First OSCAR data

[Pugsy]

there doesn't seem to be clear evidence of OSA, or any ordinary type of sleep apnoea. Is that how it looks to you as well?

Actually the absence of clear cut evidence for something doesn't mean it isn't there.
Remember that this is a TREATED with pressure report. It just means that with the pressures you don't have OSA.
My AHI last night was 0.7....all that means is with my machine being used I didn't have much OSA events happen...it doesn't tell me how many it prevented. It just tells me how many didn't get prevented.
So I wouldn't make that assumption one way or the other.
If you didn't have the other known respiratory issues complicating evaluations....the marked change in pressure the last half of the night does point to a high probability of OSA at some level being present.

If you didn't have some level of OSA I would expect the pressure to never really do much of anything.
Is your other issue with breathing and O2 levels while awake confusing the machine???? Wouldn't be impossible.
So is the pressure increase from OSA leaning breathing from OSA or from something else that the machine thinks is OSA related??? Million dollar question that we simply can't answer with the data available to us. Remember the machine only measures air flow...that's all it can measure.

Your little snippet showing the sort of waxing and waning of the air flow....actually it's entirely normal to see that sort of graph. Sometimes it is arousal related...sometimes it's positional...sometimes it's sleep stage related...sometimes it just is what it is. We simply don't breathe the same all night and we don't sleep the same all night.

Might be interesting to see what happens with your O2 levels while on cpap if we can. Again...what kind of overnight pulse oximeters do you have available?

I do think that eventually you are likely going to be needing an in lab overnight sleep study because you are just going to have questions that we aren't going to have answers to from the data available to you from the machine.
The machine was never supposed to be a diagnostic tool anyway and it was never supposed to have the data put under the microscope this way. The data is mainly for monitoring trends and patterns during the OSA treatment.

I gotta run and will be gone the rest of the day. Going over to my mom's.

[lars_the_bear]

@Pugsy Thanks. When I get a Sp02 machine that is capable of overnight recording (it is on order) I will see what effect the CPAP has on it, if any. I already know that it's 90-91% on average without CPAP. I guess if it improves, then it's worth persevering, whatever the explanation is for the behaviour of the machine. And if it doesn't improve, I guess it still doesn't matter what the explanation is.

And even if my SaO2 does improve, that doesn't (by itself) mean my palpitations will improve, and that's really my goal here.

Thank you for your assistance so far.

Best wishes
Lars.

[dataq1]

Lars, by the way the pause after a PVC is typical and called a compensatory pause and will. For what it's worth here is example of mine:
(BTW, the really tell-tale is the lead II that is a much wider QRS, signifying that the "signal" arose from an ectopic source)

So Sorry the attachment quota has been reached, maybe share later

[lars_the_bear]

Well, I didn't expect this...

From yesterday's discussion, I was more-or-less convinced that there was no significant sleep apnoea on my first successful all-night recording. So last night, as an experiment, I turned my CPAP machine down to minimum pressure (4cm), expecting to see exactly the same kind of results as the previous night with higher, variable pressure.

In fact, the recordings look quite different, at least to my inexpert eye. I've uploaded the "flow restriction" graph from OSCAR for the two nights. With minimum pressure set, there does seem to me to be more activity in this trace.

I've also uploaded a close-up of what these flow restrictions seem to be. They're almost all classified as "hypopnea" by the equipment, but the difference (to my eye) between an event classified as hypopnoea, and one classfied as apnoea, seems to be one of degree, rather than one of kind.

For the record, the "leak" and "snores" traces are at zero during this period.

I note that nearly all these events occur during a single period of about 40 minutes. I have absolutely no idea what to make of this. I don't even know whether I can conclude that the CPAP pressure makes any difference, or whether the flow oddities are just artefacts of measuring at a low pressure, or something of that kind. And, for all I know, these differences might just be random day-to-day fluctuations.

I'll try with the pressure back up tonight, and see if there is at least any consistency. If anybody has any comments or suggestions, they are most welcome.

Best wishes
Lars.

[Hoeksel]

Hi Lars,

I just posted my first item on this forum (to be approved) and it might be interesting for you. I suffered from heart issues as well, and I figured out that stopping intense sports (in my case running) got rid of them (without medicine). Obviously far from ideal, because I want to sport, but it is something you could test if you are willing. OSAS-wise I am in a "comparable boat" like you and trying to figure out what is going on!

Regards,

Hoeksel

[GrumpyHere]

As an aside: I dream exercise. I don't know how often I do, because I don't always remember. But when I do dream exercise and I wake up, I wake up panting, as if I had really been exercising.

It is possible that your rapid breathing is being incorporated into your dream rather being triggered by your dream.

https://www.google.com/amp/s/www.psycho ... eams%3famp

[dataq1]

Just a quick reaction to your posting of the minimal constant pressure support experiment, the pattern that your detail displayed suggests Cheyne-stokes breathing (both in pattern and duration ~ 40 minutes).
Cheyne stokes is a breathing pattern rather than a breathing obstruction or prelude to airway closure, that increased pressure will not address.
But I’ll let much more experienced appraisers weigh in, this is just my first impression.
BTW, the hypopneas that are marked are a consequence of the preceding “deeper” breathing for several seconds.

[Pugsy]

While that pattern is a waxing and waning of the air flow which might point to some sort of periodic breathing (which is nothing more than a waxing and waning) it doesn't meet criteria for Cheyne Stokes Respiration.
CSR is a special type of periodic breathing and we have to remember that not all periodic breathing is Cheyne Stokes Respiration.
Periodic Breathing is nothing more than a waxing and waning of the air flow that lasts at least 2 minutes.
I do NOT think those hyponea clusters are CSR.

Hyponeas are a reduction in air flow between 40 to 79 % that lasts at least 10 seconds.
Obstructive Apneas are a reduction in air flow between 80 to 100% that lasts at least 10 seconds.
Hyponeas are the same sort of air flow reduction as OAs but don't quite meet the criteria for the OA label. They are NOT simply where someone just doesn't take a deep breath...they are indications that someone CAN'T take a deep breath because the airway is at least partially blocked. Hyponeas are bad guys and we don't want to see very many of them because all the things that can happen with OAs can also happen with hyponeas....desats...sleep disruptions, etc.
It is why they are included in the criteria for a diagnosis of obstructive sleep apnea and why the machine will want to kill them.

Hyponeas can sometimes be central in nature and not obstructive in nature but it isn't very common and most of the time if they are central in nature we also see a bunch of flagged central (ClearAirway on Oscar reports) which we don't see here.
So the hyponeas above....most likely obstructive in nature.
Add in the rather marked difference in flow limitations with the fixed pressure vs the auto adjusting pressure (that we know did increase)....again points to airway tissues blocking the airway to some extent.

As for the time frame of 40 minutes and the fact that it occurs roughly a couple of hours after sleep onset (depending on actually when you fell asleep) my first suspect is REM stage sleep. It's about the time we would expect REM to happen and the duration is about the same duration we would expect....especially since we see an additional couple of similar clusters later when we would expect to see REM again.
Supine sleeping may or may not be also involved.
Google "sleep stages" and look at normal hypnograms and you can see the overall pattern we expect to see with REM stage sleep occurring.

From the fixed pressure experiment I am leaning more and more to your having some level of OSA going on...at least in REM probably.

[lars_the_bear]

While that pattern is a waxing and waning of the air flow which might point to some sort of periodic breathing (which is nothing more than a waxing and waning) it doesn't meet criteria for Cheyne Stokes Respiration.

I think in the UK we wouldn't think of CSR unless it lasted for several hours but, in practice, my (limited) experience is that CSR tends to be very long-lasting. In any case, I think (hope) I'm too well to be showing CSR. I have normal heart and lung function and, so far as I know, I haven't suffered a brain insult. I don't think I've ever seen CSR in a person who wasn't evidently unwell. Having said that, I haven't seen it at all for decades.

Also, the CPAP is showing each one of these epsiodes as being associated with flow restriction.

Having said that, I believe it is common practice -- in the USA at least -- to give CPAP to heart failure patients showing CSR, and it seems to help. I don't really understand why it would, except perhaps that CSR sufferers possibly have OSA as well.

Anyway, thanks for all the comments -- even @dataq1 for the really scary one Lacking any better ideas, I will increase the CPAP pressure tonight, and see if the periodic breathing goes away.

Best wishes
Lars.

[Pugsy]

If your machine had even remotely thought that pattern of breathing was anything close to being CSR it would have flagged it as such. These machine are overly cautious when it comes to CSR flagging meaning they often flag a breathing pattern as CSR when it just looks sort of like just simple periodic breathing. They are overly cautious just to bring a POTENTIAL problem to everyone's attention and then let the medical professionals sort things out because real CSR can be a indication of serious health problems. These machines aren't used for diagnosing CSR though...all they do it say "this needs to be looked at and evaluated and dealt with if needed".
And there are people who do have idiopathic CSR and/or real central apneas and no one knows why and they are perfectly healthy.
But idiopathic can't be determined until the homework is done to make sure that any CSR looking stuff doesn't mean an underlying heart issues. It's better to make sure the heart is okay kind of thing. You have already had that work up so we can put that scare away.

Here one of mine...flagged CSR/PB and obviously no where near real CSR. Not real CSR and certainly not prolonged...shrug shoulders and move on.



Now this guy below...he did also have congestive heart failure issues and obviously classic CSR (so much so that his machine flagged a lot of central apneas as obstructive because the machine got fooled...they aren't perfect).
He had both obstructive sleep apnea and central sleep apnea....He was put on regular cpap/apap...didn't help obviously but later put on a special bilevel machine that was finally able to get things under control. Everyone was especially careful with this guy because his cardiac ejection rate was around 35 so congestion heart failure issues a known underlying problem.
BTW....this was one of his "good" nights. He had some nights where the AHI was 50 plus and the CSR was essentially all night.

[dataq1]

Lars, It was not my intent to alarm you, but as I said the pattern was reminiscent of CSR. My wife has no brain damage, has no stroke, has no heart failure (all things) that are classically associated with CSR and yet her Resmed machine identified CSR three days in a row (out of the 90 that the has been on PaP therapy). Her cardiologist and her pulmonologist have NO explanation - but have declared it "benign"
In the attachment below she had two periods - 39 minutes and 43 minutes each that were Resmed classed as CSR. The second attachment is a zoomed look at about 8 minutes for the first episode.

CSR 11-8-21.jpg (209.13 KiB) Viewed 9100 times

[dataq1]

The machine looks at the air flow in a moving four-minute window.

Algorithmic detection of hypopneas (such as used by Resmed etc):

"A hypopnea is detected when there is a device-estimated 40% reduction in airflow for ≥ 10 sec but < 60 sec compared with the average airflow over the previous 2 minutes. The hypopnea detection algorithm requires the presence of two "recovery" breaths that nominally were at least 75% to 80% of the baseline airflow."

Note the baseline measured over 2 minute, prior to suspected event.

This algorithm may have been updated in the past few years, but that's the most detailed event definition I'm aware of.

[dataq1]

Lars, by the way the pause after a PVC is typical and called a compensatory pause and will. For what it's worth here is example of mine:
(BTW, the really tell-tale is the lead II that is a much wider QRS, signifying that the "signal" arose from an ectopic source)

So Sorry the attachment quota has been reached, maybe share later

Ok, it's later.... This reminds me (something that you might consider) the attached are from my Kardia (at home EKG), not very expensive and does not require a prescription. My Cardiologist loves that I'm using it.

Here is the example of compensatory pause after a single PVC:

PVC Compensatory pause.jpg (363.88 KiB) Viewed 9083 times

and here is an example (from my heart) of a PVC run:

PVC Run.jpg (315.72 KiB) Viewed 9083 times

Now back to regular programming....

[palerider]

Just a quick reaction to your posting of the minimal constant pressure support experiment, the pattern that your detail displayed suggests Cheyne-stokes breathing (both in pattern and duration ~ 40 minutes).

No it doesn't.
Please stop spewing ignorance.

[Miss Emerita]

Lars, thanks for posting those two flow-limitation graphs -- what a difference! I tend to think of pressure support/EPR as the number-one way to treat FLs, but those two graphs show a clear role for a well-set minimum pressure too.

You commented that the whole period was about 40 minutes long. Is it possible you were tucking your chin toward your chest during that period? This posture (whether you're on your back, stomach, or sides) can make it easier for all kinds of restrictions to develop in the airway.

When chin-tucking is a problem, one way to address it is to use a flatter, firmer pillow. Another is to use a soft cervical collar at night.