central apneas and hypoventilation?

[wobblycrayon]

Hi

My son has been using a resmed airsense for just over 3 months now but no change in excessive daytime sleepiness or fatigue. He has had chronic fatigue for 10 years and is on disability benefits. When I look at his oscar charts I see that his median tidal volume over the three months is 360 and minute ventilation is 6.0. Given that he is 6 foot 2 inches and 77 Kg this seems very low to me (I think ideal weight about 81kg). He is also averaging about 8 apneas per hour, pretty much all central. He has been told that he is doing well and will be reviewed in a year. We have asked for a telephone call with the technician and may get that in another 3 weeks or so. I mentioned the tidal volume issue to him previously but he said that they are really focussed on the AHI. This newbie would really appreciate some views. I think I have included a recent oscar chart.... but that might not have worked.

Thanks

[lazarus]

recent oscar chart.... but that might not have worked.

This might help:
viewtopic/t88983/Pugsys-PointersSleepyH ... ml#p816549

[lazarus]

. . . 3 months now but no change in excessive daytime sleepiness or fatigue. . . . averaging about 8 apneas per hour, pretty much all central. . . . Technician . . . said that they are really focussed on the AHI.

Welcome.

The technician is right that CPAP/APAP is primarily aimed at treating AHI.

Getting an imgur posting of OSCAR info up might allow for some here to have suggestions for improving that AHI, hopefully.

But PAP alone doesn't always fix sleep until all aspects of the principles of sleep hygiene and overall health are able to be applied and explored.

Glad you are able to be helpful to him; hopefully posters here can be of assistance to you.

[wobblycrayon]

I think this is a link to the Oscar chart.
https://imgur.io/a/ugP0BVT

[Miss Emerita]

I hope others with more expertise will chime in, but here are my initial thoughts.

The median TV might be a tiny bit low and the median RR a tiny bit high, but the median minute ventilation looks good. This would not be the focus of my worries.

The CA index is not good, and I would be curious to know whether CAs were prominent in your son's sleep study. Just how to think about the problem depends a lot on the answer to that question. Can you post a copy of the sleep study report with personal information blanked out?

A first step in trying to tame CAs is to eliminate EPR. Is that a change that your son would be willing to try?

[wobblycrayon]

Many thanks for the replies.
We don't have a copy of the initial sleep report but will try and get hold of it. He was told in the letter that 'there is a degree of obstructive sleep apnea'. However when I look at oscar charts it was basically central apneas from the first day.
I will ask him about changing epr. I don't think he will do it yet but I think he wants me to collect as much advice from this forum as possible so that we have a few things to bring to the technician conversation.

[Miss Emerita]

Do you live in the U.S.? If so, you or or son (depending on his age) have a legal right to a copy of his sleep study.

Could you zoom in on the beginning of one of those areas that include a lot of CAs? A snippet of about 5 minutes would be good. If it include a second CA as well, that would be nice.

What I'm trying to figure out is whether the CAs mostly come in the wake of arousal breathing or not. You can try judging this yourself; in the flow rate, arousal breathing tends to have deeper inhalation and exhalation and an irregular or messy appearance compared with nice, steady asleep breathing.

Does your son take any medications? Use any narcotics? Live at a high altitude?

[wobblycrayon]

Thanks for the reply Miss Emerita.

We live in the UK and can probably get it ok.
He is not on any medication at present, no narcotics, no altitude. Here is a link to some centrals from a few days previously. Just under 10 mins I think. It doesn't look like arousals to me (based on what I have read here) but see what you think.

https://imgur.io/a/q89VRm9

[ozij]

Edit:
I wrote this post before seeing the full OSCAR chart - don't know how I missed it. I'm changing what I wrote.


Unfortunately, it seems the British NHS doesn't consider an AHI of less than 15 to be worth paying for.... but that does not at all mean the your son is doing fine.
It's a financial consideration, not one based on health. (I've hear the British NHS will also only fund one cataract operation, since one seeing eye is enough...).

Since the sleep study identified "some obstructive apneas" and the pressure on this chart is swinging up and down a lot, mostly in response to flow limitations, it is my guess that the a) the minimum pressure is too low to keep your son's airway open consistently, and b)he is probably being woken up by those flow limitations.

I would stop the EPR, since he's usually on low pressure as it is and EPR at low pressure may exacerbate treatment emergent central apnea.

Try to track the relationship between the flow limitations, central apneas and pressure swings - you can do that by placing the vertical cursor on where the flow limitations appear, and looking at what's happening in the flow chart.

Don't accept an AHI of 9 as "fine" and see if you can get the technician to raise the minimum.

[Wondering1]

The technician is right that CPAP/APAP is primarily aimed at treating AHI.

Better: The technician is right that CPAP/APAP is primarily aimed at treating Obstructive apneas and flow limitations, not at all for clear airway apneas.

[dataq1]

Stop the EPR, and contact the doctor immediately.

Juggling the EPR seems to be the only trick that CPAP is capable of, and there is no assurance that will combat the Clear Airway Apneas. Until your son is able to determine causation of the Clear Airway apneas, proceed with caution.

[wobblycrayon]

Thanks everyone.
Apparently there are no cardiac issues. He sees a cardiologist every six months to a year as he has POTS syndrome along with the chronic fatigue. In fact he has seen 3 sets of cardiologists over the last 10 years. They all say that his heart is fine. No treatment for the POTs beyond staying hydrated, lots of salt and exercise. They are fed up with me constantly asking for further investigations.

I am beginning to suspect myasthenia as it is basically the only thing left that might explain all his symptoms.
The cpap data feels like it is getting us somewhere. It is very validating for others to say that yes, there is definitely something going on here. So your input is much appreciated.

POTs stands for postural orthostatic tachycardia syndrome. It means that the heart rate rises quite dramatically when going from lying to standing. It often goes alongside chronic fatigue. A lot of covid long haulers get it.

Am I right in thinking that although these central apneas look like csr the cycle is too short? I think there was a previous thread that discussed this.

Osij do you think that there is evidence of hypoventilation beyond the centrals?

[ozij]

Thanks everyone.
Apparently there are no cardiac issues. He sees a cardiologist every six months to a year as he has POTS syndrome along with the chronic fatigue. In fact he has seen 3 sets of cardiologists over the last 10 years. They all say that his heart is fine. No treatment for the POTs beyond staying hydrated, lots of salt and exercise. They are fed up with me constantly asking for further investigations.

Osij do you think that there is evidence of hypoventilation beyond the centrals?

I hope my correction of my previous response - before I saw what I have quoted above - gives you a partial answer.
Here's my correction:

Since the sleep study identified "some obstructive apneas" and the pressure on this chart is swinging up and down a lot, mostly in response to flow limitations, it is my guess that the a) the minimum pressure is too low to keep your son's airway open consistently, and b)he is probably being woken up by those flow limitations.

I would stop the EPR, since he's usually on low pressure as it is and EPR at low pressure may exacerbate treatment emergent central apnea.

Try to track the relationship between the flow limitations, central apneas and pressure swings - you can do that by placing the vertical cursor on where the flow limitations appear, and looking at what's happening in the flow chart.

Don't accept an AHI of 9 as "fine" and see if you can get the technician to raise the minimum.

I don't know enough to about hypoventilation to say yes or no, and I believe it's a descriptive term, of a phenomenon that may have a number of different reasons.
https://emedicine.medscape.com/article/304381-overview

Were there any indication of hypoventilation during the sleep study? If myasthenia were one of the reasons, don't you think the central apnea and hypoventilation would have been noted in the sleep study? Did either of those words even appear there?

I would start with asking for a monitoring of his oxygen on CPAP.
Please do your best to get the sleep study report and upload it -hiding personal and other identifying data of course.

[wobblycrayon]

Thanks.

I will definitely get a copy of the sleep study as clearly it will hold many answers. It was an at home study so it might not have as much information as an in lab study.

[ozij]

Thanks.

I will definitely get a copy of the sleep study as clearly it will hold many answers. It was an at home study so it might not have as much information as an in lab study.

Absolutely correct.
This also means that the CPAP pressure was set as alternative to titration.
I wonder if the fact that CPAP is not helping can be sufficient grounds for him being give in lab study and titration.