Reason for Concern?

[grounded]

Hey folks,

Coming up on finishing my first week of cpap. Are these (apparently) central apneas any cause for concern?

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[LSAT]

Try turning off EPR and see if that reduces the CAs...How did you sleep? Were you restless? Has the whole week been like this?

[Pugsy]

Any chance you were awake or semi awake during the clusters of those centrals?

The cluster you sort of zoomed in on....looks more like awake breathing flagged events than asleep but really needs to be zoomed in more to know for sure.

The last cluster starting shortly after 07:30....did you lay awake tossing and turning a lot???

If you weren't asleep when those clusters of central apneas happened....they don't count and we ignore them except to wonder why such prolonged awake time with mask and machine on.
Are you having problems staying asleep or going back to sleep when you wake up in the middle of the night?

Do you take any medications? If so, what?

You might want to learn how to zoom and even closer to help identify awake vs asleep flagged events (and it can happen with any event and not just centrals).
http://freecpapadvice.com/sleepyhead-free-software

[grounded]

Try turning off EPR and see if that reduces the CAs...How did you sleep? Were you restless? Has the whole week been like this?

Will do on the EPR. Had a really tough time falling asleep. Stayed up until 1:30a and I must have been awake for at least another 30 minutes. Didn't seem particularly restless overnight. My nights have varied this week. Started off with a full-face mask, which was a disaster. Transitioned to a nasal and did much better.

[grounded]

Any chance you were awake or semi awake during the clusters of those centrals?

I don't think I was awake for the 3a clusters

The cluster you sort of zoomed in on....looks more like awake breathing flagged events than asleep but really needs to be zoomed in more to know for sure.

Here ya go:

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The last cluster starting shortly after 07:30....did you lay awake tossing and turning a lot???

Yes. My mom texted me and I tried to sleep some more but no dice.

Are you having problems staying asleep or going back to sleep when you wake up in the middle of the night?

Not in the middle of the night. Just falling asleep. If I awake early I cannot fall back asleep.

Do you take any medications? If so, what?

I'm on TRT, HCG, and lisinopril for hypertension (perhaps caused by the apnea?)

You might want to learn how to zoom and even closer to help identify awake vs asleep flagged events (and it can happen with any event and not just centrals).
http://freecpapadvice.com/sleepyhead-free-software

I'll take a look. Thanks.

[Pugsy]

If EPR was the trigger for the centrals I would expect to see more centrals throughout the night and not just in these clusters which might be related to being more awake than asleep.

But it won't hurt to turn EPR off and see what happens.
Or if you feel you need EPR to help fall asleep...your machine does have a ramp only setting for EPR and you can use it in ramp and use ramp and have it available.
Don't do anything that makes it harder for you to fall asleep...you already have that problem so don't make it worse.

What is TRT and HCG?

That zoomed in section looks like awake breathing to me.

[grounded]

If EPR was the trigger for the centrals I would expect to see more centrals throughout the night and not just in these clusters which might be related to being more awake than asleep.

Sure hope so. So many centrals looks spooky.

But it won't hurt to turn EPR off and see what happens.
Or if you feel you need EPR to help fall asleep...your machine does have a ramp only setting for EPR and you can use it in ramp and use ramp and have it available.
Don't do anything that makes it harder for you to fall asleep...you already have that problem so don't make it worse.

Sounds good.

What is TRT and HCG?

Testosterone Replacement Therapy. HCG is another hormone to help stimulate natural T production. Unfortunately TRT is also suspected to be a contributing factor to sleep apnea.

That zoomed in section looks like awake breathing to me.

Glad to hear that. What would a legit central look like?

[grounded]

One more thought: you said this looks like awake breathing but it appears that I’m not breathing for 10 seconds at a time. I cannot imagine why I would ever do that.....

[Pugsy]

For any apnea event to be legit first you have to be asleep.

So nice regular breathing like this



or up closer asleep looks like this



When we are awake the breathing flow rate pattern changes and sometimes rather dramatically and easy to spot...sometimes not so easy but we do the best we can.

These are flagged OAs and they are legit. A central would look the same but just be labeled central. I will look around for a legit central but I don't have many of them myself so may take a bit.


Here's a good example of asleep breathing (circled in red) and what follows is awake/arousal breathing.


And here more zoomed out....again asleep circled in red...anything not circled or flagged when not asleep simply doesn't count.


This flagged CA/central below is NOT legit. See the circled area in red? That's a big gulp of air right before the pause in breathing.
What most likely happened here was a very brief arousal (most likely not remembered) where someone had the arousal and took a gulp of air and then simply didn't breathe for a few seconds ....maybe turned over in bed. We do that often and don't realize it.


So a lot depends on the breathing pattern right before any flagged event as well as during the event.
So go watch those videos in the link above and get a handle on asleep vs awake/arousal breathing flow rate and then you will have a guide for what any event you see flagged might be.
While it talks mainly about centrals/CAs....it's not limited to centrals.
If you weren't asleep when all those centrals got flagged...they don't count in terms of apnea therapy evaluation. If we aren't asleep there are no apneas. Gotta be asleep first and foremost.

Compare your known awake time breathing clusters like after 7:30 with the pattern in the middle of the night where you think you were asleep but still had the central clusters. It is very possible you were more awake than asleep and simply don't remember it.
We don't always remember all arousals or awake time especially when sort of half asleep.

[Pugsy]

One more thought: you said this looks like awake breathing but it appears that I’m not breathing for 10 seconds at a time. I cannot imagine why I would ever do that.....

Because we simply often pause our breathing and don't remember it and it's no big deal. We just don't notice the irregularities.
Hold your breath for 10 seconds...easy to do...no distress....we do that all the time while awake and simply don't realize it.
Some people do it even a lot longer and don't realize it.

[grounded]

If I hold my breath while wide awake for 30 seconds, I can definitely feel the effects and absolutely want to breathe again. So I got myself a recording pulse-ox. In this series, I repeatedly stop breathing for 30 seconds at a time. My Sp02 swings by 10 points as seeming proof I really did stop breathing.

Still think this is all normal?

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[Pugsy]

Well obviously if you repeatedly hold your breath for 30 seconds back to back over a period of time of several minutes the oxygen levels will drop.
You aren't asleep though...you are doing it on purpose.....it's not the same thing as when we are asleep.
A random breath holding won't cause a desat. Pack a bunch of them together in a short span of time...yeah...oxygen levels will drop but unless you are really for sure asleep they don't mean anything in terms of the data the machine is reporting as to therapy effectiveness.

In terms of evaluating machine data as to therapy effectiveness from the cpap.....awake data simply doesn't count for anything.
This is sleep apnea therapy....sleep is a critical part. It's not awake apnea therapy.

If this bugs you too much....have a chat with your doctor about it.
Maybe ask him/her why you get desats so easily. Maybe something else is going along to cause the desats. There are a lot of reasons people's oxygen levels drop besides just sleep apnea.

[grounded]

Well obviously if you repeatedly hold your breath for 30 seconds back to back over a period of time of several minutes the oxygen levels will drop.
You aren't asleep though...you are doing it on purpose.....it's not the same thing as when we are asleep.

I did not deliberately and repeatedly hold my breath last night. Not even once. Whatever happened above, I was not "consciously awake". Do the waveforms indicate I was fully awake?

If this bugs you too much....have a chat with your doctor about it.
Maybe ask him/her why you get desats so easily. Maybe something else is going along to cause the desats. There are a lot of reasons people's oxygen levels drop besides just sleep apnea.

It's definitely bugging me. My BP has been creeping up and this may be the reason why....

[Julie]

Have you gained even a small amount of weight recently? It can do surprising things to your therapy!

[Pugsy]

I did not deliberately and repeatedly hold my breath last night. Not even once. Whatever happened above, I was not "consciously awake". Do the waveforms indicate I was fully awake?

It's not always easy to spot awake vs asleep breathing. It's nice when it is clear cut and easy to spot but unfortunately life doesn't always give us easy.
We don't always remember our awake times either. So we can't rely on remembering anything as a marker.

I think that you should be having a chat with your doctor. If you can't tell me that you know you were in fact awake (so we could for sure blame things on awake breathing) when all the ugly happened then you should at least alert your doctor to the fact that something isn't going right with your therapy and let your doctor decide the best course of action.
To know for sure....a sleep study has to be done that can for sure measure sleep status, along with the other parameters sleep studies measure, because something potentially problematic can be happening. We have very limited data from the machine so it can't always give us the definitive answers we want or need.

Then there is the possibility that the OAs are real and they are causing arousals which in turn give us arousal related central flagging.

If that were my report above...this is what I would do
I would first try turning EPR off or at least change it to ramp only and use the ramp function if I needed EPR to fall asleep.
If that didn't change anything then I would increase the minimum pressure and work on only the OA cluster reduction and see if it helps or not. More pressure isn't going to help the centrals though UNLESS the centrals are arousal related from OA causing arousals. We can fix OAs with more pressure but not centrals that aren't related to arousals.
If nothing helped then I would be having a chat with the doctor and discussing options for further investigation.

Finally if I can hold my breath enough to cause the O2 levels to drop 10%....I would be having a chat with the doctor about that as well. Normally a handful of holding your breath episodes even packed together wouldn't/shouldn't cause that big of a change.
I would want to rule out other lung issues as well that might not be related to apnea at all.