Recognizing Central Apneas

Snoredog, thanks!! I will try straight CPAP at 9. You're right, I don't have a full mask, it's the Mirage Activa and F&P 405. However, I don't typically have large mouth leaks, here's why:

1. I have been using an oral dental appliance (most of the time) which really keeps my mouth closed. Lately, I have not been using it. The daily graphs via Encore Pro show low leakage, 30-35. Rarely, does it go above 75. Occasional rises are seen but they are usually due to my mask coming apart or me tugging on it, or even removing it. I have found the software can be somewhat skewed in this regard.

2. While the MAX leak is high, largely due to me removing the mask or the hose coming loose from the mask, the 90% mask leak is consistently around 35. I have been told that is good and it's normal?

In the link below, I was not wearing the Oral Appliance, so there was above average snoring going on but the leak shown is typical, while the lack of big concentration of OA during the early hours is NOT typical (usually it's much higher), yet the AHI is high:

http://img187.imageshack.us/img187/1564 ... 013ek5.jpg

Based upon this other information, do you still think there are no or few centrals happening?

christinequilts wrote: On the few occasions I've woken up during a central event, breathing is the last thing on my mind; I start going through the checklist of 'why the heck am I awake?'...cats aren't running laps on my bed, don't have to pee, nothing hurts or feels funny, no dogs barking, TV not on, no alarm clock going off, not too cold, not too hot, no thunderstorm, etc. By the time I get through all the possibilities, I know several breathing cycles have taken place, as I've heard my BiPAP ST switching from IPAP to EPAP, but, oh yeah, there is something I'm suppose to be doing when it does that, isn't there? Like maybe actually BREATHING the air into my lungs, not just letting it air condition my nose Totally different then all the tension and struggle you feel when you hold your breath for more then one or two breath cycles to simulate a central.

.

This is how I typically get arousals...of course, I don't have a BiPAP ST tellimg me anything. I end up going to the pantry and get something to eat, if it's a week day, my alarm wakes me up and startles me and my heart is racing. Of

Justin_Case wrote:Snoredog, thanks!! I will try straight CPAP at 9. You're right, I don't have a full mask, it's the Mirage Activa and F&P 405. However, I don't typically have large mouth leaks, here's why:

1. I have been using an oral dental appliance (most of the time) which really keeps my mouth closed. Lately, I have not been using it. The daily graphs via Encore Pro show low leakage, 30-35. Rarely, does it go above 75. Occasional rises are seen but they are usually due to my mask coming apart or me tugging on it, or even removing it. I have found the software can be somewhat skewed in this regard.

2. While the MAX leak is high, largely due to me removing the mask or the hose coming loose from the mask, the 90% mask leak is consistently around 35. I have been told that is good and it's normal?

In the link below, I was not wearing the Oral Appliance, so there was above average snoring going on but the leak shown is typical, while the lack of big concentration of OA during the early hours is NOT typical (usually it's much higher), yet the AHI is high:

http://img187.imageshack.us/img187/1564 ... 013ek5.jpg

Based upon this other information, do you still think there are no or few centrals happening?

If you are not breathing through your mouth then it probably wouldn't hurt to try some tape to make sure. Your leak rate is consistently bad, software might be off but not by that much.

Look at your flow chart that came with your mask then at 9.0cm pressure, that is what your leak rate should be and what should be showing up on the reports. Your leak shown on those reports should not be over about 32L/m at that pressure.

Anonymous wrote:
This is how I typically get arousals...of course, I don't have a BiPAP ST tellimg me anything. I end up going to the pantry and get something to eat, if it's a week day, my alarm wakes me up and startles me and my heart is racing. Of

Waking up for no reason at night is not uncommon; there are a lot of things that can wake you up at night that we can't always pinpoint at the time for anyone, with or with out apnea. I gave that example to help illustrate how different a central apnea is from simply holding your breath, as you were questioning why your machine wasn't scoring your breath holding as NR. Your bodies attempt to breath, even though you are not allowing it, is much more similar feeling to an obstructive event then a central event. Even for me, its a very unusual occurrence, happening only a handful of times I've been aware of in the past 3 years I've been on BiPAP ST, even though BiPAP ST isn't fully able to treat my CSA.

I was glancing back through some of your previous post to see if you ever posted results of your original sleep study & titration, but I did see any. It was hard to figure out when you were originally diagnosed and started on CPAP, but I did noticed you mentioned you had went off or changed several medications in a post Sept 9th, the first thread you started about your increase in apneas towards morning:

Justin_Case wrote: This morning, I had big insomnia. I have been on prescription sleeping meds for about 6 months (Zopiclone) and Seroquel for anxiety. With my GP's consent I have stopped both drugs during the last few days. The Seroquel was making my PLMS worse or creating it. It should up as being bad in my initial sleep study without titration but not in my second one. I am now taking LYRICA for the PLMS. I also have a "touch" of asthma.

A few weeks later, you were concerned the increase in apneas was due to your shoulder injury/vacation/chiropractic treatment, but I wonder if the medication changes might have more to do with your increase in AHI & other problems you're having?

I'll ask my DME about the chin strap, but he has said many many times before that I dont have a leakage issue. He never said anything about the OSA in the early mornings except that we need to do another PSG.

Looking at the previous screenshot http://img187.imageshack.us/img187/1564 ... 013ek5.jpg
you should be able to tell that my numbers are within the 30L/m area.

Unless I am mistaken. At any time, the machine will record maximum leak if you take off the mask and don't turn your machine off immediately, that leak will have been recorded and then your numbers will be off, that's why it's important to look at the avg leak as oppose to the maximum leak. As I get up about 4/5 times a night, this maxium leak quickly adds up.

I dont have the paperwork for my mask anymore that indicates the acceptable leakage level, I cant recall if I had it either.

I find this entire thread to be VERY TROUBLING. I don't know whether you are having centrals or not Justin. None of us do, and no APAP can determine that. Respironics machines "guess" that you are having a non-responsive event if a flow degradation doesn't respond to three successive pressure increases. ResMeds don't even attempt to guess. They simply stop titrating when it senses a cessation of flow.

Rested Gal was quite right (as usual). Centrals are measured during PSGS by the exertion belts around your chest and abdomen. If you stop breathing while asleep, and you chest and belly are NOT moving, it means that your brain isn't sending the signals to your musculature to create the volume changes that cause breathing. If you are having obstructive events, your chest and belly will move, but the air can't get in because your upper airway is collapsing. Sort of like a straw that you try to suck through while you plug the distal end.

The problem is that excessive centrals are SERIOUS and are often a sequellae of other serious problems, either cardiological or neurological. The occurence of centrals is often associated with heart-failure, and are thought to be caused by defects in the way that your body "triggers" to carbon-dioxide leves.

Now, like I said, I don't know whether you're having centrals or not. Most of us experience an increase in SDB events in the early morning hours when we spend most of our night's time in REM sleep. SDB events happen most often in REM. But, that doesn't mean central events. Normal REM sleep is associated with a relaxation (almost a para-paralysis) of musculature to prevent you from injuring yourself if you were to have movements associated with vivid dreams. And that contibutes to obtsructive events; the musculature becomes so relaxed that it allows your upper airway to collapse more.

However, this is way TOO risky for you to rely on the advice offered here. ANY of it. STAY with the therapy settings prescribed by your sleep doc. If you are experiencing disordered sleep, or AHIs consistently > 5.0, PLANT YOURSELF AT YOUR SLEEP DOC'S OFFICE MONDAY MORNING and don't leave until you get an answer that you trust.

Absent a direct EXAMINATION of you, and adequate training and experience to conduct and evaluate that examination, NONE of us can or should be offering you advice on your settings.

Please Justin, DON'T mess around with this, and don't listen to us.

BE CAREFUL!!!

Chuck

Thanks Goofy!

Snoredogs recommendation was not that far off from my sleep doc. At my last visit, he said 10-12/13 is in using auto. At my titration I was at 12 but with only a few residuals of hypos. He does not like auto machines.

My sleep doc has had a lot of complaints about his demeanor and attitude...frankly, he is an arrogant SOB. He said to ignore all my software and dont look at my AHI, just continue with the treatment. He also relucatantly agreed to another PSG. He said there is no correlation with any neurological conditions and apnea...and I think to myself, what the heck is a central apnea then?

Even if the software is off, it's still telling me that my AHI is consistently over 5, of course my sleep doc says that's wrong....the machines' data is wrong because it didnt come from a sleep lab.

Christina, I was diagnosed about 3 years ago. Tried CPAP at first, didnt work, tried different machines, too a long time, couldnt get use to it. Finally tried an oral appliance last year, January. Seemed to help a bit, but not really....anxiety issues developed, fragmented sleep, poor memory, lack of concentration.

Then, this April, after having a few panic attacks I went and tried CPAP again. This time was tolerating quite well, until recently and the machine I was using started getting louder.

Like Chuck, I too find this thread very troubling.

Justin_Case wrote:Even if the software is off, it's still telling me that my AHI is consistently over 5, of course my sleep doc says that's wrong....the machines' data is wrong because it didnt come from a sleep lab.

There is abolutely nothing consistent about the data you have presented, Justin. You are not getting the treatment prescribed by your doctror, because you are switching your machine back and forth on a daily basis. The software is not "off". The treatment is.

The only occasions on which your data is beneath 4 are actually those where the pressure has been close - in both upper and lower limits to what the doctor described.

I wouldn't plant myself at the doctors office with those data because there is nothing the doctor can do with them.

Justin_Case wrote:Therefore, in addition to my nerve issues, it is my belief that I am having centrals around 5AM onwards. This, I believe will be difficult to prove since I am kicked out of bed at the sleep lab around this time and my opinionated and arrogant sleep doc won't allow me to have an extended session by staying longer.

If I understand you correctly, Justin, you are convinced you have central apneas, which appear in the early morning, convinced there were mistakenly not identified in previous PSGs and convinced they will only be discovered if the sleep lab lets you sleep till about 10 AM.

I hope you will eventually find a doctor and lab whose diagnosis and recommendations you trust.

O.

ozij wrote: If I understand you correctly, Justin, you are convinced you have central apneas, which appear in the early morning, convinced there were mistakenly not identified in previous PSGs and convinced they will only be discovered if the sleep lab lets you sleep till about 10 AM.

I hope you will eventually find a doctor and lab whose diagnosis and recommendations you trust.

O.

That's almost dead on, but not quite. I don't believe I was mistakenly not identified earlier (two years ago) but I know things have changed since then... things have changed quite a bit from my injury to my shoulder area from two months ago. There was a marked increase in OSA during chiropractor care and immediately following injury.

Nobody [from the medical community] has come forth with any explanation one way or another as to why my OSA events are so high in the morning with my current treatment. One thing that is almost certain is that I am not a mouth breather when sleeping, at least not when I am using my oral appliance.

The info provided to me here is fantastic and it's better than what I have received anywhere else. In fact, I went to see my GP the other day and I had an appointment already set up from over a week ago. I had to wait for over 8o minutes to see the doctor and the waiting room wasnt crowded either. I cant help wonder if this was deliberate. This is the kind of BS I have to put up with, so my faith in the medical profession is almost non existent.

Bottom line is I am not getting any answers only more and more questions and frustrations...they tried to shut me up with anti-depressants but that only gave me RLS.

You spend more time in REM during the early morning hours, as a result of that you will experience more SDB during those same hours. Don't be so quick to discount those leak rates unless they all start to look like the report below.

Leak rates on your last EncorePro report below look great:
http://img187.imageshack.us/img187/1564 ... 013ek5.jpg

But the prior ones from the Bipap reports are terrible and I don't see any data errors as a result of that. If the leak on those went over 75L/m you might as well toss out that data (probably what your doctor may have been trying to say about the reports).

But what we do know is the Bi-pap reports do show NR events, looking at other aspects taking place at the same time, they are indicative of pressure induced centrals. Your EncorePro reports also confirm this. Last EncorePro report above shows pressure induced central logged as a NR event in therapy hour 7.5.

If you look at that time frame you will see a series of 4ea obstructive apnea, then the NR is tic is shown above that. This means machine seen & logged those 4 events as obstructive then realized after they didn't subside that they were a NR event or did NOT respond to prior pressure increases.

One way to spot those is when you see a series (tics become solid instead of individual ticks). The same thing appeared on Wally's Bi-pap EncorePro report, it also was logged as a NR event.

The NR events are shown. Next you look at what was pressure doing during that same time frame: If you look at that same report you see your Max. pressure was set to 13.0cm. During that series of OA events, pressure went to the Max. 13.0cm setting for 2-minutes. It is even shown in the report at the bottom, with a AI index of 90.0. It did NOT see 90 events, it calculated "daily events per hour" or what it would be if it went at the current frequency for 60 minutes. It only stayed at that pressure for a total of 2-minutes, then you woke up and stopped treatment. I bet that event was what woke you up, because that is what they usually do, wake you.

If the machine sees an obstructive apnea it should increase pressure by .5cm. If it does that 3 times in a row or increasing by 1.5cm it should level off with pressure and pause, if the events continue or increase the machine realizes those events it increased pressure for were most likely central events, it then drops pressure and logs the NR event. NR=Non Responsive event, meaning it did not lessen in frequency to prior pressure increases. NR events on Remstars are most likely central events.

A few posts here want to suggest and confuse Cheyene-Stokes respiration and CHF with pressure induced centrals. This person couldn't identify their own condition when it was explained to them and now wants to suggest your options. As I see it there is a big difference between CSR and this discussion . CSR can happen weather you are on a machine or not. There is a clear and distinct pattern the machine is the cause of those NR events.

Then they suggest not taking any advice, from them I'd have to suggest the same. Fact is I see no difference between this thread and the Apnea vs. Hypopnea thread, maybe we should have told that person to go see his doctor in that one, he'd still be wondering around aimlessly. If that is all they can suggest they should head over to TAS and argue with lunatic over there, a match made in heaven as I see it.