nighttime stress. If I were you I think I would take the time to spend some quality time with the machine during the day.

Some of the time should be in bed both learning to fit the mask, move around in the mask with pressure, laying calm in all the positions, moving too all positions, and learning to breath quietly. With the lights on and with your full awareness problems are likely to be sorted out much more quickly than seeing leaks in the data and trying to figure out why.

Then time reading a book, watching non-violent TV, listening to music or the radio, or browsing the Internet. With the involvement of the full resources of consciousness the development of the necessary new “breathing with the machine” reflexes are likely to be much more quickly made.

Breathing reflexes do not come quickly. Right now I think your healing is making changes so I think I would plan on doing this for several weeks for about an hour a day.

Be sure to spend some special time learning to breath with the machine with special emphasis on breathing volume and gentle breathing. You do not need a lot of air where you are at rest in bed.

There are alternatives to consider now[1] and perhaps available in the future[2] if stress management and daytime practice do not solve the issue. It is important that you do not ignore it as others have pointed out. It is “doctor time” if it does not resolve. I think the stresses imposed on the body by unstable breathing (e.g. CSR) precede the heart attack.

Have a great week!

Todzo

[1]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[2]: Dynamic CO2 therapy in periodic breathing: a modeling study to determine optimal timing and dosage regimes
Yoseph Mebrate, Keith Willson, Charlotte H. Manisty, Resham Baruah, Jamil Mayet, Alun D. Hughes, Kim H. Parker and Darrel P. Francis
J Appl Physiol 107:696-706, 2009. First published 23 July 2009; doi: 10.1152/japplphysiol.90308.2008
Link: http://www.ncbi.nlm.nih.gov/pubmed/19628721

[NotLazyJustTired]

Todzo, interesting theory regarding the healing process. I like the sound of that. I look at my data every day, religiously, so I will quickly know if this is a repeating pattern that deserves more attention, or just a one night wonder that can be ignored. I suspect it is the latter, but will post back if it is indeed the former.

[-SWS]

In that case, when present for smaller amounts of time, I wouldn't even COUNT the CA's because the device doesn't really differentiate between a pause in breathing due to CSR from a pause because the brain forgot to say BREATHE!

Since it's relatively normal wake-related phenomena that many of us experience, it's usually discarded from PSG sleep study data as well. When it gets to be unrelated to wake/sleep transitions or overly prolific, then it ceases to be normal phenomena. My understanding is that at that point, the sleep tech will score it and/or note it.