Unusual ResScan Obstructive Pattern

[Bandnuts]

I'm only 5 days into using my CPAP machine. In 5 days use I sure feel like I'm getting a lot more sleep than before and I'm a lot more rested.

However, in looking at my ResScan data, it looks like my sleep patterns are still really very bad. My normal night shows a large amount of obstructive apnea events and a very consistent pattern. I guess it's this very steady pattern that has me most curious. I looks like my breathing is in "waves" with 10 second obstructions between each wave. I'll post a typical view. This pattern seems to go on for 4 to 5 hours each night.

System: S9 (non-auto) set to 13 using a nasal pillow system (but I tried a full face and the pattern was the same).

Does anyone have any thoughts on this pattern?

Link: http://bandnuts.com/Sleep/typical_patern.jpg

Image:

[Lizistired]

Welcome. That is disturbing. Don't you wish you had an Autoset! Maybe if you sent that picture to your doctor, you could get one. I would definately bump my pressure up a notch. I think I would go up in the minimum increment to see the response. It might not take much. How is your Leak Line?
Does your Flow Limitation Line coorespond to the apneas?
It's pretty amazing that you feel better. I can't imagine what your study looked like.

If you change your equipment to show text instead of the pictures, it will be easier for others to see that you have an Elite.

[robysue]

I'm not a doctor, but that pattern looks suspiciously like something called "periodic breathing" or "Cheyne-Stokes respiration" Do a search here on periodic breathing and Cheyne-Stokes and you'll get some hits. Also google "periodic breathing" and Cheyne-Stokes.

This definitely is important enough to call the sleep doctor's office to report the problem and (in my opinion) it's important enough to insist on an appointment to talk to the doc or a PA about the problem.

Did your sleep study mention any Cheyne-Stokes patterns or periodic breathing? Do you have any history of heart disease?

[idamtnboy]

Welcome. That is disturbing.

Amen!

Don't you wish you had an Autoset! Maybe if you sent that picture to your doctor, you could get one.

Bandnuts, I wouldn't send it, I would take it to him ASAP. From what I see you still have an AHI somewhere between 50 to 100. Terrible, terrible.

[Bandnuts]

Thanks for some of the quick responses. This is great info...

Lizistired: Thanks for the welcome and I made the change in equip display. Based on what I'm reading, you make sense. The flow limitation line is flat, however the leak line has very slight movement that flows the breathing trends (but it's minor at no higher than 5 on the leak graph. As for my study, it was a mess. I guess I didn't know how much of a mess I was in. 74 events per hour, 22 second average, 63 second longest. I suspect it's been a while since I've seen a decent night's sleep.

robysue: Great info!!! Thanks a lot and I agree the patterns are a very good match. This is helpful. As for heart, I do have a current condition that's being treated (A-fib) that runs in the family. I suspect these two are very much tied together. I've already left messages for the DR and are working to discuss options.

idamtnboy: While I'm not going to panic, I'm sure going to get in touch with the doctor as quickly as possible. I guess it's hardest on me to feel better after my first week of use, yet to know that I'm still so far away from any type of "real" night's sleep. Why didn't I do this years ago?

[NotMuffy]

"IMHO", those are ALL central. The diagnostic methodology (Forced Oscillation Technique) isn't identifying them properly. The liklihood of having "closed airway" centrals (which would make the algorithm call them obstructive) is small at 13.0 cmH2O pressure, and even if there were a remote chance that they were closed-airway centrals, the lack of resuscitive breaths post-event makes that academic.

[DreamDiver]

"IMHO", those are ALL central. The diagnostic methodology (Forced Oscillation Technique) isn't identifying them properly. The liklihood of having "closed airway" centrals (which would make the algorithm call them obstructive) is small at 13.0 cmH2O pressure, and even if there were a remote chance that they were closed-airway centrals, the lack of resuscitive breaths post-event makes that academic.

NotMuffy does this for a living, so when he speaks, it pays to listen. Central apnea (not open airway apnea) needs to be treated differently than obstructive sleep apnea. You probably need a different machine -- something with servo-ventillation. At the very least, you probably need another titration. If this were my data, I'd show it to my doctor as soon as possible. I'm not a professional, but this really does look like full-blown Cheynes Stokes.

[Lizistired]

It seems that your average AHI hasn't changed, though the average duration may have dropped to 20( just guesstimating). BFD.
Since you can't see your Doc til Monday, I would up the pressure by 0.2-0.4 tonight and check the difference in the morning. Then adjust, or not, based on those results.
Can you see your Doc Monday? I really think you should. Like RobySue said there may be another sleep disorder at play and he needs to look into it. That said, he needs to script you an autoset rather than schedule another $2000.00 sleep study since the last one got you where you are today.
If you can improve your results with adjustments over the weekend, I would still see him on Monday and push for an Autoset... but not show him the improved results! Just show him what you posted here, the results that his script got you.
On Rescan, there is an icon in the upper right of a graph with a check mark that will let you add or remove graphs in your view pane. Adjusting that will make it easier for you to get screen shots. Example: The AHI graph is kind of a waste of screen space if you have the events graph. The Pressure you already know...

[NotMuffy]

Since you can't see your Doc til Monday, I would up the pressure by 0.2-0.4 tonight and check the difference in the morning. Then adjust, or not, based on those results.

"IMHO", it might be a better idea to try to figure out what's underfoot first. With his hx of AF and the clocklike precision of the events (there's an event there at the beginning even thugh the SW didn't score it) this is undoubtedly central. But it's short-cycle, so there could be some CompSAS component as well. A look at sleep study and patient history may clear some of this up.

Regardless, this pattern screams for ASV.

[Lizistired]

Notmuffy, If this is your area of expertise, maybe you can enlighten me as to why the Op was sent home with this machine and this pressure in the first place. Assuming they had knowledge of the OP's medical history, doesn't it scream of medical malpractice?! If not we wouldn't be here trying to figure it out on our own.

[avi123]

Last time that I saw those spindles was here:

viewtopic.php?f=1&t=60083&st=0&sk=t&sd=a

In this case, since there is a question about diagnosis, the S9 Elite is safer than an APAP AutoSet.

I never saw those rhythmic events on my S9 Elite. Could there be something wrong with the machine?

[NotMuffy]

Notmuffy, If this is your area of expertise, maybe you can enlighten me as to why the Op was sent home with this machine and this pressure in the first place. Assuming they had knowledge of the OP's medical history, doesn't it scream of medical malpractice?! If not we wouldn't be here trying to figure it out on our own.

I think there's still a lot of details left to be uncovered. For all I know he could have be in and out of AF and results vary dramatically. Or he was set up on CPAP to document failure in preparation for ASV. Perhaps a glance at the NPSG would offer insight.

[avi123]

"IMHO", those are ALL central. The diagnostic methodology (Forced Oscillation Technique) isn't identifying them properly. The liklihood of having "closed airway" centrals (which would make the algorithm call them obstructive) is small at 13.0 cmH2O pressure, and even if there were a remote chance that they were closed-airway centrals, the lack of resuscitive breaths post-event makes that academic.

1) I thought that only the S9 AutoSet uses the Forced Oscillation Technique (FOT) but not the S9 Elite.
2) My S9 Elite does distinguish all these events at 6 to 7 cmH2O:

Statistics

2/2/2011 - 2/10/2011

Device Settings
Therapy Mode: CPAP Set Pressure: 7.0 cmH2O EPR: Full_Time
EPR Level: 2.0 cmH2O

Leak - L/min
Median: 3.6 95th Percentile: 24.0 Maximum: 54.0

AHI & AI - Events/hr
Apnea index: 17.3 AHI: 18.4 Obstructive: 11.5
Central: 3.8 Unknown: 1.0 Hypopnea index: 1.1

Usage
Used Days >= 4 hrs : 9 Used Days < 4 hrs : 0 % Used Days >= 4 hrs :
100
Days not used: 0 Total days: 9 Median daily usage:
7:00
Total hours used: 66:53 Average daily usage: 7:25

[NotMuffy]

"IMHO", those are ALL central. The diagnostic methodology (Forced Oscillation Technique) isn't identifying them properly. The liklihood of having "closed airway" centrals (which would make the algorithm call them obstructive) is small at 13.0 cmH2O pressure, and even if there were a remote chance that they were closed-airway centrals, the lack of resuscitive breaths post-event makes that academic.

1) I thought that only the S9 AutoSet uses the Forced Oscillation Technique (FOT) but not the S9 Elite.

No, those bursts are FOTs up there.

Both the S9 AutoSet & the S9 Elite have CSA (Central Sleep Apnea) and OSA (Obstructive Sleep Apnea) detection. The enhanced Easy-Breathe motor features small diameter lightweight impellers that provide lower inertia. This enables the motor to track your normal breathing waveform and produce the small oscillations in pressure required to detect CSAs. It uses the forced oscillation technique (FOT) to determine the state of the airway during an apnea. When an apnea is detected, small oscillations are added to the pressure to measure airway patency. The CSA algorithm uses the resulting flow and pressure to measure airway patency and differentiate central and obstructive events. Your S9 AutoSet has the ability to compensate for these events with its enhanced autoset algorithm.

[avi123]

"IMHO", those are ALL central. The diagnostic methodology (Forced Oscillation Technique) isn't identifying them properly. The liklihood of having "closed airway" centrals (which would make the algorithm call them obstructive) is small at 13.0 cmH2O pressure, and even if there were a remote chance that they were closed-airway centrals, the lack of resuscitive breaths post-event makes that academic.

1) I thought that only the S9 AutoSet uses the Forced Oscillation Technique (FOT) but not the S9 Elite.

No, those bursts are FOTs up there.

Both the S9 AutoSet & the S9 Elite have CSA (Central Sleep Apnea) and OSA (Obstructive Sleep Apnea) detection. The enhanced Easy-Breathe motor features small diameter lightweight impellers that provide lower inertia. This enables the motor to track your normal breathing waveform and produce the small oscillations in pressure required to detect CSAs. It uses the forced oscillation technique (FOT) to determine the state of the airway during an apnea. When an apnea is detected, small oscillations are added to the pressure to measure airway patency. The CSA algorithm uses the resulting flow and pressure to measure airway patency and differentiate central .

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

Sorry, but I don't see in my detailed graphs any FOTs spikes every couple of minuts clicking in the EVENT or FLOW graphs.