Obstructive + Central Sleep Apnea w/Cheyne-Stokes Breathing

[ewains]

Hello,

I just came across this site while searching the various terms on my husband's sleep study report and I'm hoping you can help. He was diagnosed with obstructive sleep apnea in early 2005. His ENT requested another follow-up study, which was recently completed. This study showed far worse sleep apnea than the first study. His study showed: total AHI of 100 events per hour, oxygen 83%. Total AHI was 217 events, 144 obstructive apneas and hypopneas, 26 central apneas and 52 mixed apneas. Further, his central apneas were associated with periods of Cheyne-Stokes respiratory pattern. Everything was fine with CPAP at level 8. However, we are concerned about the central apneas - we don't believe those were present in 2005. Also alarming is the Cheyne-Stokes breathing, which at first glance online, references heart failure! The respiratory therapist who gave him a new CPAP machine said that it was the worst case of sleep apnea she had seen in 11 years. Do any of you have any experiences with obstructive combined with central sleep apnea and Cheyne-Stokes breathing? What were the underlying causes...any cardiac or pulmonary problems? I want him to be evaluated further, but we're not sure what kind of doctor to see next. An ENT originally ordered the sleep study, but we think maybe he should be seen by a heart or lung doctor. I would be grateful for any advice you have.

Kindly,
Elaine

[kteague]

Elaine,

Your hubby is blessed to have you on the lookout.

I can't speak to the specifics of his medical problems, but I wonder why this ENT doc didn't refer him to the appropriate specialist. It's just my opinion, but an ENT, now that a sleep study has revealed the complexity of your husband's issues, should not be the major player in this picture.

Maybe your family doctor could direct you to the appropriate specialist.

Hopefully you have a copy of his sleep studies. Did his titration study show that a cpap at a pressure of 8 resolved all his apneas, both obstructive and central? If so, great. If not, there are more sophisticated machines to take care of special needs - did he get a standard cpap?

You are on the right track to question those things that don't make sense to you. Maybe some others can kick in here on the medical and technical aspects of your questions. Best wishes.

Kathy

[Wulfman]

There have been a number of discussions about Cheyne-Stokes on this forum over the last several years (and they can be found using the Search function).

Here are a couple of them:

viewtopic.php?t=1537&highlight=cheynestokes

viewtopic.php?t=643&highlight=cheynestokes

At one time, ResMed had a special machine for that condition, but the link to it in their site came up empty.

Apparently, however, they have incorporated the characteristics needed to treat that condition into this new machine (which came out a year or so ago).

http://www.resmed.com/en-au/products/fl ... u=products

This condition is probably WAY out of the league of your local sleep lab, so seeing a specialist who has experience with it would be MY recommendation.

Den

[Guest]

He needs to see a csrdiologist.

[Banned]

http://www.resmed.com/en-au/products/fl ... u=products

Wulfman would be correct. Your husband needs to be titrated on a ResMed VPAP Adapt SV. That is the only cure. Accept no substitutes. Goodluck, and keep us informed.

Cheers

[StillAnotherGuest]

Your husband needs to be titrated on a ResMed VPAP Adapt SV. That is the only cure. Accept no substitutes.

That is incorrect information. The right answer is

He needs to see a csrdiologist.

to determine the cause and extent of the CSR. If it is due to CHF, medical management, including diuretics, nitrates, digoxin, ACE inhibitors, β-blockers, aldosterone receptor blockers, and/or ARBs could go a long way in relieving symtomology. Low level CPAP can be effective (as you have already implied). And the Respironics BiPAP AutoSV, should one get that far, is an additional tool in the ASV approach.

SAG

[dsm]

Banned,

SAG is being his usual charming self but he is right. CSR needs investigation & hopefully an SV class machine can provide the best relief.

Again, here we have a dedicated wife out to save her husband's life. These types of husbands are just so lucky. (my wife fits into the same category).

Cheers

DSM

[Banned]

Banned,

SAG is being his usual charming self but he is right. CSR needs investigation & hopefully an SV class machine can provide the best relief.

Again, here we have a dedicated wife out to save her husband's life. These types of husbands are just so lucky. (my wife fits into the same category).

Cheers

DSM

Agreed DSM,

I did not mean to exclude the cardiologist. I have a cardiologist and am on Lipitor, a light beta-blocker, and store some nytro, myself. Since I got on the ResMed VPAP Adapt SV, I spend significantly less time with the cardiologist (haven't seen her in over a year) and around hospitals. There simply is not much to talk about. And I defer to SAG as the senior unofficial spokesmodel for the (albeit mediocre) Respironics BiPAP AutoSV.

Banned

[ewains]

Thank you all for your responses. They are greatly appreciated by both my husband and me. Since you all are so willing to help and offer opinions I would like to toss out a little more detail for discussion and I have a couple of other questions.

First, one response suggested my husband's case was possibly out of the league of his local ENT and sleep doctor (DO). We were thinking this originally as well. In fact, the sleep doctor he saw didn't even mention the Cheyne-Stokes breathing or that it may be beneficial to see either a cardiologist or a neurologist and he never even offered a copy of the sleep study. He also didn't explain to him what Central sleep apnea is. So my husband didn't ask when at his office because he wasn't aware of this information until the respiratory therapist kindly took the time to walk us through the results of the sleep study (at which point we began to realize the severity of his case). We were simply amazed that this didn't come up at all at the sleep doctor's office. Is it possible the sleep doctor wasn't worried about this? Did he miss it altogether? I hope it's the former and not the latter, but given the complexity we obviously need to be sure.

Also, it should be noted for the record that my husband is fairly young (early 30s). Other than being overweight he is generally in good health. He takes no medications for anything heart related as he has never had any issues with his ticker ever. In fact, he takes no medications period. Are there cardiologists and neurologists that specialize in these types of sleep diorders? If so, does anybody know which practices out there are regarded as tops in this field? We're trying to figure out where to go from here - a more renowned sleep doctor/specialist, or directly to a cardiologist or neurologist? And again, if the general consensus is to go to a cardiologist or a neurologist, are there any out there who specialize in sleep disorders?

Sorry for the novel and thanks again for your help!

[rested gal]

And I defer to SAG as the senior unofficial spokesmodel for the (albeit mediocre) Respironics BiPAP AutoSV.

Banned

ROTFL!!

Well...I expect it kind'a depends on what's the primary problem a person is trying to treat, as to which of the the two ASV brands would work better for a person. If they even need an ASV type of machine in the first place.

ewains mentioned this about her husband's sleep study:

Total AHI was 217 events, 144 obstructive apneas and hypopneas, 26 central apneas and 52 mixed apneas.

I dunno, but it just might be that the Respironics brand of ASV would address his primary problem (obstructives) better, in addition to dealing with the much fewer number of centrals he had, whether or not they really were associated with Cheyne-Stokes respiration. I could be wrong, but I think the BiPAP Auto SV is more adjustable to address obstructive events than the resmed machine is.

Neither of those machines is "mediocre", imho. As best I understand them, the Respironics machine is designed mainly to handle obstructives, and centrals secondarily. The resmed machine is primarily for centrals, especially to normalize Cheyne-Stokes respiration, and obstructives secondarily. But I may be completely wrong about that.

Glad you're happy with your choice, Banned. You're definitely enthusiastic about the machine you're using, and that's good. But that doesn't mean the resmed adapt SV is the magic machine for everyone who has some centrals turn up. Nor that it would necessarily be the most comfortable machine to use if primary central sleep apnea or CSDB was not a person's main problem.

As someone else in this thread has said often...gotta know what you're trying to treat before deciding how to treat it. All the more reason for ewain's husband to see a cardiologist sooner rather than later. Heck, he may not even need an ASV type of machine at all. Another pair of eyes looking at the supposed "Cheyne-Stokes" breathing on his sleep study might be a good idea...especially since the sleep doctor did not comment on that or tell ewain's husband to get himself to a cardiologist.

I do agree that he should see a cardiologist just to be sure about the condition of his heart. Years of untreated OSA can sure do a number on it.

You don't happen to live near Poway, do you, Banned?

[Capri]

Thanks RG for all your comments and gentle suggestions! I was prescribed CPAP when I was 39, used it for snoring for awhile then put it away for about 7 years.

Now after +25 lbs, manic-depression , a heart "incident", GERD, elevated cholesterol, trigycerides, blood glucose; even narcolepsy. I (no doctor, mind you) decided to request another sleep study. Unfortunately it was a disaster, but a did get an Rx for a new machine (the "white" one ) and through this site and my own investigations have discovered I probably have - scratch that - I DO have a big problem and no medical professional to help me.

So I agree, it's not about the machine - it's about finding a sleep professional who can get you on the right track and then working out the fine details like DME equipment, dealers, machine color... etc.

May we all have significant others who are so involved in helping us get the best care available.

[Banned]

Well...I expect it kind'a depends on what's the primary problem a person is trying to treat, as to which of the the two ASV brands would work better for a person. If they even need an ASV type of machine in the first place.

Neither of those machines is "mediocre", imho. As best I understand them, the Respironics machine is designed mainly to handle obstructives, and centrals secondarily. The resmed machine is primarily for centrals, especially to normalize Cheyne-Stokes respiration, and obstructives secondarily. But I may be completely wrong about that.

As someone else in this thread has said often...gotta know what you're trying to treat before deciding how to treat it. All the more reason for ewain's husband to see a cardiologist sooner rather than later. Heck, he may not even need an ASV type of machine at all.

You don't happen to live near Poway, do you, Banned?

Hi RG,

I'm the first to admit that I'm somewhat of a rogue when it comes to ASV therapy, so please bear with me.

If what Elaine is telling us is true, this guy is a walking nightmare. It would be my hope that even the most hardened soles on this forum would come to the realization that anything a cardiologist may recommend, including meds, O2, and surgery, would not preclude the use of Adaptive Servo Ventilation. To not prescribe would simply be a failure to practice medicine. It is likely we will not hear from Elaine to get to the end game.

But, it is for the reason that my sleep-lab doctor would not practice medicine that I got the ResMed VPAP Adapt SV. To this day, I have never been diagnosed as to why I would wake up in the middle of the night scared to death, gasping for breath. CPAP therapy initially cured it. After two years on CPAP I started waking up and couldn't tear my mask off fast enough to get a breath (I was not over-ventilated). It is precisely when you do not have a clue what is going on that the ResMed Adapt SV comes into its own. It saves my life every night. my wife has been after me to go in and bond with my cardiologist so she doesn't take me off her case-load. I'm reluctant to accept that different machines do different things, especially when I know the the ResMed Adapt SV does it all, even the stuff you don't know about. Could the Respironics BiPAP ASV provide the same outcome for me. I'm reluctant to try because I'm as addicted to that proximal sensor tube at the mask as some people are to their 'nasal pillows'.

I'm in northern California, Poway is in southern California, But when I do call ResMed it feels like a local call.

Best,
Banned

[ewains]

Banned,

I am a little confused by everyone's talk of ASV. I'm not sure what this is? My husband has been on cpap for a few years and even in his recent sleep study it mentions that ALL apneas are resolved with the cpap, level 8. However, it does mention that if the patient does continue to be symptomatic with cpap, consideration for Servo ventilator treatment could be made. Is this the same as ASV?

Nonetheless, is sounds as though we need to consult with a cardiologist immediately. Why was this stuff not mentioned by his sleep doctor? I am livid

Thank You,
Elaine

[rested gal]

I'm reluctant to accept that different machines do different things, especially when I know the the ResMed Adapt SV does it all, even the stuff you don't know about.

"does it all", eh? Interesting statement.

I truly am glad you like your machine, Banned, and that you feel it's doing the job for you.

It would be my hope that even the most hardened soles on this forum would come to the realization that anything a cardiologist may recommend, including meds, O2, and surgery, would not preclude the use of Adaptive Servo Ventilation.

I don't think anyone who has been making suggestions in this thread is a hardened soul. When things like Cheyne-Stokes respiration are mentioned, it's time to see a cardiologist, don't you think? Getting the heart checked out doesn't at all preclude the possibility that an ASV machine is best for Elaine's husband.

There's also the possiblity that that's not the machine he needs. Jury's still out on that, and as SAG said, it would be good to have a closer look at his titration. A closer look by someone (not me!) who knows what the squiggles mean.

It would be my hope that the most enthusiastic user of a particular machine would come to the realization that the very specialized machine he uses is not necessarily the one-and-only be-all, end-all treats-all does-everything machine for everyone. Yes, that machine can be a lifesaver for people with specific conditions who really need that particular machine. It could also give poor treatment, imho, to someone who needs a completely different machine.

I agree absolutely with:

Elaine,

Your hubby is blessed to have you on the lookout.

I can't speak to the specifics of his medical problems, but I wonder why this ENT doc didn't refer him to the appropriate specialist. It's just my opinion, but an ENT, now that a sleep study has revealed the complexity of your husband's issues, should not be the major player in this picture.

and with Julie about needing to see a cardiologist.

[rested gal]

I am a little confused by everyone's talk of ASV. I'm not sure what this is? My husband has been on cpap for a few years and even in his recent sleep study it mentions that ALL apneas are resolved with the cpap, level 8. However, it does mention that if the patient does continue to be symptomatic with cpap, consideration for Servo ventilator treatment could be made. Is this the same as ASV?

Yes. Servo ventilator = ASV = Adaptive Servo Ventilator

Nonetheless, is sounds as though we need to consult with a cardiologist immediately.

I think that's a very good thing to do.

Why was this stuff not mentioned by his sleep doctor?

Possibly because the recent sleep study says that ALL apneas were resolved with a pressure of 8.

Elaine, thank goodness your husband has your support and active interest in seeing that he gets better. A cardiologist really is the next step.