What to do to reduce Central and obstructive apneas

[GLeas]

Hello! I've been using a Respironics system One auto-pap w/ builtin humidifer for about 4 weeks now, and I'm not seeing any improvement at all. I've been pretty steady at around 25 or so with about 50% CA's and a mix of OA and Hypopneas. After 2 weeks or so, I talked to my DME about the situation, and showed her my results on SleepyHead software (which was new to her). She realized she was out of her league and called the ENT that's handling my care. Her suggestion to him, and what he ended up prescribing was to raise the upper pressure value from 15 to 20. I was at 6 - 15 cm H2O. After reading on this board that increasing pressure was a great way to increase Central apneas, I didn't think this was a great way to go, but he's a Dr right? Anyway, the CAs have gone up a little bit and the others are the same. My body must not have needed that extra pressure because it never went above 17, and then only a few times. I am seeing the ENT next week, and I'm wondering what if anything I can sugggest to get a handle on the high overall AHI, as well as reducing the CAs in particular. If anyone has any ideas about using a different machine or maybe having a proper titration sleep study (I didn't get titrated when I had my sleep study due to insurance screwing it up), I'd be open to about anything now. I know this won't be an overnight fix for me, but I'm going in the wrong direction at this point. Thanks in advance!

Greg

[Pugsy]

Could you please post a couple of typical detailed nightly reports?
Include the AHI breakdown on the left side of the SleepyHead detailed report and these graphs on the right side. Are we talking about 25 AHI or 25 events all night long?
Events graph
Flow rate graph
Pressure graph
Leak graph.
Turn off the AHI graph...not needed and don't need all those other graphs below leak. Turn off in Preferences...graphs tab by removing check mark.
You can resize the graphs so that 4 graphs will fit on one screen shot.
Don't know how to post an image of your report...explained here with examples.
viewtopic.php?f=1&t=81072&p=737779#p737779

You need to get a doctor that understands the relationship with pressures. Raising the maximum wasn't the way to go...wouldn't help the obstructive apneas and very possibly could cause more centrals if the centrals are related to pressure and at this point we don't know that they are.
Since your OA is about 50% of your AHI...still way too many OAs and along with the OAs could be some simple post arousal centrals.
To reduce the OAs you need more minimum pressure so that the airway stays open better and the machine doesn't have to always be in fix it mode...it needs to be in prevent mode instead.

Also answer this question in regards to the couple of reports you post...did you sleep straight through the night or did you have multiple awakenings for whatever reason???

[avi123]

Greg, you need to show some graphs showing the pattern of those CAs to get an idea what problem could it be if any.
I would not be surprised to find in Mo someone like this one: "After reading on this board that increasing pressure was a great way to increase Central apneas, I didn't think this was a great way to go, but he's a Dr right?", sorry Larry Swedroe, but you're a NewYorker from thee Bronx, and also you're a financial advisor and not a Doc.

[Pugsy]

And I am glad to know that Avi is back to putting words in my mouth that I didn't say again. Way to go grumpy.

[LSAT]

Hello! I've been using a Respironics system One auto-pap w/ builtin humidifer for about 4 weeks now, and I'm not seeing any improvement at all. I've been pretty steady at around 25 or so with about 50% CA's and a mix of OA and Hypopneas. After 2 weeks or so, I talked to my DME about the situation, and showed her my results on SleepyHead software (which was new to her). She realized she was out of her league and called the ENT that's handling my care. Her suggestion to him, and what he ended up prescribing was to raise the upper pressure value from 15 to 20. I was at 6 - 15 cm H2O. After reading on this board that increasing pressure was a great way to increase Central apneas, I didn't think this was a great way to go, but he's a Dr right? Anyway, the CAs have gone up a little bit and the others are the same. My body must not have needed that extra pressure because it never went above 17, and then only a few times. I am seeing the ENT next week, and I'm wondering what if anything I can sugggest to get a handle on the high overall AHI, as well as reducing the CAs in particular. If anyone has any ideas about using a different machine or maybe having a proper titration sleep study (I didn't get titrated when I had my sleep study due to insurance screwing it up), I'd be open to about anything now. I know this won't be an overnight fix for me, but I'm going in the wrong direction at this point. Thanks in advance!

Greg

If I am reading this right, you are saying that you have about 25 events during the night with about 50% (12) being centrals.
25 events with 7 hours of sleep leaves you with an AHI of about 3-4 which is not unreasonable for just 2 weeks. Even 12 centrals (or about 1-2 an hour) is not unreasonable. The most common central apneas come when you are trying to get to sleep or just before you wake up. These do not present a problem. The problem centrals are when you get lots of them in clusters every night. Pugsy is right...you need to show us what your data looks like.

[avi123]

And I am glad to know that Avi is back to putting words in my mouth that I didn't say again. Way to go grumpy.

There are lots of dumb people in and around SNTL!

[LSAT]

And I am glad to know that Avi is back to putting words in my mouth that I didn't say again. Way to go grumpy.

There are lots of dumb people in and around SNTL!

You are proving that there are some on this board also Avi.

[BlackSpinner]

Greg, you need to show some graphs showing the pattern of those CAs to get an idea what problem could it be if any.
I would not be surprised to find in Mo someone like this one: "After reading on this board that increasing pressure was a great way to increase Central apneas, I didn't think this was a great way to go, but he's a Dr right?", sorry Larry Swedroe, but you're a NewYorker from thee Bronx, and also you're a financial advisor and not a Doc.

Did you forget your meds again, Avi?

[chunkyfrog]

Am I going to have to put you kids in "time-out?"

[Pugsy]

Now I remember you. Ugly report. Do all your reports look like this?
Only thing I can think of that you might do that might help is increase the minimum pressure to see if the centrals go away with the reduction in OAs thinking the centrals might be post arousal centrals...and that's a big if. I have seen it happen...prevent the OAs and the CAs go away but I can't promise that would happen in your situation.
I really think you need to get in to see a real sleep doctor who understands centrals and obstructives and pressure...and not be reliant upon an ENT doc with no experience with OSA or possible complicating factors (if those centrals are the real deal) who is relying on DME person who suggested increasing the maximum pressure (which was pretty much a useless suggestion BTW).

viewtopic.php?f=1&t=93916&p=867296#p867296

[avi123]

Greg, I would look for a sleep Doc at the Washington University in St Louis

I like this Doc b/c he holds both MD and Phd:

John Zempel, MD, PhD


http://wuphysicians.wustl.edu/physician ... ysNum=3102

Neurology / Pediatric


{if it bothers you that he also deals with children then call him and ask for a Doc similar to his qualifications for yourself.}

Current Position
Associate Professor, Neurology and Pediatrics
Division of Pediatric Neurology
Director, EEG Laboratories, St. Louis Children's Hospital

Specialty Areas
Pediatric Neurology
EEG
Pediatric Epilepsy
Sleep Medicine

Patients Seen At

St. Louis Children's Hospital
One Children's Place, Suite D, Floor 2
St. Louis, MO 63110
314-454-4089
Fax: 314-454-4225
Mailing Address

Department of Neurology
Washington University School of Medicine
660 South Euclid Ave.
Campus Box: 8111
St. Louis, MO 63110

Areas of Clinical Interest Epilepsy in children, autism, pediatric sleep disorders, Landau-Kleffner syndrome.

Board Certification
Child Neurology -- Certified
Neurology -- Certified

Medical Education

B.S. : Molecular Biology, University of Wisconsin-Madison, Madison, Wisconsin, 1985
Medical Degree: Washington University School of Medicine, St. Louis, Missouri, 1995
Ph.D.: Neurobiology, Washington University, St. Louis, Missouri, 1995
Residency: Pediatrics, St. Louis Children's Hospital, St. Louis, Missouri, 1997
Residency: Adult Neurology, Barnes-Jewish Hospital at Washington University School of Medicine, St. Louis, Missouri, 1998
Residency: Child Neurology, St. Louis Children's Hospital, St. Louis, Missouri, 2000
Fellowship: Pediatric Epilepsy, St. Louis Children's Hospital, St. Louis, Missouri, 2003
Hospital Affiliations
Barnes-Jewish Hospital
St. Louis Children's Hospital

Honors and Awards

Listed in Best Doctors in America, 2011-2013 (Best Doctors, Inc.)

{this means that Dr Zampel has been voted by his colleagues MDs as "best" in his field throughout Mo, I think}


Publications:

skip

p.s. Greg, thanks for making me take the time to find this Doc b/c I have two teen grandchildren living in St Louis

More:
http://sleep.wustl.edu/faculty-staff/

I can't believe it that a Doc who graduated from Harvard Medical School went to STL:

Brendan Lucey, MD

Instructor, Neurology
Fellowship: Clinical Neurophysiology/EEG, Harvard Medical School, Boston, MA
Board Certified: Sleep Medicine, Neurology and Clinical Neurophysiology

[pbriggs]

very interesting thread for sure in my opinion....

As I look at my history -
I started with a loaner machine while they ordered mine - the loaner was a System One RemStar BiPAP Auto with Bi-Flex (750P). I used this machine for 10 days. The settings were IPAP 25 and EPAP 5. During the 10 days my AHI was around 5 every night with a lot of centrals (10-20) and a few obstructive (4-6) with a hypopnea count of 15-30. Looking at the data is shows pressures in 9-10 rage for IPAP with the max in the 15 range.

My machine is the System One RemStar BiPAP Pro with Bi-Flex (660P) using this now for ~120 days. my AHI is around 1 and typically well under 1 every night. My pressure setting is IPAP 14 and EPAP 10.

So, in my case - changing from the Auto to the fixed level BiPAP was much better.
Paul

[TheChuckster]

Now I remember you. Ugly report. Do all your reports look like this?
Only thing I can think of that you might do that might help is increase the minimum pressure to see if the centrals go away with the reduction in OAs thinking the centrals might be post arousal centrals...and that's a big if. I have seen it happen...prevent the OAs and the CAs go away but I can't promise that would happen in your situation.
I really think you need to get in to see a real sleep doctor who understands centrals and obstructives and pressure...and not be reliant upon an ENT doc with no experience with OSA or possible complicating factors (if those centrals are the real deal) who is relying on DME person who suggested increasing the maximum pressure (which was pretty much a useless suggestion BTW).

viewtopic.php?f=1&t=93916&p=867296#p867296

Increase the min pressure, and set the max pressure to the highest it can go. There shouldn't be a cap at 15; you can see in the graph that the machine needs to raise the pressure even higher than that to treat the OA/CA cluster, but it is "clipping" at 15, and so treatment is ineffective. I'm inclined to think that the CAs are actually miscategorized OAs or post-arousal OAs, but I would check for central apnea in a sleep study -- I've never seen them that frequent before in a graph, and so maybe an ASV will kill them all off. It even looks like a min pressure of 13-15 or even higher is necessary here.

[Pugsy]

Increase the min pressure, and set the max pressure to the highest it can go. There shouldn't be a cap at 15;

Until I know for sure if the centrals seen are related to pressure itself (CompSA) or maybe post arousal centrals....I don't normally suggest increasing the maximum when I see reports like this.
If we do have Complex Sleep Apnea involve here...it's pretty ugly and letting the machine go with higher pressures to threat the obstructives (and yes it definitely wants to go there) might make the Comp SA (if that is what is going on here) much worse so I prefer a more conservative approach myself.
If Comp SA is involved here...APAP isn't the best way to go anyway and sure not with a wide range...maybe a really tight range might work..or something that mimics cpap mode.

I think the doctor needs to be aware of what is going on...that's my first recommendation.
My second is simply try more minimum and cross our fingers that the Centrals will go away because they are arousal centrals related to the obstructive apneas or hyponeas. If we reduce the OAs and hyponeas and centrals still look ugly then we pretty much know that we are looking a CompSA here and one of those high dollar ASV type of machines is indeed going to be needed.
Looks like substantially more minimum is likely needed for those OAs and hyponeas....but I would cap the maximum until if and when I saw them trending downwards in numbers with the hopefully reduction in the obstructive components we see here.
My gut tells me that this isn't going to be so simple...and that's why my first recommendation is "get the doctor involved". Since follow up appointments are not something we can normally make and be seen sooner than later...maybe use the waiting time to try more minimum pressure just in case we get lucky...and maybe that follow up appointment won't be needed. That's a real big maybe though.

[avi123]

Greg, you are facing here medical advice offered by laymen that seems to be as given by Physicians. Having those many CAs could indicate serious medical conditions such as cardiac impairment, CO2 body/lung receptors malfunction, etc. Only EEG equipment results, read by qualified neurologists who are also certified in Sleep Medicine, could tell if these CAs are true and they indicate pathology. Home CPAPs can't do it. Also, most Sleep Clinics and regular Sleep Docs are not to be trusted when it comes to ASV machines territory. You need to take action and select reputable physicians in the field and be checked by them ASAP.

Example:
Rachel Darken, MD, PhD
Assistant Professor, Neurology
Fellowship: Neurology, Washington University School of Medicine, St. Louis, MO
Board Certified: Sleep Medicine and Neurology