Cheyne Stokes

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Whiskey1234
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Cheyne Stokes

Post by Whiskey1234 » Fri Sep 23, 2022 4:57 am

I was hoping someone could look at my OSCAR chart from last night and let me know what you think. I felt like I had decent night's sleep, but was kind of freaked out when I looked at the OSCAR chart. I have been on therapy for over a year and had another episode a couple of weeks ago. I think I was dozing off and on during this period as it occurred just after I got up to use the bathroom.


https://imgur.com/HuTf7Lu

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dataq1
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Re: Cheyne Stokes

Post by dataq1 » Fri Sep 23, 2022 6:27 am

Are you seeking a medical opinion or advice?
If so, please read the disclaimer at the bottom of this page to the effect that this website is not intended as a substitute for professional medical advice.
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Pugsy
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Re: Cheyne Stokes

Post by Pugsy » Fri Sep 23, 2022 6:36 am

Some of those flagged events don't look nice and symmetrical like we would expect CSR flagged events to look like.
Makes me wonder if there is a mix of awake/asleep breathing flagging going on here.
If not asleep....doesn't count.

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Re: Cheyne Stokes

Post by Pugsy » Fri Sep 23, 2022 7:02 am

dataq1 wrote:
Fri Sep 23, 2022 6:27 am
Are you seeking a medical opinion or advice?
If so, please read the disclaimer at the bottom of this page to the effect that this website is not intended as a substitute for professional medical advice.
Knock it off.
Your "job" here isn't what you want to make it out to be.

While it may surprise a lot of people ...we are all adults here and we know about the disclaimers....they are everywhere on the web.

Give it a rest...your "job" here isn't to keep beating this dead horse to death with your "warnings"....furthermore continued posting like this will constitute double posting and be promptly removed.

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Whiskey1234
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Re: Cheyne Stokes

Post by Whiskey1234 » Fri Sep 23, 2022 7:20 am

Thanks for the response. This episode occurred after I had awakened and was trying to fall back to sleep. I have an appointment with my sleep doctor next month and will discuss it with him. I appreciate your thoughts on this.

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Re: Cheyne Stokes

Post by Pugsy » Fri Sep 23, 2022 8:10 am

Whiskey1234 wrote:
Fri Sep 23, 2022 7:20 am
Thanks for the response. This episode occurred after I had awakened and was trying to fall back to sleep. I have an appointment with my sleep doctor next month and will discuss it with him. I appreciate your thoughts on this.
Always best to play it safe and talk it over with your doctor if you are seeing a lot of anything unusual on your reports that you can't explain away.

Can't tell for sure but it wouldn't be impossible for that ugliness to be more related to not being full asleep than the cause of not being asleep..
Some of it is obviously not asleep breathing but some of it does appear to be asleep breathing and maybe sleep onset centrals are being shown. So it's really hard to say for sure but since this is a random occurrence I don't know how much of a "problem" it might be pointing to.
Or even if it is a problem or not.

Your doctor may or may not be concerned but he knows your medical history and whether or not this is a concern.

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Re: Cheyne Stokes

Post by lynninnj » Fri Sep 23, 2022 9:06 am

Not questioning you here at all Pugsy-you are so knowedgable that I have little doubt as to the veracity of what you say.

This time however the machine has flagged it as CSR. You are saying, if I am reading you correctly, that while talking to the doctor is important that even tho it is flagged as CSR it may not be CSR? I know the machine flags all kinds of events when we are tossing and turning (SWJ) so I wanted to be clear.

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Re: Cheyne Stokes

Post by Pugsy » Fri Sep 23, 2022 9:27 am

lynninnj wrote:
Fri Sep 23, 2022 9:06 am
This time however the machine has flagged it as CSR. You are saying, if I am reading you correctly, that while talking to the doctor is important that even tho it is flagged as CSR it may not be CSR? I know the machine flags all kinds of events when we are tossing and turning (SWJ) so I wanted to be clear.
Just because the machine flags it as something doesn't mean it is always the gospel. The machines are good but not perfect. They have some limitations and awake irregular breathing is always suspect and a cause for the limitations. Especially noted when someone mentions that they know they were having some "in and out of sleep" going on....and when not all the flagged events look like real asleep events anyway.

Always best to have a chat with a person's doctor about anything out of the norm if it concerns a person.

See below....

This got flagged as CSR/PB as well. Obviously it's not CSR.

Image

And a long way from real CSR like this one.

Image

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Re: Cheyne Stokes

Post by lynninnj » Fri Sep 23, 2022 9:28 am

Thanks Pugsy.

I had a few events this morning that I wonder, are they real even though they are flagged. I hope to continue to learn by reading here so I can more critically evaluate.

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Re: Cheyne Stokes

Post by Pugsy » Fri Sep 23, 2022 9:39 am

lynninnj wrote:
Fri Sep 23, 2022 9:28 am
Thanks Pugsy.

I had a few events this morning that I wonder, are they real even though they are flagged. I hope to continue to learn by reading here so I can more critically evaluate.
Watch the videos here
http://freecpapadvice.com/sleepyhead-free-software
and eventually it will start to sink in.

FWIW....it took me probably 2 years to get sort of comfortable with this sort of evaluation and even now there are times that I am just not so sure.

Start a new thread and post your report in Sleephq and lets look...and you also need to learn to look. Lets not hijack this thread/topic.

But just so everyone knows....just because it got flagged doesn't mean much and in fact means nothing if a person isn't asleep.
Bad, bad case of insomnia on this night below for me....absolutely never even dozed off until past 01:30 but I had a ton of flagged events.
The machine got it wrong. Again....the machine is good but it isn't 100% perfect because it has some limitations.

Image

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Re: Cheyne Stokes

Post by robysue1 » Fri Sep 23, 2022 10:21 am

lynninnj wrote:
Fri Sep 23, 2022 9:06 am
This time however the machine has flagged it as CSR. You are saying, if I am reading you correctly, that while talking to the doctor is important that even tho it is flagged as CSR it may not be CSR? I know the machine flags all kinds of events when we are tossing and turning (SWJ) so I wanted to be clear.
The biggest limitation our machines have is that they cannot tell when we are genuinely asleep, genuinely awake, or transitioning between sleep and wake.

And that data, which comes from the EEG data on an in-lab sleep test, is critically important in determining which events are and are not real events. It's important to realize that wake breathing is much, much less regular than sleep breathing. So no sleep disordered breathing events are scored during epochs where a person is awake based on the EEG data. And the breathing in the transition to sleep does not always happen smoothly, but some sleep onset centrals (which are not scored on in-lab sleep tests as real events) are considered perfectly normal if the breathing resolves into normal sleep breathing relatively quickly as the EEG data indicates real sleep is reached and maintained. But since our machines can't tell when we're asleep and when we're not, they score everything that meets the manufacturer's criteria for scoring an H, an OA, a CA, or a RERA (or anything else the machine scores.)

Another limitation our machines have is that they use puffs of air or pressure oscillations to determine whether our airway is open (central or "clear airway" apnea) or blocked (obstructive apnea). In an in-lab sleep test, the bands and sensors around your chest and abdomen are used to determine whether you are attempting to breath when there is no air getting into your lungs. As a result, our machines are reasonably good, but not perfect in figuring out when an apnea is most likely caused by a blocked airway, but they're not perfect.

Another caution in interpreting machine data is that as much as we think we know about the various machine's algorithms for detecting and classifying events, that knowledge is proprietary and there are differences between how different manufacturers chose to classify particular snippets of "bad breathing."

The upshot of all this is not that we can't trust our machines' data. It's rather that we have to understand the limitations of the data and we have to accept that there's no real statistical difference between a machine scored AHI = 0.5 and a machine scored AHI = 2.5.

And it's also important to note that our machines are great at generating trending data: While the AHI for any given night might not be 100% accurate, if you're seeing bad AHI numbers on most nights for several weeks or a steady increase in AHIs over several weeks or several months, that's significant enough to worry about. Whether that means a trip to the sleep doctor or self-treating by deciding to dial wing is an individual's decision based on just how bad the trending data is.

Finally a note about CSR breathing in particular:

Since real CSR breathing is associated with chronic heart failure, it's important to take into account a detailed medical history of the person whose data you're looking at. If a person has any history of chronic heart failure, then machine scored CSR breathing, even if it doesn't look like a dead ringer of "classic" CSR breathing, is worth bringing up with the cardiologist, particularly if it's hard to dismiss the CSR as "SWJ" because you are pretty sure you were not tossing and turning during the times when the CSR was recorded.

It's also important to remember that the length of time CSR breathing continues is important. A few random minutes of flagged CSR here and there in a person with a healthy heart is not something to get overly concerned about. Long periods of CSR breathing night after night for a week or more when you think you're sleeping well needs to be investigated regardless of your heart health. But what "long periods of CSR breathing" means is somewhat in the eye of the beholder, particularly if you see it on most nights.
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Re: Cheyne Stokes

Post by Miss Emerita » Fri Sep 23, 2022 11:14 am

A note on terminology. "Periodic breathing" is a general term that includes CSR as well as non-CSR patterns. The machine's algorithms can't distinguish between CSR and non-CSR patterns; they can only spot the presence of periodic breathing of one sort or the other. For that reason, the label "CSR" is misleading.
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Re: Cheyne Stokes

Post by robysue1 » Fri Sep 23, 2022 12:50 pm

Miss Emerita wrote:
Fri Sep 23, 2022 11:14 am
A note on terminology. "Periodic breathing" is a general term that includes CSR as well as non-CSR patterns. The machine's algorithms can't distinguish between CSR and non-CSR patterns; they can only spot the presence of periodic breathing of one sort or the other. For that reason, the label "CSR" is misleading.
You are right, "Periodic breathing" (PB) is a general term that includes both CSR and non-CSR patterns. I don't know if/how Resmed machines flag periodic breathing. I do know that on PR machines, periodic breathing patterns get flagged as CSR only when the PB pattern is at least somewhat pronounced and lasts for at least a couple of "periods". But quite frankly, PR ought to call it PB instead of CSR.

Basically a PR machine typically flags something as CSR only when there is some kind of waxing/waning pattern over at least a few minutes. But whether that flagged CSR pattern is actual, genuine periodic breathing of any type is another question altogether.

True CSR breathing is associated with congestive heart failure and has specific characteristics. So if you have been diagnosed with congestive heart failure, it's worth talking to your cardiologist about what true CSR breathing looks like and it may be worth investigating any stretches in your data that are flagged as CSR by your machine, particularly if they are frequent (occur on most nights) and are prolonged (last more than a few minutes).

It's also worth pointing out that for folks who are diagnosed with Central Sleep Apnea (CSA), the dysfunctional CO2 overshoot/undershoot cycles (with the CAs at the nadir of the cycle) can be flagged as CSR on a PR PAP machine: The overshoot/undershoot cycle is, in fact, a form of periodic breathing, but in CSA the problem is not necessarily related to heart disease. It's also worth noting that controlling genuine CSA is more difficult than controlling OSA and many (most) people with CSA will need a much more expensive machine than a simple APAP or even a simple Auto BiPAP.

It's also important to remember that PR machines also score something that PR calls Variable Breathing and that there's a big between Variable Breathing (VB) and periodic breathing that gets flagged as CSR on a PR machine.

The PR machines score VB (Variable Breathing) much more frequently than they score CSR and these VB periods do not necessarily display any kind of distinct waxing/waning pattern. In other words, VB can be scored simply because the breathing is indeed variable---the inhalations and the exhalations are simply not nice and regular and all about the same size. (It is also possible for a PR machine to flag a given stretch of breathing as both VB and CSR.) Apparently, based on something rubicon posted not too long ago, VB is one of the things the PR auto machines use to decide both how and when to change the pressure.

Here's a zoomed in snippet of some breathing my PR Dreamstation AutoBiPAP flagged as "VB" last night shortly after I turned the machine off and back on after a middle of the night wake:
Image
The flagged VB section of breathing is in the red box. You'll notice there's nothing "periodic" about this breathing at all.

Here's another zoomed in snippet of some breathing my BiPAP also scored as "VB" last night that has just a vague hint of some periodicity in it:
Image
I'm pretty sure I was asleep during this time frame, although I did wake up about 3 minutes after this stretch because I turned the machine off and back on around 5:18. I suspect, based on my husband's sleep patterns that he was either getting out of bed to go to the bathroom or getting back in bed after going to the bathroom during this time frame, and I suspect that's what probably woke me up. But I don't remember the wake and hence I'm not worried about trying to figure it out.

The upshot of all this is:

For an average PAPer with a simple diagnosis of OSA and who knows they don't have congestive heart failure, there's no good reason to worry about either VB or CSR/PB being scored on your machine if the CSR/PB stuff doesn't last for very long and/or only occurs now and then.

For a PAPer who has a diagnosis of congestive heart failure, it's worth looking at anything scored as CSR/PB that is prolonged or frequent just to see whether it has the characteristics of real CSR breathing. And if it does, that may be worth mentioning to your cardiologist.

For a PAPer who has been formally diagnosed with CSA, it's worth looking at anything scored as CSR/PB in conjunction with when the CAs (and Hs) are scored on your machine. And if it's frequent problem that lasts for significant periods each night, you need to let your sleep doctor know about it. And if you're not already using a machine that is designed to treat CSA, it's time to start asking questions about why not.
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Re: Cheyne Stokes

Post by dataq1 » Fri Sep 23, 2022 8:37 pm

robysue1 wrote:
Fri Sep 23, 2022 10:21 am

... we have to accept that there's no real statistical difference between a machine scored AHI = 0.5 and a machine scored AHI = 2.5.
Agree with every thing else you wrote there, but did you mean to say 'statistical', or did you mean to say 'practical' ?
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Re: Cheyne Stokes

Post by lynninnj » Sat Sep 24, 2022 8:34 am

Thanks for the excellent explainers.

Appreciate the time taken.

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