Interpretation-periodic breathing and CA events

[stevealive]

After two months on a cpap machine, I've changed over to a PR SystemOne Auto as of a week and a half ago. With Encore Viewer I'm looking at the data, which is quite informative, but I could use some help with where to go from here. Eventually I'll present all this to my sleep doc, but thought I'd see what the collective brain trust here had to say. I'm very impressed with the knowledge I see pass through this forum, so thanks in advance for the help. I couldn't have done the analysis that I've been able to do without the learning I've done on this forum, so maybe that can give some hope to others new at this like me.
I had been running the cpap at 9, and feeling much better and finally more energetic. The Auto is running between 8 and 12, and I'm not feeling as chipper as I was. The last few days were a chore not to give in to fatigue later in the day. The data on the Auto shows a very acceptable leak rate according to the mask chart so I won't show that graph. Where my original sleep study showed a large number of hypopneas, the treatment has removed almost all of them, and that's great. What the data showed is that in the first week I was spending an average of 45% or more of the night in periodic breathing, with an average AHI of 29 or 30, all made up of clear airway (central) events. That's the same AHI as what my original sleep study said, except that now the central events have increased as the hypopneas have decreased. The last three nights have been better, with the periodic breathing down to about 30%, and the AHI in the low 20's. I'd like to do alot better than that. The nightly pattern is very uniform. Here are typical graphs of the pressures, flags, and events-



It seems like the machine needs to go up to 10.5 to head off the events. (Only twice on other days has it hit the ceiling at 12. OA's are almost non-existent, as they were in the original sleep study.) The sleep study noted that in my case centrals increased above 10, so I'm wondering if this setting for the Auto is causing the increase in central events. The recommendation was for cpap between 8 and 9. I'm thinking about trying a night at cpap-9, like I used before the Auto machine and when I was feeling better, so I can see what the data looks like, and maybe a night on auto between 8 and 10. Any suggestions?
I've tried to read all I can about periodic breathing, which seems to be a pattern of rapid breathing interspersed with central apnea events. There doesn't seem to be much written about how to adjust settings on the Auto for central events. Does anyone have experience with that? The centrals do seem clustered. Also, can anyone explain why at the beginning of hour five, there are events happening but the Auto did not seem to respond?
How significant are the System One and the A-flex setting? I have the System One set on 1, which I gleaned from a post about the Swift FX mask, and the flex on three, because the RT had it set that way.
Any comments would be very appreciated. Thanks again.

[OutaSync]

Since you felt better at a straight pressure of 9, I agree that you should run it at straight CPAP 9 for a night and see what the difference is. It could be that the changes in pressure are what is messing you up.

[Hawthorne]

Yes, I would be trying straight cpap at 9 or 10 cm - set it at 9.5 cm just to see.

It seems like it may be pressure changes that are causing so many events. It would be worth a try anyway.

Please post a night's data after you have tried straight cpap for 3 or 4 days anyway. I'd like to see if that helps!

[stevealive]

OutaSync, thanks for the reply. I've been watching my post, and when it reached almost 70 views with no reply, I was wondering if I said something wrong or had cheese on my moustache.
Last night I set the machine for cpap on 9 cm, and set the flex down to 2. The results were as bad as anything I've seen since I started having data, about 2 weeks ago. Here are the charts-

As it shows, the pressure flat-lined at 9, my time in periodic breathing went up to 42%, and the AHI was 29.7. I tried this setting because I had been on a straight cpap machine for 2 months (with no data) and had gotten to feeling a lot more energetic. Now that I have this data from these settings, I'm wondering if it was just getting used to the treatment that caused the improvement.
I'm guessing at what to do next. My first week with the machine on auto, 8-12, produced results just like this. The last few days had gotten better, with AHI's mostly in the low 20's, once as low as 15. Maybe there is still a component of getting used to the treatment. I think I'll go back to the auto mode, maybe with the max setting at 10. During my sleep study, they saw an increase in central apnea events above 10. But here I am at 9, with the centrals very much present. Any comments from those with more experience would be much appreciated. I'll also try to get an appointment with my sleep doctor, but that usually takes a few weeks.

[Hawthorne]

I think people are hesitant to reply because, maybe like myself, they have not seen anything like this before!

I didn't know how to reply. It was also a holiday weekend.

Looking at the straight cpap at 9 cm, I might go back to auto, setting my machine at 9 cm to 12 cm, narrowing the range. It LOOKS like you do better on auto. With 8-12 though, you had a lot of events at 8 cm (so I think maybe 9 cm minimum). I would not up the maximum because you may well have runaway centrals. May be keep that 3 to 4 days or a week. The Flex setting may be an issue too. You tried 2 last night with straight cpap so maybe 2 with the 9-12 auto settting may be better. I still would not use ramp, but if you feel you need it, I would put it at say 7 cm, not 4 (you had a lot of events at the 4 cm ramp setting). I don't know how long it takes you to get to sleep so you will have to experiment with ramp time if you use it.

I'm not a medical professional but that is what I might try. It can take several days to a week for everything to adjust so give it some time, if you can.

Hope things improve!

[OutaSync]

Wow! I've never seen anything like that, either. Maybe you should change your title to "Help! 42% of night in PB" and see if that gets the attention of -SWS or Muffy. I know that the next thing that they are going to want to see are the reports from your sleep study. Can you get those and post?

Good luck,

Bev

[ldj325]

I'm not an expert, just a user that goes into periodic breathing. In my case it is Cheyne-Stokes Respiration which is likely secondary to a heart issue. Have you had your heart checked to know if anything is going on there?

I don't know what your sleep study looked like. I do know that if your pressure gets too high it can induce Central apneas. Did the titration portion of your sleep study mention CA happening at a particular pressure? Perhaps you want to do some reading on Complex Apnea. In that scenario, the Hypopneas would be handled by the pressure of CPAP, but induce the Centrals at the same time. I do not know the System One machine, nor am I familiar with the System One reports. But if it is like my ResMed S9, it doesn't actually treat Central apneas and in auto will respond my reducing the pressure in response to a CA.

I'm not sure by your history if you ever used CPAP at lower than 9. But if you didn't do so well at 9, maybe try 8.5 and see if the Centrals reduce (after all you sleep study did say 8-9. I have seen that a whole step (like 8 to 9) in pressure can be too big and get different reactions at either end.

Of course if you have a doctor that will work with you a consultation with them would be best.

Good luck.

[-SWS]

I think I'll go back to the auto mode, maybe with the max setting at 10. During my sleep study, they saw an increase in central apnea events above 10. But here I am at 9, with the centrals very much present. Any comments from those with more experience would be much appreciated. I'll also try to get an appointment with my sleep doctor, but that usually takes a few weeks.

I would suggest faxing those reports into your sleep doctor tomorrow. Then give a call a little later that same day to see if your sleep doctor would recommend any treatment changes in the short term---even before seeing you for consultation.

If that periodic breathing and those central apneas emerged only AFTER being treated with pressure by the machine, then there's a pretty good chance that you have complex sleep apnea (CompSAS). Here are some references about that condition:
http://www.rtmagazine.com/issues/articl ... -11_03.asp
http://www.chestnet.org/accp/pccsu/comp ... a?page=0,3
http://www.sleepreviewmag.com/issues/ar ... -06_03.asp

Generally, APAP is thought to be the worst PAP treatment modality there is for CompSAS. Since your centrals emerged around 10cm H2O CPAP in the sleep lab, and since you still have PB and centrals at 9cm CPAP at home, I think I'd probably try 8cm CPAP or lower (i.e. fixed pressure) with CFlex turned OFF.

Good luck and get your sleep doctor in the loop soon.

[stevealive]

Thanks for all the replies, and suggestions. The articles that -SWS suggested were wonderfully informative. I do have my sleep study, and I'll post it as soon as I can get a scan of it. I'll also post a leak chart, but I think it is the normal range for my mask. I didn't think I had a problem with mouth-breathing, but I noticed a few nights of dry mouth since I started with the Auto machine. I'll have to look into that. I don't think I have a heart problem, as I recently had my annual physical, and I am usually intensely physically active with no problems.
I used 8cm Cpap for the first six weeks of my treatment, and increased to 9cm with my sleep docs approval when I didn't think I was getting sufficient results. Now that I am data capable, I'll give that another try and see if that helps with the centrals. I'll also try to get my sleep doctor involved as soon as I can--like tomorrow.
Once again, thanks for all the help. It's late for me, so good night all.

[sleepsurfer]

if you can post a portion of your waveform report, that could be helpful. did your sleep doctor mention that you may have a touch of upper airway resistance? on my pr system 1 reports my hypopneas tend to turn to centrals as i raise the pressure, however they are not really centrals. the machine just recognizes them as such.

[stevealive]

Last night I ran the machine at 8cm cpap, no ramp, no flex. Here are the charts.

The OA's did go up, but the centrals were greatly reduced. I'm glad to see the centrals respond. I'm thinking tonight I might try 8.5cm cpap, and see if it reduces the hypopneas without increasing the centrals.
I took another look at the expected leak rate for the mask I am using. I had misread the value for 12cm, which I realize now should be 37. The value for 8cm should be 29. I had thought the charts were within bounds, but maybe not. This chart shows leaks at up to 44. I assume the difference is significant. I'm not aware of the mask itself leaking, so I'm wondering if this is mouth breathing. I haven't tried taping my mouth, as up till now I didn't think there were any issues. Occasionally I do wake up with a dry mouth, but I think that is mostly since I started using the Auto machine and the larger pressure swings. I have a large bushy moustache and the tape would have to stick to my upper lip. Maybe a chinstrap would work. Anyone else tape over a moustache?
Here are the data sections and one chart from my sleep study. There are 3 pages of other info, but maybe this will suffice.

Sleepsurfer, I don't have a waveform report in my sleep study (would it be anywhere else?), and I've heard no mention of upper airway resistance from my doctor. How can you tell the difference from hypopneas and centrals beyond what the PR1 reports?
I really appreciate all your expertise and help. I also have a call into my sleep doctor, to see how I can best get my current data in their hands.

[sleepsurfer]

on your pr system 1 report there should be a little blue icon with a squiggly line next to the number of hours you slept that night. click on that. if you haven't seen this you will be blown away at the info you have been missing. in order to get this info, you have to download your night everyday, as it is erased from the sd card. post a page that shows when you have alot of events. centrals, obstructive, and hypopneas.

[Hawthorne]

sleepsurfer - I'd like to be "blown away by the info I have been missing" if it is possible for me!

Are you using Encore Pro 2 or Encore Viewer 2?

I have Encore Viewer 2 and I can't locate this "little blue icon with the squiggly line next to the number" What page of the report are you talking about here?

I expect your answer answer will be that I need Encore Pro 2 to get this info but thought I would ask anyway.

Thanks

[sleepsurfer]

yes, i am using encore pro 2. the waveform reports show your every breath through the night. get updated!

[Hawthorne]

Thanks.

The OP has Encore Viewer 2.0 as well, according to his profile, so he won't get this info either.