Cheyne Stokes? or UARS?

[justinjustin]

Can anyone help make sense of this graph? I'm constantly fatigued but my AHI looks good. The MD didn't diagnose me with central apnea.

I'm wondering if something like UARD or CSR is going undetected. Does this sort of graph look normal to everyone?

I've had MMA surgery, Septoplasty, LAUP.

Thanks for any help!

[Julie]

Did they say anything about clear airway (or central) events on your sleep study? Is all this new? And what is a LAUP? Have you had a study since all that surgery?

[The Latinist]

Looks like a typical central apnea, to me. A few in isolation does not constitute CSR, and are probabky no cause for concern.

[mellabella]

Centrals/"clear airway events" are not UARS, and I have UARS and what's happening with your events on this snippet doesn't look like what my problematic patterns look like, for what that's worth.

Check your manual for how your machine determines how to classify events, but in general, machines code events as "clear airway events" when the machine guesses that, instead of an obstruction interrupting airflow, there is no respiratory effort/struggle happening during that period. (How well they do that minus the rest of the monitoring that goes on during an actual sleep study is up for debate, I'm sure.) The "r" in UARS stands for resistance--it means your brain's respiratory drive is just fine but you're struggling (or the brain perceives you are) against a narrowed airway. On waveform data, it looks like flattened/irregular inspiratory peaks, not cessation of breathing. I have UARS, and this is what a "good" epoch looks like for me when I'm not actively struggling (usually during light sleep when I haven't lost much airway muscle tone):



....and this is what UARS symptomatic waveform data looks like for me--notice what happens to the peaks (this is a mild example, but it's what I have on photobucket right now):

[justinjustin]

So, something more like this could be an example of struggling UARS waveforms?

[justinjustin]

Did they say anything about clear airway (or central) events on your sleep study? Is all this new? And what is a LAUP? Have you had a study since all that surgery?

LAUP is a laser UPPP.

No followup study, they just want to go on symptoms, as I've had 3 studies already and won't do another.

The centrals were dismissed as 'everyone gets those' and 'the cpap can sometimes cause centrals'

[Julie]

I'd want to get a referral to a pulmonologist or neurologist who understands and can interpret what's going on, to see what they say about whether you should be on a different machine (what are you using now?), because while e.g. the S9 auto is a good machine and can detect centrals (or CA's), it can't treat them like the Vpap/ASV machines do, and you need to address that asap.

[mellabella]

So, something more like this could be an example of struggling UARS waveforms?

Only your doctor knows for sure. But what I'm seeing here on your graph is just one, max two breaths that might qualify, in isolation--my UARS diagnosis is based on the fact that I have long enough series of restricted breaths (4-5 in a row is typical, on my nightly waveform data--even normal sleepers have isolated, stray "flat" breaths intermittently all night that don't disrupt their sleep) that it wakes me up 40+ times per hour. If you didn't hear about "Respiratory Event Related Arousals" on your sleep lab report, you're probably fine. Note that the part of the breath that indicates resistance is the peak curve.

[Todzo]

I really would like to thank mellabella for the great explanation and example flow wave forms. Yes Upper Airway Resistance Syndrome (UARS) is a fight. The air flow flattens but if you look at the amount of vacuum in the esophagus you would find that each breath shows a bit more vacuum as the event proceeds. Respiratory effort can become great enough to warp the walls of the heart.

Most people think of sleep apnea only as obstructive sleep apnea. However there is a much broader spectrum of causes of apnea. As well the point at which arousal occurs with an event may well change. They are beginning to sort it out[2,3].

What I see in your graphs is a time of great respiration (much breathing) followed by an apnea. When you breath more you also wash out more carbon dioxide (CO2). In the context of hyopcapnic (hypo=low capnic=CO2) central apnea as the CO2 level decreases it goes beyond the “apneic threshold” and so the hypocapnic central apnea occurs.

From the over simplified world of Wikipedia: http://en.wikipedia.org/wiki/Cheyne-Stokes_respiration Cheyne–Stokes respiration and periodic breathing are the two regions on a spectrum of severity of oscillatory tidal volume. The distinction lies in what is observed at the trough of ventilation: Cheyne–Stokes respiration involves apnea (since apnea is a prominent feature in their original description) while periodic breathing involves hypopnea (abnormally small but not absent breaths).

To me it looks like you show both a bit of Cheyne–Stokes respiration and periodic breathing in the flow waveforms provided. Since they did not find central apnea in the original study but we now see indications of it in your flow waveforms you may well be showing signs of CPAP emergent central apnea often known as Complex Sleep Apnea (CompSAS).

In terms of your being “constantly fatigued but my AHI looks good” I am suspicious that this results from two of the nonanatomic causes of sleep apnea[2,3] ganging up on you as you use CPAP. High respiratory control system gain working with low arousal threshold could mean that the times of more breathing brought forth by the respiratory gain issues would cause respiratory effort above your low arousal threshold and fracture your sleep with excessive arousals. In a recent comparison study looking at how CompSAS responds to treatment by ASV vs CPAP[1] they found that at the end of 90 days both arms were essentially equal in the number of arousals with over twenty per hour still in play. Both arms had excessive daytime sleepiness affected only a little by treatment. ASV however did well to severely reduce the hypocapnic central events so probably does better protect the brain.

I have found EERS[4] helpful to deal with this issue.

I and others[5] have found moving vitamin D3 into its active range helpful.

And during my journey away from sleep apnea I have found that I did not know how to eat well or move well. My three years with a dietitian helped start me on my continuing life long journey to eat well. I still strive toward the basic goal of 10,000 steps a day (running about 80% at this time) and do intend to use more personal trainer time as I pursue an active lifestyle. Lately I have been thinking that running, which is known to help with brain development, might well be worth the risks to my knees at my advanced age. By eating well and moving well I hope to promote whole body metabolic health and I can say it does appear to help with my tendency to have centrals emerge as I use CPAP.

hth


[1] Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. SLEEP 2014;37(5):927-934 Related article (commentary):833

[2] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman "Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets", American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004. doi: 10.1164/rccm.201303-0448OC

[3] Sairam Parthasarathy M.D., Emergence of Obstructive Sleep Apnea Phenotyping. From Weak to Strong! American Journal of Respitory and Critical Care Medicine VOL 188 2013
-- critical closing pressure [Pcrit] - Arousal Threshold - ventilatory control Loop gain - and genioglossal Muscle responsiveness. Pcrit, Loop, Arousal, Muscle (PALM)--

[4]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[5]: Those who are working with the D3 hormone (A.K.A. Vitamin D3) (e.g. Dr. Stasha Gominak, Michael F. Holick, Ph.D., M.D., Vitamin D Council) seem to be finding that the very low side of the “normal” range of 30-100 ng/L produces a range of symptoms including OSA, pain, and infection. All believe that a level lower than 50 ng/mL is not good and Dr. Stasha Gominak recommends 60-80 ng/mL for good health. It would probably be wise to check your vitamin D3 levels. See “The Vitamin D Council” for assay details.

[49er]

Looks like a typical central apnea, to me. A few in isolation does not constitute CSR, and are probabky no cause for concern.

Agree with the Latinist. If I remember correctly, central apneas become a concern when you consistently average more than 5 per hour and they are more than 1/2 of the AHI over a period of days.

Of course, please check with your doctor if you have any concerns.

49er

[justinjustin]

[quote="Todzo"]
In terms of your being “constantly fatigued but my AHI looks good” I am suspicious that this results from two of the nonanatomic causes of sleep apnea[2,3] ganging up on you as you use CPAP. High respiratory control system gain working with low arousal threshold could mean that the times of more breathing brought forth by the respiratory gain issues would cause respiratory effort above your low arousal threshold and fracture your sleep with excessive arousals.

Todzo, I'm immensely grateful for your thorough and informative reply. What an eye opener! You clearly have a strong grasp the subtleties of complex sleep apnea and the contemporary research. Are you a sleep apnea respiratory therapist or medical professional? In any case, thank you for taking the time to reply and give me more insight on this condition.

In your opinion, could my non-anatomic features be better served with an oral appliance than a CPAP? I've had absolutely no luck with CPAP and don't know where else to turn. I have a very strong vitamin D3 profile at 90/m ( my physician was impressed) and tried to keep somewhat active at the gym and cycling but they don't seem to resolve the underlying mental fog and fatigue.

Thanks again for your time and thoughtful reply!

Sincerely,
Justin

[49er]

In terms of your being “constantly fatigued but my AHI looks good” I am suspicious that this results from two of the nonanatomic causes of sleep apnea[2,3] ganging up on you as you use CPAP. High respiratory control system gain working with low arousal threshold could mean that the times of more breathing brought forth by the respiratory gain issues would cause respiratory effort above your low arousal threshold and fracture your sleep with excessive arousals.

Todzo, I'm immensely grateful for your thorough and informative reply. What an eye opener! You clearly have a strong grasp the subtleties of complex sleep apnea and the contemporary research. Are you a sleep apnea respiratory therapist or medical professional? In any case, thank you for taking the time to reply and give me more insight on this condition.

In your opinion, could my non-anatomic features be better served with an oral appliance than a CPAP? I've had absolutely no luck with CPAP and don't know where else to turn. I have a very strong vitamin D3 profile at 90/m ( my physician was impressed) and tried to keep somewhat active at the gym and cycling but they don't seem to resolve the underlying mental fog and fatigue.

Thanks again for your time and thoughtful reply!

Sincerely,
Justin

Hi Justin,

Obviously, I am not Todzo but if you have an interest in a dental appliance, you might want to take a look at this study on them:

https://advancedbrainmonitoring.app.box ... 7pjn8s11y4

As you can see, they mostly work for mild and moderate apnea in reducing the apnea range below 5. The adjustable appliances have a better success rate than the fixed ones. There are a few severe ranges that have good success rates.

I would also strongly urge you to visit this forum, http://www.apneasupport.org/sleep-apnea ... n-f20.html and pay particular attention to the posts by sleepdent. This guy saved me big time from making some very stupid decisions regarding dental appliance therapy when I was considering it.

One thing he has constantly stressed is that they work better when your nasal potency is optimized. So if it isn't, that is something you might want to look into.

You might also register for this forum and PM sleepdent so you can ask him about what type of anatomical features would best lead to success with a dental appliance. I can't remember off hand what he has said about that but if anyone knows, he definitely would.

Best of luck.

49er

[patrissimo]

If you didn't hear about "Respiratory Event Related Arousals" on your sleep lab report, you're probably fine. Note that the part of the breath that indicates resistance is the peak curve.

Or perhaps it was one of the many labs that doesn't measure or report RERAs. I've been told by a sleep doctor that RERAs and UARS were made up by Stanford, not real, and most sleep labs don't bother to measure them.

[justinjustin]

If you didn't hear about "Respiratory Event Related Arousals" on your sleep lab report, you're probably fine. Note that the part of the breath that indicates resistance is the peak curve.

Or perhaps it was one of the many labs that doesn't measure or report RERAs. I've been told by a sleep doctor that RERAs and UARS were made up by Stanford, not real, and most sleep labs don't bother to measure them.

Patrissimo!! How are you doing? I read your old thread " UARS, low numbers bad sleep, MMA, now on CPAP" and your experience *exactly* mirrors mine. Your symptoms, diagnosis, frustrations, questioning if it really is SDB, you name it. Identical. I just recently recovered from an MMA and turbinate reduction, yet I'm still heavily fatigued and have an AHI of < 5. My ENT thinks UARS exists and that I have it, but it was never detected on a sleep study. I've tried CPAP, APAP, BiPAP and TAP (oral appliance) and nothing has worked for me.

Did your ASV give you immediately noticeable improvements? Or did you have to use it for a few weeks before you felt better? Did you ever get confirmation of RERAs on a sleep study? Here's a look at my data that DME therapists said 'seems fine'. Does it look familiar?

Cheers,
Justin

[patrissimo]

If you didn't hear about "Respiratory Event Related Arousals" on your sleep lab report, you're probably fine. Note that the part of the breath that indicates resistance is the peak curve.

Or perhaps it was one of the many labs that doesn't measure or report RERAs. I've been told by a sleep doctor that RERAs and UARS were made up by Stanford, not real, and most sleep labs don't bother to measure them.

Patrissimo!! How are you doing? I read your old thread " UARS, low numbers bad sleep, MMA, now on CPAP" and your experience *exactly* mirrors mine. Your symptoms, diagnosis, frustrations, questioning if it really is SDB, you name it. Identical. I just recently recovered from an MMA and turbinate reduction, yet I'm still heavily fatigued and have an AHI of < 5. My ENT thinks UARS exists and that I have it, but it was never detected on a sleep study. I've tried CPAP, APAP, BiPAP and TAP (oral appliance) and nothing has worked for me.

Did your ASV give you immediately noticeable improvements? Or did you have to use it for a few weeks before you felt better? Did you ever get confirmation of RERAs on a sleep study? Here's a look at my data that DME therapists said 'seems fine'. Does it look familiar?

Hey, I'm doing great! Congrats on doing the MMA, it wasn't enough for me but it definitely helped. Kept me going for several more years, but ultimately I needed some form of PAP. I only had a couple good nights in the first couple months after MMA, though, it was definitely a gradual improvement for me. It could well be that MMA was ultimately what allowed PAP to work for me. My pressure (especially for APAP - less so but still somewhat for ASV) limits my therapy, as I get aerophagia at high pressures, yet still have residual SDB at lower pressures, and MMA should decrease needed pressure. I'm actually considering using one of the face remodeling dental devices (Homeoblock or DNA) in the future when finances allow, for additional airway expansion and even better PAP.

I noticed using ASV in the sleep study that my sleep felt noticeably better. It wasn't an amazing improvement by any means, but by then I was amazed by any significant and noticeable improvement! I could feel that I was sleeping more deeply, dreaming more often, relaxing more during sleep. I didn't feel energized the next day like some people say. For both CPAP & ASV, it took months to feel significantly better during the day, it was a very gradual process.

Get endocrine tests to check those possibilities, use PAP for months and see if it does better with MMA added (perhaps TAP as well, some say CPAP/dental can synergize), see if you can get a sleep doctor to prescribe ASV and rent it, and consider flying to see Dr. Krakow. He is very thorough, and has clinical and theoretical experience in a variety of different sleep problems - everything from ASV for UARS to mindfulness for insomnia. I have lots of additional things to follow up on still from seeing him last year, I now feel like I have a solid handle on what additional problems I need to solve, even if other specialists are required to solve them (ie GERD).

Best of luck. It sucks to try to solve a deeply complex ambiguous physical problem which saps your energy, creativity, and bandwidth to solve it.