Central Apneas

[OneAlaskan]

I had a home sleep study about one year ago. Results indicated AHI 40.9 (CA 10.9, OA 11.6, Mixed 8.2, Hypopnea 10.3). I've been on CPAP therapy since then, very loosely overseen by medical professionals (and assorted nonprofessionals in the DME end of things) as our sleep specialists are overwhelmed and appointments are very hard to get and spaced months into the future. I was titrated in a sleep lab six months ago and put on a steady pressure of 8. I have EPR turned off as it definitely increases my centrals. My concern is that I have not yet hit my AHI target of consistently below 5 apneas. Last night Oscar showed AHI of 11.15 (CA 6.47, OA zero, H 4.68 and .14 RERA) with Cheyne Stokes Respiration of 10.95%). I rarely show any OAs anymore, mostly CAs and Hypopneas. I do not show CSRs every night, but often with an average of 7.99% last week and 4.37% last 30 days. I would download my most recent night if I knew how, but haven't been able to figure how to do that. I have concerns that someone should be caring about the central events, but so far no one in the medical realm seems to care. Does this seem reasonable? Thanks in advance for any advice offered here. I am so happy I discovered this forum as it's full of interesting and helpful information.

[Pugsy]

Welcome to the forum.

We need more information....please read the top topic/thread in the Announcements section "Newbies please read before posting".

It contains some information on software and how to post images of the software results.

[Miss Emerita]

Welcome! Yes, someone should be paying attention to your centrals. But to advise you further, the experts do need more information.

Please carefully read points 3 and 4 in the sticky that Pugsy has pointed you to. Do you have a laptop or desktop computer? An SD card in your machine? An SD slot in your computer? If not, see if you could borrow a friend's computer; buy an SD card (any kind that will fit in the slot in the machine); and buy an SD card reader (any kind that will accept the size of SD card you have).

Once you're all set, then download Oscar. Read the guide first; I didn't, and I wish I had. Let us know if you hit any snags; we will be happy to help you.

[OneAlaskan]

Thank you, Miss Emerita. I do have Oscar but even following Pugsy's very clear screenshot posting guidelines, cannot get Oscar screenshot to post from my clipboard. Your attachment button directs me to my photo program so I even saved the screenshot as a .jpg but that didn't work either. Can you tell me what type of file I could save as to be successful?

[OneAlaskan]

Untitled-1.jpg (845.38 KiB) Viewed 562 times

[OneAlaskan]

Whew, finally got that bugger to post. Look forward to some direction from those knowledgeable at this site.

[zonker]

Untitled-1.jpg

close, but no cigar. try more like this-

paptalk.com/wiki/index.php/Oscar:organize

good luck!

oh and did i miss where you may have said why you are in fixed cpap mode?

ETA: sorry, i see you were set on a fixed pressure. seems a shame seeing how in my humble opinion you would be better served in apap mode.

but let's wait and se what others have to say once you get the chart thing figured out.

[Pugsy]

You figured it out in terms of posting. Good job. Now look at this thread for graph formatting.
We don't need the AHI graph...already got that information and better on the left side. But we do need the Flow limitation graph and maybe the snore graph if it is very active.

viewtopic/t158560/How-to-post-images-for-review.html

Now go here and watch all the videos so you can learn how to figure out if those centrals are real or awake/arousal breathing flagged by mistake.

http://freecpapadvice.com/sleepyhead-free-software

It says SleepyHead but OSCAR is based on SleepyHead and all the directions and results will work the same.

Real CSR looks like this


or like this in OSCAR


But sometimes looks like this below....CSR is a form of Periodic Breathing where the flow waxes and wans...CSR isn't the only form of PB though but it is the one we worry about when we see a lot of it and it's real and you were definitely asleep when it gets flagged.
This is also flagged as CSR but it means nothing...obviously a big difference in the breathing pattern but it meets the criteria of waxing and waning for at least 2 minutes. No events in it and we ignore this.



Not going to worry about the cpap mode thing just yet...want to figure out how much of your flagged stuff is awake breathing related.
We can have false positives in all categories..
Now it is possible that the obstructive stuff is real and they are causing arousals which in turn cause false positive centrals and if we deal with the obstructive stuff the centrals will reduce because less chance of arousals with less obstructive stuff.

I don't want to advise pressure changes just yet or mode changes until I know for sure what we are fighting.
Sometimes apap mode isn't the best thing to be using when a lot of real centrals are present and not many real obstructive events are present.

[LSAT]

YIn my opinion, you also could use a pressure change...If you are going to remain on fixed pressure, raise it to 9 and maybe even 10. If you decide to change to auto, your pressures should be minimum 8, maximum 15.

[OneAlaskan]

I do not tend to snore, Bugsy, so did not include that info. Most nights zero snore, occasionally like 1% so believe that's insignificant. I did add the flow limitation info and an expanded view of what my ResMed machine is showing during CSR. I should mention that I was increased to 9 but when only CAs remained, decreased back to 8. Then 7 was tried but I found it too difficult to breathe at that pressure and so returned to 8.

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oscar2.jpg (848.1 KiB) Viewed 532 times

[palerider]

Bugsy,

Pugsy, with a "P", like the cute little dogs.

I should mention that I was increased to 9 but when only CAs remained, decreased back to 8. Then 7 was tried but I found it too difficult to breathe at that pressure and so returned to 8.

Seems like an excellent reason to go back to 9. The goal is to have as few obstructive events as possible, your body not needing to breathe now and then for a bit is much less stressful on your system.

[OneAlaskan]

So sorry for the typo, Pugsy. I need to proofread better. You may be right on the pressure setting. I don't see my sleep tech again until June and they really don't like me changing my settings. So annoying to have to wait so long between appointments but that is how it is in this area. Interestingly, my CAs did decrease with the pressure decrease initially and OAs remained good, but the CAs do seem to be creeping back up again now. Do you know much CSR is too much or seriously concerning? BTW, thanks a lot for sharing your expertise.

[Dog Slobber]

I don't see my sleep tech again until June and they really don't like me changing my settings. So annoying to have to wait so long between appointments but that is how it is in this area.

Change it anyway.

You should not have to be in discomfort for 4 months because they are shitty at what they do.

[Pugsy]

Fair warning...I am in novel writing mode and to get all my thoughts put down it's the best I can do. I tend to ramble a lot when I am writing novels mode. If I ramble and you don't understand where I am going....ask for clarification. I seem to forget people can't see inside my head and read my thoughts that don't make it to paper.

I have never been able to find a numerical value for how much CSR is "too much" or cause for worry". In general we tend to go by gut feeling. The fact that you don't have it every night and aren't having it half the night when you do have it points to it not being hugely worrisome at this time.

Some of those hyponeas look like they might be central in nature as well...and it's fairly obvious that your flow rate looks more like real CSR. Hyponeas are hard to evaluate because we can't often see clearly the flow reduction or change well enough to determine sleep status or if it leans towards being central in nature.

Here's the deal with centrals caused by cpap pressure...and it can be any pressure, even as little as 4 or 5 cm, they can sometimes gradually reduce on their own and most doctors will adopt a wait and see attitude when someone is first put on cpap and centrals pop up.

Have you ever used the EPR exhale relief? I know people are now in panic mode about EPR causing centrals but that's really a very small minority that will have that happen and for years the first line of defense for people who get too many centrals pop up just because of cpap therapy was step up to a bilevel machine which is what EPR effectively creates when we use it. So the very thing that used to be the first choice for dealing with central apneas now has a bad rap because of a few people having that problem.

You aren't having enough centrals for the doctor to probably tell you anything but "let's give it time and see if they reduce on their own"....because sometimes the "give it time" thing actually works. You barely are having enough to raise an eyebrow over.

If they hyponeas are central in nature ...more pressure is unlikely to help but since we don't know for sure and really don't have a really accurate way to determine hyponeas being central in nature vs obstructive in nature we tend to us the first "normal" definition which is obstructive. More pressure will help reduce obstructive stuff...does nothing for central stuff.

Your diagnostic home study showed centrals at approx 10 per hour....so even without cpap therapy you had centrals pop up.
Means that cpap pressure is unlikely to be the cause of your centrals. You had them before you ever started cpap.

Here's what I would consider doing if I were in your shoes...

First thing would be fall back on the old tried and true thing that people did for centrals for years because sometimes it worked...go to bilevel and we can do that with your machine to a limited extent by utilizing the EPR exhale relief. Unless you have already tried it and it made things much worse. I would simply turn on EPR and set it to 3 and see what happens.

Second thing would be try more pressure like 9 cm and see if the hyponeas reduce at all and watch the centrals carefully.
With and without EPR possibly.

You could try apap mode but I wouldn't do a big range to start with. Let the machine decide if it wants to increase the pressure or not.
It won't try to increase the pressure unless it is sensing obstructive related events. Centrals it won't even try...it's built in to the auto adjusting algorithm not to even try for a couple of reasons. One being it simply won't help them and two it potentially could make them worse. I would do a tight range....8 minimum and maybe 12 maximum.

I doubt your centrals are related to the pressures themselves meaning if you could use a lower pressure you wouldn't have them...you had them even on the home study.
And you have already tried a lower pressure but felt uncomfortable using it. Probably felt air starved which is quite common.
I do wonder if you added in EPR if it would still be uncomfortable at a lower pressure...so something to think about. Often the drop during exhale will be more comforting and allow people to use a pressure that wasn't particularly comfortable before.

I don't like making more than one change at a time unless there is no choice. Remember Science 101...keep your variables to a minimum so you can best judge your results good or bad and know what to put the blame or credit on.

Finally this give it time thing (which doesn't mean you can't do other experiments in the meantime while you are giving it time)...sometimes the body just adjusts and centrals will reduce on their own. Now since you did have some centrals prior to starting cpap....it's a crap shoot how much chance there is of them reducing just with time but nothing is totally impossible until given a shot and the shot fails.

All this with the assumption that you aren't taking any medications that might suppress respiration....so are you taking any pain meds of any sort?

That's all for now. Ask questions if you need further explanation and can't read my mind..

Oh...your flow limitation graph is a wee bit ugly....are you having much, if any, nasal congestion going on at night?

[palerider]

So sorry for the typo, Pugsy. I need to proofread better. You may be right on the pressure setting. I don't see my sleep tech again until June and they really don't like me changing my settings.

If you don't want to change your settings to something that works better, then what can we possibly do for you?

How much do they pay you, btw, since apparently you're working for them.