Would I Benefit from BiPAP or ST?

[Maryland_Mike]

I suffer mostly from hypopneas, with an AHI typically between 5 and 10. Many nights my AI is 0 as are my leaks. I suspect my hypopneas are central in nature, as my sleep study showed no obstructive apneas but several centrals. My AHI in sleep study was 36.

I am titrated at 9 per my sleep study, and I have confirmed this with self-titration.

Would I benefit from a BiPAP or from an ST machine if my hypopneas are central? The duration of these is usally 10-11 seconds, never more than 19 seconds.

I feel great, but if I can do better I'd like to know.

[ozij]

Some of your hypopnea may be a result of turning around, and sighing.

Dr. Michael Berthon-Jones, the person who was closely involved in developing the Resmed Autoset algorithm has the following to say about hypopneas in an inteview published in Resmedica :

When you are lying quietly awake, or when you
first go to sleep, or when you are dreaming, you
can have hypopneas (reductions in the depth of
breathing) which are nothing to do with the state of
the airway. For example if you sigh, which you do
every few minutes, you usually have a hypopnea
immediately afterwards. This can also happen if
you have just rolled over and are getting settled, or
if you are dreaming. And the annoying thing is that
when you are on CPAP, this tendency to have what
are called central hypopneas - hypopneas that are
nothing to do with the state of the airway - is
increased. If you make an automatic CPAP device
that responds to hypopneas, you will put the
pressure up to the maximum while the patient is
awake.

Do you think there is a misconception clinically
that all hypopneas should be treated ?
For simple obstructive sleep apnea, central
hypopneas should not be treated. They are not a
disease. Everyone has them. And they don’t go
away with CPAP.
There is a rare and important exception: central
hypopneas due to heart disease. This is called
Cheyne-Stokes breathing. CPAP does help with
that.

I would trust him and the way you feel.

O.
Edit: Correcton in Berthon-Jones' name.

[Maryland_Mike]

Excellent source, ozij. I feel even better, now.

[tonycog]

There is a rare and important exception: central hypopneas due to heart disease. This is called Cheyne-Stokes breathing. CPAP does help with that.

As I've written before, I was diagnosed with Cheyne-Stokes respiration. I'm trying to figure this thing out. I have had 2 episodes of atrial fibrillation. It was actually my cardiologist who sent me to the sleep doc to get a sleep study this past April. The sleep study found Cheyne-Stokes. They've done heart ultra-sound, CT-scan of heart, 48-hour heart monitor, all to rule out various heart issues. According to my cardiologist, my heart is healthy, other than the rhythm issues. He thinks that getting sleep therapy may take care of that also, although he really doesn't know why I went into A-Fib in the first place. They've also done an MRI of my brain to rule out a tumor, which can also cause Cheyne-Stokes. I've never had a serious head injury, which is another possible cause of Cheyne-Stokes.

All of the testing has come back negative, which is, of course, a good thing for a 43-year-old with a 7-year-old son, mortgage, etc. I just get uncomfortable reading about heart disease and Cheyne-Stokes, wondering what else out there could have caused this. I've read about the causes, but there is nothing obvious to blame it on. I'm fairly happy with my sleep doctor, but I do wish he was more inclined to delve into the causes of Cheyne-Stokes instead of just a shrug and "some people just get it and we don't really know why."

Thanks,
Tony

[ozij]

[quote="tonycog
As I've written before, I was diagnosed with Cheyne-Stokes respiration. I'm trying to figure this thing out. I have had 2 episodes of atrial fibrillation.[/quote]
That's your heart rythm problem

It was actually my cardiologist who sent me to the sleep doc to get a sleep study this past April

.
Good for him.

The sleep study found Cheyne-Stokes.

That's the name for a certain pattern of respiration.

They've done

• heart ultra-sound,
  CT-scan of heart,
  48-hour heart monitor,

all to rule out various heart issues. According to my cardiologist, my heart is healthy, other than the rhythm issues.

Good for you.

He thinks that getting sleep therapy may take care of that also, although he really doesn't know why I went into A-Fib in the first place.

Looks like he's up to date. But the point is, this therapy makes sure you have proper oxygenation all night through, not waxing and waning. That's what's so good for your heart.

All of the testing has come back negative, which is, of course, a good thing for a 43-year-old with a 7-year-old son, mortgage, etc.

A very good thing.

I just get uncomfortable reading about heart disease and Cheyne-Stokes, wondering what else out there could have caused this.

Berthon-Jones is talking about people with chronic heart failure.

I'm fairly happy with my sleep doctor, but I do wish he was more inclined to delve into the causes of Cheyne-Stokes instead of just a shrug and "some people just get it and we don't really know why."

I understand the wish part, but I think he honestly doesn't know. Seems to me your cardiologist has ruled out the usual types of heart disease related to Cheyne -Stokes respiration.

[jnk]

. . . diagnosed with Cheyne-Stokes respiration. I'm trying to figure this thing out. I have had 2 episodes of atrial fibrillation. It was actually my cardiologist who sent me to the sleep doc to get a sleep study this past April. The sleep study found Cheyne-Stokes. . . .

I guess there is much to be understood by docs and studied by researchers yet about CSR and AFib:

http://www.pubmedcentral.nih.gov/articl ... d=19578392

I think living at high altitude and certain medications can sometimes be factors with CSA/CSR, but I don't really understand that stuff.

[dsm]

. . . diagnosed with Cheyne-Stokes respiration. I'm trying to figure this thing out. I have had 2 episodes of atrial fibrillation. It was actually my cardiologist who sent me to the sleep doc to get a sleep study this past April. The sleep study found Cheyne-Stokes. . . .

I guess there is much to be understood by docs and studied by researchers yet about CSR and AFib:

http://www.pubmedcentral.nih.gov/articl ... d=19578392

I think living at high altitude and certain medications can sometimes be factors with CSA/CSR, but I don't really understand that stuff.

JNK

That was an excellent find !

Tony,

The classic CSR cycle is (as I am guessing you have read) cycling between patterns of hyper & hypo ventilation. The traditional case for why that occurs relates to the heart being too weak to pump enough adequately oxygenated blood to maintain a normal breathing pattern. The body then cycles between building up excess CO2 in the blood & then the body via the lungs trying to clear it away.

I gather that in your case the CSR is only happening in occasional bursts & the belief is it is tied to atrial fibrillation.

You have an interesting situation. My immediate & instinctive reaction is that SV may well add further improvement.

DSM
(note - I am an amateur on matters Respiration & just thinking aloud here)

[ozij]

I gather that in your case the CSR is only happening in occasional bursts & the belief is it is tied to atrial fibrillation.

You have an interesting situation. My immediate & instinctive reaction is that SV may well add further improvement.

DSM
(note - I am an amateur on matters Respiration & just thinking aloud here)

That tie in is part of your thinking, dsm. I thought the sleep doc was clearly saying he doesn't know why Tony goes into Cheyne-Stokes Respiration. And I thought the cardiologist assumed the CSR was affecting the heart, and therapy would improve it, and not vice versa.

I'm an amateur too in these matters, and thinking out loud here as well.

O.

[tonycog]

That is correct. The cardiologist thinks it's possible (most-likely culprit) that apneas caused the heart to rebel and go into A-Fib since it was consistently being oxygen-deprived. The sleep doc doesn't know why CSR began. His only concern has been to treat it with Bi-PAP.

I read the article above linking A-Fib with sleep disorders. Would someone help me with the conclusions, though? Did that study put an order on this? Are they thinking sleep apnea causes A-Fib or that A-Fib can cause Cheyne-Stokes? Or did they make any conclusions. I'm not very good at reading medical-eze yet.

Thanks,
Tony

[jnk]

That is correct. The cardiologist thinks it's possible (most-likely culprit) that apneas caused the heart to rebel and go into A-Fib since it was consistently being oxygen-deprived. The sleep doc doesn't know why CSR began. His only concern has been to treat it with Bi-PAP.

I read the article above linking A-Fib with sleep disorders. Would someone help me with the conclusions, though? Did that study put an order on this? Are they thinking sleep apnea causes A-Fib or that A-Fib can cause Cheyne-Stokes? Or did they make any conclusions. I'm not very good at reading medical-eze yet.

Thanks,
Tony

I don't speak the language, either. Maybe ozij can help--I believe she is multilingual.

My main reason for posting the study, though, was not to point to any conclusions; I just wanted to show that studies are still being made in an attempt to understand the relationship between the different forms of sleep-disordered breathing and various heart conditions.

I tend to be simple-minded with this stuff. My way of looking at it is that breathing is good, and sleeping is good. Anything that can be done to make those effective is a good thing for ANY medical condition. So treating those things is a given, for me. Always. I don't think docs always look at it that way, but that is how I view it as a patient, myself.

Do you live at high altitude? Are you taking medications that may affect your breathing or your sleep? Those are things to talk to your doctor about and to study in figuring out possible reasons for periodic breathing, along with searching for any medical conditions themselves.

It can be worth taking the time to learn a little medicalese about any condition you may have so you can ask your doc meaningful questions and understand the answers in relation to your personal medical history and family history. But, in my opinion, even if your doc were to have a personal opinion on what causes what as far as AFib and periodic breathing, that opinion might not necessarily affect the course of action, or what should or should not be worried about, or ignored.

It is a fine line for many of us to walk as we research things related to our health while trying not to get too frustrated about how much is unknown and trying not to worry too much about things that worry won't help. We take the knowledge we get, work with a doctor we trust, and do the best we can to do what it is reasonable to do for our health. It is a process.

I admire your participation on this board and your continuing to mention your personal experiences and circumstances as you gain more knowledge on sleep-disordered breathing and how it may relate to AFib. I am sure others will continue to benefit from your posts on that and related subjects. Sorry I don't know more. Maybe others do.

jeff

[ozij]

That is correct. The cardiologist thinks it's possible (most-likely culprit) that apneas caused the heart to rebel and go into A-Fib since it was consistently being oxygen-deprived. The sleep doc doesn't know why CSR began. His only concern has been to treat it with Bi-PAP.

I read the article above linking A-Fib with sleep disorders. Would someone help me with the conclusions, though? Did that study put an order on this? Are they thinking sleep apnea causes A-Fib or that A-Fib can cause Cheyne-Stokes? Or did they make any conclusions. I'm not very good at reading medical-eze yet.

Thanks,
Tony

I don't speak the language, either. Maybe ozij can help--I believe she is multilingual.

Grrrr... the computer just ate my witty way of saying "I don't know either". They seem to be speaking out of both sides of their mouths when discussing the causality....
I wonder if its the Grerman to English translator's fault....

O.

[tonycog]

Do you live at high altitude? Are you taking medications that may affect your breathing or your sleep? Those are things to talk to your doctor about and to study in figuring out possible reasons for periodic breathing, along with searching for any medical conditions themselves.

It can be worth taking the time to learn a little medicalese about any condition you may have so you can ask your doc meaningful questions and understand the answers in relation to your personal medical history and family history. But, in my opinion, even if your doc were to have a personal opinion on what causes what as far as AFib and periodic breathing, that opinion might not necessarily affect the course of action, or what should or should not be worried about, or ignored.

It is a fine line for many of us to walk as we research things related to our health while trying not to get too frustrated about how much is unknown and trying not to worry too much about things that worry won't help. We take the knowledge we get, work with a doctor we trust, and do the best we can to do what it is reasonable to do for our health. It is a process.

I admire your participation on this board and your continuing to mention your personal experiences and circumstances as you gain more knowledge on sleep-disordered breathing and how it may relate to AFib. I am sure others will continue to benefit from your posts on that and related subjects. Sorry I don't know more. Maybe others do.

jeff

I was already someone who learns about a particular health problem that a family member or I might be dealing with, but this particular health issue and this discussion group has reinforced that we all need to be our own loudest and best-informed advocate.

One big frustration that I have with the medical community is their unwillingness to remember that while there are countless specialties that treat our various ailments, there is only one patient. The cardiologist won't venture into any sleep issues beyond saying "see your sleep doctor." The sleep doc won't talk much about heart issues since that's not his area of expertise. Meanwhile, the sick guy bounces back-and-forth between specialists with a single set of symptoms that neither doc will get into very deeply. Specialists too often are either unable or unwilling to 'step outside of the box'.

Having said all of this, I need to say that I will stick with both doctors. I don't think I'll do any better, and both seem interested in trying to help (which is their job after all). Both have been willing to sit down with me at my appointments for 30+ minutes. The medical system is simply not set-up to allow docs to treat the "whole patient", which makes it all the more important to be an educated advocate for ourselves.

Thanks for your kind words. I owe this group more than I'll ever be able to re-pay.

Best wishes,
Tony

[jnk]

. . . Grrrr... the computer just ate my witty way of saying "I don't know either". They seem to be speaking out of both sides of their mouths when discussing the causality....
I wonder if its the Grerman to English translator's fault....

O.

You don't know how comforting it is to me to hear you say that! I thought it was just me.

"What we just researched was very important and timely, although we can't explain exactly why, or even what it is we found, for that matter. But here's the very significant data anyway."

Sorry to link to such a curve-ball study, guys. At least it may help prove the docs can be as confused as I am.

I was already someone who learns about a particular health problem that a family member or I might be dealing with, but this particular health issue and this discussion group has reinforced that we all need to be our own loudest and best-informed advocate.

One big frustration that I have with the medical community is their unwillingness to remember that while there are countless specialties that treat our various ailments, there is only one patient. The cardiologist won't venture into any sleep issues beyond saying "see your sleep doctor." The sleep doc won't talk much about heart issues since that's not his area of expertise. Meanwhile, the sick guy bounces back-and-forth between specialists with a single set of symptoms that neither doc will get into very deeply. Specialists too often are either unable or unwilling to 'step outside of the box'.

Having said all of this, I need to say that I will stick with both doctors. I don't think I'll do any better, and both seem interested in trying to help (which is their job after all). Both have been willing to sit down with me at my appointments for 30+ minutes. The medical system is simply not set-up to allow docs to treat the "whole patient", which makes it all the more important to be an educated advocate for ourselves. . . .

Well said, Tony.

If I had CSR, I would want a cardio, a pulmo, and a neuro doc to all three admit defeat with their search before I filed the cause under "mystery," myself. And I might still ask about a change of drugs, depending, just to be sure. And if I lived very high above sea-level, I might wonder what O2 would do for me. But that's just me.

[dsm]

I gather that in your case the CSR is only happening in occasional bursts & the belief is it is tied to atrial fibrillation.

You have an interesting situation. My immediate & instinctive reaction is that SV may well add further improvement.

DSM
(note - I am an amateur on matters Respiration & just thinking aloud here)

That tie in is part of your thinking, dsm. I thought the sleep doc was clearly saying he doesn't know why Tony goes into Cheyne-Stokes Respiration. And I thought the cardiologist assumed the CSR was affecting the heart, and therapy would improve it, and not vice versa.

I'm an amateur too in these matters, and thinking out loud here as well.

O.

Tks

D

[dsm]

This info is just me using this thread to store the data that am digging up (am still working my way thru JNK's linked doc)
Am hoping by assembling nuggets from the study, some may turn out to be gold. There is a lot of asking self questions
interspersed with extracts.

Firstly, I located a description of AtFib

**************************

"
Atrial fibrillation (AF or afib) is the most common cardiac arrhythmia (abnormal heart rhythm) and involves the two upper chambers (atria) of the heart. Its name comes from the fibrillating (i.e. quivering) of the heart muscles of the atria, instead of a coordinated contraction. It can often be identified by taking a pulse and observing that the heartbeats don't occur at regular intervals. However, a conclusive indication of AF is the absence of P waves on an electrocardiogram (ECG or EKG), which are normally present when there is a coordinated atrial contraction at the beginning of each heart beat. Risk increases with age, with 8% of people over 80 having AF.

........

Atrial fibrillation is often asymptomatic, and is not in itself generally life-threatening, but may result in palpitations, fainting, chest pain, or congestive heart failure. People with AF usually have a significantly increased risk of stroke (up to 7 times that of the general population). Stroke risk increases during AF because blood may pool and form clots in the poorly contracting atria and especially in the left atrial appendage (LAA). The level of increased risk of stroke depends on the number of additional risk factors. If a person with AF has none, the risk of stroke is similar to that of the general population. However, many people with AF do have additional risk factors and AF is a leading cause of stroke.

Atrial fibrillation may be treated with medications which either slow the heart rate or revert the heart rhythm back to normal. Synchronized electrical cardioversion may also be used to convert AF to a normal heart rhythm. Surgical and catheter-based therapies may also be used to prevent recurrence of AF in certain individuals. People with AF are often given anticoagulants such as warfarin to protect them from stroke.
"

****************************

[dsm comment] Here is the study conclusion para ...

"
We have demonstrated an increased frequency of sleep-disordered breathing in patients with AFib. As well as the known higher prevalence of OSA, which is of clinical relevance in the primary and secondary prevention of AFib (both after cardioversion and after ablation) (17– 19), we have shown for the first time a high proportion of patients with CSA/CSR, which can be attributed to raised pulmonary capillary pressure resulting from the diastolic dysfunction caused by AFib. Although no studies on CSA/CSR with regard to primary and secondary prevention have been carried out, it can be surmised that this form of sleep-disordered breathing is also of clinical relevance. Therefore, routine screening appears advisable for these patients.
"

*****************************

[dsm comment] Below are some excerpts from the linked to Study

"
Sleep-disordered breathing was documented in 111 (74%) of the 150 patients studied. Sixty-four patients (42.7%) had OSA and 47 (31.3%) displayed CSA/CSR. In the OSA group, 27 patients (18%) showed mild, 18 (12%) moderate, and 19 (12.7%) severe disease. Additional CSA/CSR was found in 3 patients (2%). In the CSA/CSR group, 10 patients (6.7%) had mild, 16 (10.7%) moderate, and 21 (14%) severe disease. Nine patients (6%) also had OSA. Further sleep medicine data are shown in table 2.
"

"
In addition to the known higher incidence of OSA (42.7% in this study), the data presented here show for the first time an increased prevalence of CSA/CSR (31.3%) in patients with AFib and normal global systolic left ventricular function. Both groups of patients with sleep-disordered breathing displayed an increased LAD, and patients with CSA/CSR showed higher PAP, higher AHI, and lower pCO2 than patients with OSA.
"

[dsm comment] from the above - it says higher PAP, AHI and lower pCO2 for the CSA/CSR category of patients. I am interpreting that as highlighting that the CSA/CSR patients had worse Sleep Apnea that the straight OSA patients & that their CO2 blood gas levels were lower that straight OSA patients which to me is going to trigger Centrals or a CSR waning cycle (which in turn leads to a build up of pCO2 & the waxing cycle).

**********************

[dsm comment] The following extract seems to be a conclusion of the study - still trying to work out its importance

"Such an increase in pulmonary capillary pressure is also possible in patients with purely diastolic dysfunction. One predisposing factor is AFib, which is often an expression of increased left atrial pressure and/or volume. The present study found more frequent occurrence of CSA/CSR in patients with AFib. Another sign of the pathophysiological interrelationships described is a correlation between AHI and PAP, particularly in the CSA/CSR group. The patients in this group also displayed significantly lower pCO2, an expression of sensitivity of the chemoreceptors to CO2, analogous to CSA/CSR patients with cardiac insufficiency (7, 8, 13).
"

**********************
[dsm comment] Another nugget from the study ...

"
It was shown as early as 2003 that OSA has an influence on recurrence of AFib after cardioversion (17). Kanagala et al. described recurrence in 82% of 27 patients with untreated OSA, compared with rates of 42% in 12 treated patients and 53% in the control group (n = 79). It should be mentioned, however, that the control group was recruited from patients who had not undergone any sleep medicine investigation.

Recently it was reported that even after ablation, OSA is an independent factor for the recurrence of AFib (18). Moreover, Gami et al. retrospectively showed in 3542 patients that OSA increased the risk of a first episode of AFib in individuals under 65 years of age (19).
"

[dsm comment] Here they are talking OSA (Obstructive apnea) rather than CSA/CSR ? - the study seems to flit between refs to OSA then CSA/CSR

************************

[dsm comment] This looks like another significant point ...

"
It has long been known that hypoxia as a consequence of sleep-disordered breathing and particularly OSA can result in arrhythmias (20). .....
"

************************

[dsm comment] another significant point ?

"
However, it has been shown that arrhythmias occur in the hyperventilation phases of CSR (23). This seems to be caused by, among other factors, sympathicotonia resulting from increased coactivity of the autonomic cardiovascular and respiratory nervous system (24).
"

[dsm comment] this seems to imply the arrhythmias (am assuming leading to atFib) are a consequence of the CSR ?

***********************

[dsm comment] this statement seems definitive ...

"
However, prevention of hyperventilation phases seems to be a sine qua non for effective management.
"

***********************

[dsm conclusion]
I find the study wanders a bit & certainly for this amateur (me) too vague to follow as to the key points they were seeking to make.
I started reading it thinking I knew what they were saying but ended wondering what the real point was

This study needs a lot of absorbing.

DSM

#2

It would be remiss not to include the statements from the 'Key Messages' table (one would expect it to make the study clear ) ...

* Sleep-disordered breathing occurs with increased prevalence in patients with AFib and good systolic left ventricular function.
* For the first time, it has been shown that CSA is also more common in patients with AFib.
* In comparison with OSA, patients with CSA have higher LAD and higher PAP on echocardiography. The pCO2 is lower, the NT-proBNP higher.
* A weak correlation between PAP and AHI was found for patients with CSA but not for those with OSA.
* Patients with OSA displayed significantly longer hypopnea phases and tendencies towards longer apnea phases and lower maximal oxygen saturations than patients with CSA.

D