ASV vs CPAP - and the winner is...

[Pugsy]

I just had another sleep study. They called me and told me I will be getting an asv machine. Does this relate to what your talking about. What is eers?

Benny your primary diagnosis should have been central sleep apnea because you had too many centrals on your first diagnostic sleep study. Your obstructive apnea numbers weren't even enough to earn you a sleep apnea diagnosis if your centrals hadn't been there. Your centrals were too high even without a cpap machine.
Some people have centrals pop up only after cpap pressure is started (complex sleep apnea) but you weren't one of those people. Regular cpap/apap/bilevel pressures weren't/can't ever address your issue.
Your diagnosis shouldn't ever have been OSA ...IMHO...it should have been CSA (Central sleep apnea).

[jnk]

"Treatment" of centrals can often be an inexact science for anyone, I think:

"Much of the evidence comes from investigations on CSAS related to congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well."--http://www.aasmnet.org/Resources/Practi ... rs/CSA.pdf

Treating the condition that is causing central sleep apnea can help manage symptoms. For example, if central sleep apnea is due to heart failure, the goal is to treat the heart failure itself. Devices used during sleep to aid breathing may be recommended. These include nasal continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) or adaptive servo-ventilation (ASV). Some types of central sleep apnea are treated with medicines that stimulate breathing. Oxygen treatment may help ensure the lungs get enough oxygen while sleeping. If narcotic medicine is causing the apnea, the dosage may need to be lowered or the medicine changed.--http://www.nlm.nih.gov/medlineplus/ency ... 003997.htm

[Pugsy]

Treatment" of centrals can often be an inexact science for anyone, I think:

My comments about cpap/apap/bipap not helping centrals were directly related to Benny and his Central Sleep Apnea...he doesn't have CompSA that I could tell from his sleep study results. Not enough obstructives even on the diagnostic sleep study..8 over the entire sleeping period which was around 6 hours if I remember right.

But yes...cpap/apap/bipap can sometimes be made to work when CompSA is involved. If that fine line can be found that prevents the OAs and doesn't promote the centrals. Some people are lucky and can find that fine line and use it with just a plain cpap machine or maybe the body finally adjusts and the centrals go away on their own.

Benny has been using a bilevel pressure machine at god awful high pressures (must have been pulled out of some tech's butt) and no reduction in centrals at all (10 to 20 per hour)...and even at minimum EPAP/IPAP no real reduction in centrals.
He doesn't have an obstructive component to his sleep apnea that amounts to anything. His is strictly central sleep apnea from some sort of unknown cause (don't think it has been investigated) as for the past year he has been struggling simply with the wrong diagnosis to start with. The doctor really dropped the ball in this case.
No amount of time on a regular machine is ever going to help Benny. He should have had an ASV type of machine from the beginning.

[jnk]

Generally makes sense to me to try CPAP/BPAP before ASV. In fact, if I understand correctly, insurance may require it for CSA:

"Central sleep apnea may be treated with CPAP, bilevel PAP, or bilevel PAP with a back-up rate or servocontroller features. Prior to initiating therapy, complete facility based attended polysomnography must be performed documenting the primary diagnosis of central sleep apnea (CSA). If central sleep apnea requires pressure therapy and is not adequately controlled with standard bilevel PAP, then bilevel PAP with a back-up rate or a servocontroller feature will be covered upon a demonstration of effectiveness."--http://www.bcbsnc.com/assets/services/p ... evices.pdf

Obviously, though, abandoning a patient with high AHI for months at a time while keeping a patient in the dark is not a defensible strategy for any doc, no matter what the modality first tried.

I do hope ASV does the trick. May not, possibly, depending on whether, or what form of, hypoventilation is a factor.

http://www.ncbi.nlm.nih.gov/pubmed/22923141

You do beautiful work here, my friend.

[Todzo]

I used to think that a tracheostomy was indeed “the ultimate cure” for sleep apnea. But as they related in the commentary[1] that is not the case:

“...central apnea following tracheostomy is well described in severe OSA patients, perhaps suggesting that the mechansim underlying baseline OSA may be a critical varialbe.[10,11]”

[1] Orr J, Javaheri S, Malhotra A. Comparative effectiveness research in complex sleep apnea. SLEEP 2014;37(5):833-834

[10] Fletcher EC, author. Recurrence of sleep apnea syndrome following tracheostomy. A shift from obstructive to central apnea. Chest. 1989;96:206-9

[11] Guilleminault C, Simmons FB, Motta J, et al., authors. Obstructive sleep apnea syndrome and tracheostomy. Long term follow-up experience. Arch Intern Med. 1981;141:985-8


this also shows how things tend to get lost over time

[jnk]

Trache fixes obstruction. But no, it doesn't instantly cure the damage to health caused by years of untreated obstruction.

It is much the same with CPAP. It doesn't magically provide instantaneous perfect health. It only prevents further damage from obstruction and provides the opportunity for healing to begin and for healthier choices to become possible again.

[Sludge]

Benny has been using a bilevel pressure machine at god awful high pressures (must have been pulled out of some tech's butt) and no reduction in centrals at all (10 to 20 per hour)...and even at minimum EPAP/IPAP no real reduction in centrals.
...
No amount of time on a regular machine is ever going to help Benny. He should have had an ASV type of machine from the beginning.

Yet, this was one of his most recent downloads:



The whole ~month wasn't bad:

I had 2 studies the first one was in june. it said that I had an ahi of 110 there were 140 centrals 12 obstructive and 7 hypneas. Desaturation was as low as 80%.

An 86.7 minute "diagnostic sleep study"?

[Todzo]

Trache fixes obstruction. But no, it doesn't instantly cure the damage to health caused by years of untreated obstruction.

It is much the same with CPAP. It doesn't magically provide instantaneous perfect health. It only prevents further damage from obstruction and provides the opportunity for healing to begin and for healthier choices to become possible again.

A tracheostomy moves the air supply point post obstruction indeed. And so changes the gain of the system by removing resistance. Less resistance more gain. With CPAP more pressure more gain.

Both bring central apnea more to be.

[jnk]

. . . tracheostomy . . . central apnea . . .

May unmask, but will not cause.

[Bennnyp]

I'm not exactly following this conversation, but here is last nights data. I hope to get my asv soon. I hope it will help with the centrals. I will say that even though my ahi is high.
since lowering my pressures I feel considerable better. Hmmm.

http://s743.photobucket.com/user/Bennny ... 4.jpg.html

[The Latinist]

I'm not exactly following this conversation, but here is last nights data. I hope to get my asv soon. I hope it will help with the centrals. I will say that even though my ahi is high.
since lowering my pressures I feel considerable better. Hmmm.

http://s743.photobucket.com/user/Bennny ... 4.jpg.html

It's hard to draw much of a conclusion from this because you had huge leaks corresponding to your increased pressure and your main cluster of centrals. Did the centrals cause the increase in pressure and therefore the leaks? Or did the increase pressure cause the leaks which caused the increase in centrals? And whichever started the cycle, if you'd not had the leaks would your BiPAP have kept the centrals under control?

[Bennnyp]

Here is a screen shot with higher pressures and leaks under control.

http://s743.photobucket.com/user/Bennny ... 8.jpg.html

[jnk]

. . . not exactly following this conversation, . . .

Here is my understanding of the conversation as it relates to your therapy:

Pugsy noted that it will be good to see how you do on ASV.

I commented that it also may be a good thing that you tried CPAP and bilevel first, since it is always possible they will do better for some than ASV.

Sludge pointed out that (1) you appear to occasionally have good nights, (2) you already may be getting some benefit from PAP, and (3) your diagnostic study did not have much sleep with which to judge your needs.

My opinion (which I am only stating now for Pugsy and Sludge, in case they care to comment) is that when changes in machine pressure appear to be playing a role in contributing to destabilized breathing during sleep for someone with a tendency for repeating centrals, straight CPAP pressures or straight bilevel pressure may be more useful for night-to-night treatment than running a machine in auto mode.

It is my personal belief that even the newer auto-titrating machines with the supposed ability to discern open-airway apnea from closed-airway apnea can still react inappropriately to a central/mixed event and cause cascading centrals in someone with that tendency. I think autos work better for uncomplicated OSA, myself.

Pugsy's and Sludge's opinions on such matters are more significant than mine, since they have much, much more experience looking at pages full of squiggly lines. I hate squiggly lines. Always have.

[Pugsy]

Edit: See Benny's update later on in this thread.

[jnk]

One big problem with centrals can be the night-to-night variation, I understand. Occasional good nights and occasional bad nights seem to be the rule. The system of a one-night diagnostic study doesn't seem to work so well with people with varying central tendencies, I don't think.

I think a bigger issue than attempting to "treat" centrals is finding the cause, whenever possible. Personally, if I continued to have nights full of centrals, I would be asking my doc whether it would be good to look into why they are occurring. If a cause can be known, that can play a role in treatment choice, I believe.