Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
R3LOADED94
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Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by R3LOADED94 » Thu Aug 05, 2021 12:35 am

26 y.o. male. 160lb
Over the past year I have noticed my sleep is not as restful and generally tired. My AHI after starting CPAP for almost a decade was very low (Pressure ~10) and feeling good. Last year I was put on an APAP after not feeling well rested on CPAP.
I started looking through my data the past year and have 2 concerns;
Rising AHI (Centrals & hypopneas) and possible periodic breathing

Rising AHI
My AHI has risen to about 4 with frequent days >5 and the higher the number the worse I feel next day. Mostly Centrals and Hypopneas
Hypopneas: They always come with a flow limitation (pics incl). I noticed a good portion of them are preceeded with erratic breathing, I think these are from rolling onto my stomach after filming myself one night and with movement data. Can these be anything else? (Pics included)
Centrals: Always show up when falling asleep or before waking, some during the night. A decent amount come in clusters (pic incl)
(Pics included)
Periodic breathing:
I noticed my flow rate doesn't look like normal data and has a periodic pattern (sometimes more sometimes less pronounced). Rarely do the valleys reach zero but the pattern is visible alot. A couple times the pattern had central apneas at the nodes back to back but its rare.
(pics included)

Is this periodic breathing? Anyone have an idea whats going on and what can be done to help reduce my AHI and feel better rested?

PICS OF ALL EVENTS: https://imgur.com/gallery/ECO9qN8https: ... ry/ECO9qN8

APAP 10-11.6 (For Her Algorithm)
EPR Off
Airsense 10 with Amara View Full Face (mouth breather)
SPo2 avg ~96 most of the night

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Julie
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Julie » Thu Aug 05, 2021 4:35 am

That link doesn't work.

The 'centrals' you worry about are common at the times you get them and aren't true centrals - we call them sleep-wake junk and shouldn't be too concerning unless you get very many throughout the night.

Post Oscar results in this thread so we can see what's really going on.

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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Pugsy » Thu Aug 05, 2021 9:03 am

As Julie says....your link to your images is broken so we can't see them.

You can post them via the attachment feature available here on the forum for immediate viewing as long as the file size is less than 1 MB.
Then you don't have to use imgur to hose your images.

Periodic Breathing is nothing more than a waxing and waning of the air flow (breathing) that lasts at least 2 minutes.
It's not necessarily something bad and the only real PB that docs worry about is the Periodic Breathing which constitutes Cheyne Stokes Respiration and there has to be a lot of it.

This is PB....but it's what I call plain ordinary PB....means nothing.
Image

This is Cheyne Stokes Respiration....huge difference
Image

and what real CSR looks like on an OSCAR report from someone who has a documented for sure problem
Image
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Dog Slobber » Thu Aug 05, 2021 9:43 am


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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Morbius » Thu Aug 05, 2021 9:47 am

Beat me to it. OP just duplicated or triplicated the address.

https://imgur.com/gallery/ECO9qN8

SWJ and little sleep-onset central crap.
ogl0EFX.png
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Pugsy » Thu Aug 05, 2021 10:02 am

Dog Slobber wrote:
Thu Aug 05, 2021 9:43 am
Proper link:

https://imgur.com/gallery/ECO9qN8
Thanks DS.

To OP....what you zoomed in on isn't PB. It is just normal irregular breathing most likely from being awake or semi awake.
Other than evidence of not being asleep...doesn't mean anything at all and nothing to worry about.
The one CA/central is likely a sleep onset central and normal and no big deal.
SWJ...sleep/wake/junk

What I call false positive flagging. Remember the machine only measures air flow and it often will mistake awake breathing irregularities as some sort of apnea event and flag it as such and even respond as such. Other than evidence of not being asleep it doesn't mean much of anything. If you see much of it it means sleep quality itself isn't so great.

Here's an example I like to use to show asleep breathing vs arousal/awake breathing. The asleep breathing is circled in red.
Image

And a more zoomed out picture of same time frame. Everything flagged after the circle is related to not being asleep and despite it being ugly and flags all over the place. If we aren't asleep...it doesn't count for anything other than not being asleep for some reason or other.

Image

And here is a real asleep flagged OA. Note the very regular and rhythmic breaths/flow rate.

Image

Edit...I see Morbius chimed in...real expert instead of wannabe expert. :lol: :lol: I went to a lot of trouble posting examples and all that so will leave it up.
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Morbius » Thu Aug 05, 2021 10:10 am

Pugsy wrote:
Thu Aug 05, 2021 10:02 am
I went to a lot of trouble posting examples and all that so will leave it up.
Absolutely, great examples and explanations.

R3LOADED94
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by R3LOADED94 » Tue Aug 10, 2021 8:09 pm

Thanks for the great info everyone. Some questions;

-Should I be increasing my min pressure to closer to my Med pressure of 11.5? Currently min at 10
-Any tips to how I can reduce my arousals?
-Are there signs in my data of a CO2 driven breathing/washout?

I find that smooth regular flow pattern of being asleep is becoming less and less nowdays in my data. Less of this pattern, the worse I feel the next day. I'm usually asleep the first 3 hours (once I finally fall asleep) but after that I wake up alot. Doctor put me on Zopiclone (Lunesta) for the insomnia and arousals but I try to limit my self to a couple times a week so I don't get dependant on it to sleep. Any tips/suggestions are appreciated fellow pappers

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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Julie » Tue Aug 10, 2021 8:59 pm

Maybe I missed it, but is there a reason your max setting's so low? They're far more commonly left at 20, or at least 15=18. so leaving it low prevents it from rising when needed... and blocks the min pressure from rising too (and it's 'the' one that really does the job of lowering apneas and/or hypops).

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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Pugsy » Tue Aug 10, 2021 9:21 pm

R3LOADED94 wrote:
Tue Aug 10, 2021 8:09 pm
Thanks for the great info everyone. Some questions;

-Should I be increasing my min pressure to closer to my Med pressure of 11.5? Currently min at 10
-Any tips to how I can reduce my arousals?
-Are there signs in my data of a CO2 driven breathing/washout?

I find that smooth regular flow pattern of being asleep is becoming less and less nowdays in my data. Less of this pattern, the worse I feel the next day. I'm usually asleep the first 3 hours (once I finally fall asleep) but after that I wake up alot. Doctor put me on Zopiclone (Lunesta) for the insomnia and arousals but I try to limit my self to a couple times a week so I don't get dependant on it to sleep. Any tips/suggestions are appreciated fellow pappers
Tips for reducing arousals.....you first have to figure out what might have changed to cause the arousals.
Anything change in your life that might account for the poor sleep quality? Increased pain? Are you still having fibromyalgia issues?

Any special reason you are using the for Her auto mode..and a tight auto adjusting range?
You are hitting your max of 11.6....have you tried higher but had problems with higher?

Have you ever tried the regular auto adjusting mode?

I see no signs of CO2 wash problems. When people have that sort of problem they will usually have a truckload of real asleep central apneas clustered together and your central numbers include sleep onset central and not enough of them to make us worry about CO2 stuff even if all of them were real asleep centrals.
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Djonne » Wed Aug 11, 2021 2:02 am

Wow... your issues seem pretty similar to mine... and you have the same sleep medication (Zopiclone)! For me it doesn't seem to make much of a difference but I'll try it with my new settings on the CPAP. Maybe you could read my thread here : https://www.cpaptalk.com/viewtopic/t182 ... or-me.html

Pugsy has posted a LOT of valuable information on there.. and it really seems like your issues are similar to mine and your auto adjusting CPAP might be reacting to false flags (events that happen when you're semi-awake) and cranking up the pressure when not needed, in turn making your sleep even worse. That's exactly what seems to be happening to me.

R3LOADED94
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by R3LOADED94 » Mon Aug 23, 2021 2:52 pm

Pugsy wrote:
Tue Aug 10, 2021 9:21 pm
R3LOADED94 wrote:
Tue Aug 10, 2021 8:09 pm
Thanks for the great info everyone. Some questions;

-Should I be increasing my min pressure to closer to my Med pressure of 11.5? Currently min at 10
-Any tips to how I can reduce my arousals?
-Are there signs in my data of a CO2 driven breathing/washout?

I find that smooth regular flow pattern of being asleep is becoming less and less nowdays in my data. Less of this pattern, the worse I feel the next day. I'm usually asleep the first 3 hours (once I finally fall asleep) but after that I wake up alot. Doctor put me on Zopiclone (Lunesta) for the insomnia and arousals but I try to limit my self to a couple times a week so I don't get dependant on it to sleep. Any tips/suggestions are appreciated fellow pappers
Tips for reducing arousals.....you first have to figure out what might have changed to cause the arousals.
Anything change in your life that might account for the poor sleep quality? Increased pain? Are you still having fibromyalgia issues?

Any special reason you are using the for Her auto mode..and a tight auto adjusting range?
You are hitting your max of 11.6....have you tried higher but had problems with higher?

Have you ever tried the regular auto adjusting mode?

I see no signs of CO2 wash problems. When people have that sort of problem they will usually have a truckload of real asleep central apneas clustered together and your central numbers include sleep onset central and not enough of them to make us worry about CO2 stuff even if all of them were real asleep centrals.
Hi Pugsy, the past couple weeks I experimented with a few things and also pulled up my first sleep study from 2013.
Ive lost 20-30 pounds this year and eat very healthy which helped reduce the pain alot. I also got a new bed that supports side sleeping more than before. Ive always used the For her mode since thats what the sleep doc prescribed but I did tighten the original 8-15 settings because I was getting aerophagia (I used to eat late before which I stopped so that could be the main reason)
SID sleep study report 2013.zip
(741.5 KiB) Downloaded 1 time
I tried straight pressure for a few days and got decent numbers but I feel better on a 8-12 in regular adjusting mode with EPR 2 Fulltime the past few days with much better SPo2 (Almost zero drops).

Im still struggling with arousals, Its always the same how they show up: 30-60mins of sleep breathing > movement + accompanied with jagged breathing & Pulse rise. Alot of times there are clusters of events (Hypopneas, RERAS, flow limits) after an arousal that then go away after a second movement. Im still baffled for why I go through these arousals/clusters.
Zopiclone does seem to help me not wake up but my data shows just as much arousals, maybe I dont remember them on the medication but it does make me droswy the next day

In a night I seem to get only 4-5 of these steady sleep breathing periods that last 30-60mins max before an arousal comes, the more I get these and longer they are the better I feel. Should the ideal case have these periods last longer or is it normal for sleep to be fragmented this much?

I pulled out my original sleep study from 7-8 years ago and it looks like I have zero obstructive or centrals. Only hypopneas, RERAS and spontanious arousals. Could this info be helpful (study attached).
SID sleep study report 2013.zip
(741.5 KiB) Downloaded 1 time
Welcome to any suggestions. At least now Im not feeling exhausted with my heart ready to explode out of my chest. Havent had a bout of insomnia in a couple weeks but I can feel with these arousals Im only getting 50-60% of my full treatment potential I felt when I started CPAP 7-8 years ago.
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Pugsy » Mon Aug 23, 2021 3:37 pm

I am wondering if your arousals are related to a normal post REM stage sleep arousal.
Google sleep stages and look at when we normally have REM and see if you can spot a pattern.
It is normal to awaken after REM...normally we don't remember it as the time is so brief but sometimes we are awake long enough to form a memory of being awake.
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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by R3LOADED94 » Mon Sep 13, 2021 11:37 pm

Hi Pugsy,

My problem is definitely arousals and I dont notice many true Obstructive or Centrals this past month. Just shitty fragmented sleep. My original sleep study noted this too with only hypopneas + RERAS.

Key point I forgot to mention is when I was a child I had severe asthma, I don't have the best lungs on the market (data shows low to mid 300s tidal volume).
A few months back when the shitty sleep started I had a week where I had severe shortness of breath & a resting HR ~90-100. My doctor thought it was COVID but my test came back inconclusive since it leaked and I was better by the time I got retested as negative so we dont know what happened. A1c blood test for diabetes came as 5.9% which is normal but the max of the normal range before prediabetic, improved my diet.

Over the last few weeks I tried various different pressures and levels of EPR, also tried straight CPAP and analyzed each day after doing research on scoring PSG's.

Last nights settings/regimen gave me the best sleep in weeks!
Changes:
-400mg Magnesium Bisglycinate instead of just 200mg nightly
-Took 3.5mg of Zopiclone (been having to rely on it a couple times a week due to insomnia (sleep onset & after awakenings)
-12-15cmH2O, EPR: Max (3), Regular Autoset Algorithm

TAKEAWAYS FROM THE LAST MONTHS DATA
-Last night I had about 10 arousals I scored (movements with a break in regular flow pattern) out which became 3 awakenings (2 of them to pee which makes me think theres more that can be optimized)
-Sleep Onset looks a bit delayed, but didnt notice personally last night
-Median flow limit only 0.01 last night, usually around .1 to .15 where higher makes me feel worse
-Minute vent improved & stabilized last night, was usually between low 5's to 6. More unstable minute vent the shittier I feel
-I had 2 periods last night where the breathing was erratic/not regular (Ive noticed these periods throughout the past few weeks (the least last night) and during them my heart rate and Spo2 fluctuate)
-The more periods of stable breathing and Spo2/HR I have in the night the better I feel the next day is what I notice in my overall data
-Before arousals many times I notice flow rate shapes with flatter tops or the inhale/exhale bounces. No snores picked up during these anomalies

I uploaded a gallery of last nights data. A closeup of a good normal breathing pattern, all the arousals & the 2 periods of weird breathing (maybe REM?). The description of each screenshot is in the name. All these pictures are from last night

https://imgur.com/a/9DiDEWb

Can you check the screen shots and suggest what I can do to make my therapy better?
Do I need a new type of machine such as a BiPAP (consider lung isses)?
Is UARS a possibility? What should I look out for when looking for UARS?
Any possibility of unknown heart issues causing my sleep issues?
I had some skipped beats while exercising so my doctor ordered a 48hr holter (My BP is normal most days 120/80, 75bpm, but higher on days my sleep is bad)

Sorry for the long post but Ive found alot of useful data this past month!

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Re: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?

Post by Pugsy » Tue Sep 14, 2021 7:18 am

I don't want you to think I am ignoring you by not replying in depth to your questions.
Please read this
https://www.cpaptalk.com/viewtopic/t182 ... yping.html

The short version though is that while it is obvious that you have crappy sleep quality I am not of the opinion that the crappy sleep is from airway issues.

Hopefully the other forum members can chime in.
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