OSCAR chart to grade please? Newguy

I have about 2 months in with a ResMed 11 and currently a F&P Evora full face mask and have really had
very little problem adapting to sleeping with it. I have been battling sleepy/tired/fatigued all this year since
March. First I went to GP and he did a full range of blood/urine tests and I was low on Vit D- started on supplements
[I have taken a men's Multi for years] and I felt great for about a month and then it slowly faded back to previous.
I also did a home sleep study and scored a 59/hour. I finally got in to a sleep Dr and he did a more extensive home
test. Same great score- he prescribed a CPAP and starter pressures. We worked on finding a full face mask that
I liked and very good compliance. He just changed from constant 15# to 12# both with EPR of 2.
AHI hovers around 15 +/- 5. I have been taping my mouth to cut down on leakage [mouth breather] and have started to
wonder about a nasal mask as long as I am taping already and don't have a issue with it.
I was feeling more and more tired and went back to GP and he found I had low thyroid function- after a week on meds
I am feeling pretty good [as opposed to like crap] and now have hope. I am sure I need CPAP but my sleep Doc is pretty
much unresponsive and want to get this worked out with a better therapy program. He will allow me to transfer to a lady Dr in his practice.

I am 76yo and overweight but not [yet] obese- I have loved to work designing and creating things my entire life and this is killing me.
My mind has been so muddled for so long that I need some second opinions on my OSCAR chart please? Thanks Gene[attachment=1]screenshot-20221029-094446-10.27.png[/attachment][attachment=0]screenshot-20221029-094407 closeup 10.27.png[/attachment]

Hello, Gene, glad you've posted these charts. As you can see, most of your events are CAs. In ResMed lingo, this means "clear airway," but for everyone else it means "central apnea."

Whatever the terminology, these are times when you just don't breath for ten seconds or longer. Ordinary PAP treatment is unlikely to treat CAs. It's common for people to have a scattering of CAs during the night, but you're having enough of them to make me want to know more.

Do you have a copy of your sleep study? The big question here is whether you had a high CA index during your sleep study. (A CA index is the number of CAs you had while you were asleep divided by the number of hours you were asleep.)

If you don't have a copy of the study, get one! In the U.S., you have a legal right to it. And if you can, blank out your personal information and scan the study so you can post the scan here.

Turn EPR off or use it during ramp only (and use the ramp) and see what happens.

What altitude do you live at?

Significant time in Cheyne-Stokes. Should this be followed up by professional?

dataq1 wrote: ↑

Sat Oct 29, 2022 12:29 pm

Significant time in Cheyne-Stokes. Should this be followed up by professional?

Good eye.

dataq1 wrote: ↑

Sat Oct 29, 2022 12:29 pm

Significant time in Cheyne-Stokes. Should this be followed up by professional?

Well duh.....did you read what the OP said?

GeneMpls wrote: ↑

Sat Oct 29, 2022 9:03 am

I finally got in to a sleep Dr and he did a more extensive home
test. Same great score- he prescribed a CPAP and starter pressures.........

No one here is telling him NOT to see a professional. He is under the care of a sleep professional....if you call it "care".

We don't know what those centrals are from but there's way too many of them and the only thing that might even remotely reduce them with this machine is turning off EPR and/or giving it time....since we don't know if he had them prior to starting cpap or they popped up as treatment emergent centrals.

Pugsy wrote: ↑

Sat Oct 29, 2022 12:58 pm

dataq1 wrote: ↑

Sat Oct 29, 2022 12:29 pm

Significant time in Cheyne-Stokes. Should this be followed up by professional?

Well duh.....did you read what the OP said?

GeneMpls wrote: ↑

Sat Oct 29, 2022 9:03 am

I finally got in to a sleep Dr and he did a more extensive home
test. Same great score- he prescribed a CPAP and starter pressures.........

No one here is telling him NOT to see a professional. He is under the care of a sleep professional....if you call it "care".

We don't know what those centrals are from but there's way too many of them and the only thing that might even remotely reduce them with this machine is turning off EPR and/or giving it time....since we don't know if he had them prior to starting cpap or they popped up as treatment emergent centrals.

I didn’t notice the CSR til that poster pointed it out. I really should look at oscar charts more than I do to get used to them.

Last time I asked about whether a particular Oscar looked concerning I was treated like an idiot which I am not, and I sure wouldn’t blame a poster for posting as a question.

I know it’s normal to have a bunch of centrals here and there but that breathing pattern always seems to get to me. (rational or not)

It was my limited understanding that there’s often an underlying heart issue at play with CSR? If so that might mean a question for the cardiologist?

lynninnj wrote: ↑

Sat Oct 29, 2022 1:30 pm

I know it’s normal to have a bunch of centrals here and there but that breathing pattern always seems to get to me. (rational or not)

It was my limited understanding that there’s often an underlying heart issue at play with CSR? If so that might mean a question for the cardiologist?

Well....CSR "can" be an alarm for potential heart problems but it isn't always going to mean heart problems...and that's assuming we are seeing for real CSR here and I am not so sure. It isn't typical.
So I am not so sure what is going on here but I don't want to scare the bejesus out of someone...... just yet anyway.

1....OP is under the care of a sleep doctor and we aren't doing anything here except going on a fact finding mission to see if there is a simple reason and simple fix for what we see here.

2...No one is telling the OP to ignore their doctor

3...Before scaring the bejesus out of someone....I prefer to try to evaluate things and that involves digging deeper.

4...there's so much we don't know at this point and turning off EPR (which is a well known trigger for centrals in some people) is a simple, easy experiment to try. Heck...might work out perfect. If it doesn't...then dig deeper.

Not all CSR flagged by the machine is real CSR and even if it was....doesn't always mean heart problems. There is no need to go down that road at the present time anyway.

OP is using a fixed pressure...and there are a lot of hyponeas flagged and a sizeable chunk of OAs...are we just seeing sub optimal therapy here???? Dunno but it wouldn't be impossible for the irregular breathing to be nothing more than a symptom of arousals/awake breathing and if the obstructive stuff was better dealt with then we wouldn't have the awake/arousal breathing.
Now I am NOT saying that is for sure what is going on here but it might be.

All I know is to try to offer ideas to fix what is shown to need fixing at the present time and then see what happens.
Turning off EPR will effectively increase the therapeutic pressure a bit and that might help reduce the obstructive stuff we may be seeing.
So might help with obstructives and might help with centrals....and hurts nothing to try.

Try easy and simple first...might get lucky and if we don't then we dig deeper and come up with more stuff for the OP to have a sit down with and talk about with the doctor we know he has.

Pugsy said: OP is using a fixed pressure...and there are a lot of hyponeas flagged and a sizeable chunk of OAs...are we just seeing sub optimal therapy here???? Dunno but it wouldn't be impossible for the irregular breathing to be nothing more than a symptom of arousals/awake breathing and if the obstructive stuff was better dealt with then we wouldn't have the awake/arousal breathing.
Now I am NOT saying that is for sure what is going on here but it might be.

All I know is to try to offer ideas to fix what is shown to need fixing at the present time and then see what happens.
Turning off EPR will effectively increase the therapeutic pressure a bit and that might help reduce the obstructive stuff we may be seeing.
So might help with obstructives and might help with centrals....and hurts nothing to try.

————

Gotcha. I am unsure what situation prompts being prescribed cpap over apap but what you say about EPR makes sense.

To the OP I wasn’t trying to be alarming. It’s my own weirdness about CSR. And pugsy is right that it might not be a real finding here.

lynninnj wrote: ↑

Sat Oct 29, 2022 2:30 pm

am unsure what situation prompts being prescribed cpap over apap

Lots of doctors prefer fixed pressures for various reasons...some justified and some not so justified but since I didn't want to even go down the changing pressure modes at this time (save that for a different time)....the cpap vs apap thing is on the back burner for now.

Besides...for some people who do have central apneas for real...sometimes fixed does work better.

lynninnj wrote: ↑

Sat Oct 29, 2022 2:30 pm

To the OP I wasn’t trying to be alarming. It’s my own weirdness about CSR.

Be careful with how you express your thoughts...it can sometimes be alarming for some people because then they start reading all sorts of stuff and get the bejesus scared out of them and it isn't always a "bejesus scaring" thing. It can cause undue stress which I know you don't want to be doing.

CSR itself is a very specific breathing pattern and the machine doesn't always get it right.
The whole idea with the machine flagging anything that remotely looks like real CSR is just to bring things to the attention of the patient's doctor so it doesn't get missed....just in case. They are being over cautious and that's fine.

Just remember that what the machine might flag as CSR isn't always real CSR.
I have had CSR flagged...and I was totally awake. Go figure that one.
We don't ignore it but we don't panic either and we for sure don't want to cause unneeded panic.
Even short periods of real CSR don't always mean heart issues. There's also a thing called idiopathic central apnea once all know potential causes are ruled out.

Below is an example of real CSR and a real problem and yes...this person also did have a history of CHF full blown.

Again I apologize if I scared bejeebus.

On my message board for my other medical condition I can’t really spend much time there because someone has died about once a month.

I wasn’t suggesting a change of settings so much as trying to understand the different reasons for doing so. Conversation for another day.

5-18 settings on those charts but pressure line barely moves.

Hope the OP will forgive me.

lynninnj wrote: ↑

Sat Oct 29, 2022 3:07 pm

5-18 settings on those charts but pressure line barely moves.

We are looking at a really zoomed in view of that person with real CSR and that accounts for it seeming like the pressure barely moves which is as expected with central apnea flags. The machine absolutely won't go changing the pressure for the centrals but it still might try to kill OAs and hyponeas with more pressure. I don't remember if that person had much pressure movement and it is obviously very old. I think that is a SleepyHead report and I didn't snag any other images and I should have. At the time I didn't think it was needed that I store his stuff. So this is all I have and it's been some time and I have forgotten all the other particulars.

At any rate I do remember that everyone told him "notify your doctor" and he did and he ended up being put on the ResMed VAuto (S9 I think) but in a fixed pressure. Doc was afraid to put him on ASV because of the heart issues and this happened way back when that crappy study scared people because it was thought that ASV caused increased mortality...a story for a different day.
He actually did fairly well on the VAuto in fixed bilevel mode....centrals went way down in number to a normal acceptable level and his OSA got treated as well.
He had both...obstructive apnea and central apnea and his central apnea was NOT caused by xpap.

Just because we asked questions and offer ideas does NOT mean that we always tell people to blow off their doctor.....as sometimes it is alluded to...not by you but by others.

Welcome GeneMpls

First I want to say: Please read everything Pugsy has posted in this thread carefully. There's a lot of good advice there.

GeneMpls wrote: ↑

Sat Oct 29, 2022 9:03 am

I have about 2 months in with a ResMed 11 and currently a F&P Evora full face mask and have really had
very little problem adapting to sleeping with it.

[stuff deleted]

AHI hovers around 15 +/- 5.

Has this been your AHI for the full time you've been using your CPAP?

And have you informed your sleep doc's office that your treated AHI is still usually between 10 and 20?

And have you let them know that half your events are being scored as CAs?

The reason I asked these questions is that you also write:

I am sure I need CPAP but my sleep Doc is pretty
much unresponsive and want to get this worked out with a better therapy program. He will allow me to transfer to a lady Dr in his practice.

It seems to me that if the sleep doc's office was informed that your treated AHI is between 10 and 20 most nights and that CAs are making up at least 50% of your events, that ought to trigger a pretty rapid response---either by getting you an appointment with the unresponsive doc or getting you transferred to the lady doc asap. Because this data is showing that the current settings on your machine are not doing a very good job of treating your sleep apnea problem.


In general, most people who need help tweaking their CPAP settings come to this forum with straightforward problems---i.e. if their AHI is still too high, the vast majority of events are OAs and Hs, both of which point to the need to increase the pressure. But when a significant number of CAs is also mixed into that too high treated AHI number, there's a lot more to consider. Some of the things that need to be considered are:

• The original sleep study and what it showed. In particular, were CAs a problem on that study? That's why Miss Emerita suggests that you get copies of your diagnostic sleep study. If you are comfortable blacking out the personal identifying information and posting a scanned version of the sleep study results, that will help the real experts (particularly Pugsy and Rubicon) figure out what might be going on.

• A heads up on any known heart disease problems or confirmation that the poster has no known heart conditions. As Pugsy has pointed out, real Cheney-Stokes respiration patterns (CSR), are associated with certain cardiac problems. In particular, CSR is often seen in people with congestive heart failure. So if a patient is known to have any heart disease, that colors what the experts are likely to be looking for and what they'll likely say about OSCAR charts that look like yours does. And obviously, the docs treating the heart disease and the sleep disorder ought to be working together to figure out how to optimize xPAP therapy. On the other hand, if we know for sure that there is no history of heart disease, then there's a good chance that CPAP machine-scored CSR is not real CSR, but it could be symptomatic of a problem with central apneas caused by something other than a cardiac issue. And that goes back to what the diagnostic sleep study says about CAs.

• How often does the data look really, really bad?. We don't sleep the exact same way every night and sometimes Pugsy's aliens pay us a visit and we get an atypically bad night in terms of the data. If it's one night out of a whole bunch of nights, the answer may well be to just ignore that one night until/unless it becomes a recurring pattern. But since you say your AHI is usually 15 +/- 5, that indicates the night you posted is not just a random bad night. In other words, something does need to be done to make xPAP do a better job of treating your apnea. But since the night you posted has a CAI = 7.3, that says that it's worth being cautious about just suggesting a pressure increase. The reason why is that some people with central apnea problems get more CAs when using more pressure. But some people also see more apneas when EPR is set too "high", and Pugsy's suggestion to turn EPR off is less likely to trigger more CAs (and it could reduce the number of OAs and Hs) than bumping up the pressure. Which brings me to the next question:

• What did the data look like at the previous pressure setting? In your case, you say the sleep doc has reduced your pressure from 15 to 12 cm. It would be useful to know why the doc made that decision. Did he do it after downloading your CPAP's SD card and looking at the data? And it would also be useful for you to go back through the OSCAR data for the days when your pressure was at 15cm. Did you have more CAs than now? Did you have fewer OAs than now? Did the amount of CSR getting flagged go up or down when your pressure was lowered?

You also write:

I have been taping my mouth to cut down on leakage [mouth breather] and have started to
wonder about a nasal mask as long as I am taping already and don't have a issue with it.

The leak line on the night that you posted data for is not great, but it's also not horrible. In other words, the real question right now is whether those leaks are waking you up. And whether your mouth is getting too dry at night.

So yeah, you could try a nasal mask with taping if you wanted to. It might (or might not) be more comfortable. You'll only know if you try them.


Finally, you write:

I have loved to work designing and creating things my entire life and this is killing me.
My mind has been so muddled for so long that I need some second opinions on my OSCAR chart please?

I know it's difficult when your mind is still muddled, but try to think about getting your xPAP therapy optimized as a puzzle that requires creative thinking to solve.

Pugsy wrote: ↑

Sat Oct 29, 2022 2:47 pm

The whole idea with the machine flagging anything that remotely looks like real CSR is just to bring things to the attention of the patient's doctor so it doesn't get missed....just in case. They are being over cautious and that's fine.

Bringing this to attention of his professional was what I was suggesting.

What the original poster has not disclosed is if the CSR in his OSCAR report is a one-off, OR if his doctor has seen the Resmed interpretation of any CSR events. If his doctor did not observe CSR on his sleep study, the doctor may not be aware.

If it is not a one-off, he would be well advised to call it to his professional's attention and allow the doctor to determine if it's a problem.

I agree that being cautious is a fine idea.

GeneMpls wrote: ↑

Sat Oct 29, 2022 9:03 am

He just changed from constant 15# to 12# both with EPR of 2.

Do you know why? What did he see in your results before he made he change?

GeneMpls wrote: ↑

Sat Oct 29, 2022 9:03 am

I have been taping my mouth to cut down on leakage [mouth breather] and have started to
wonder about a nasal mask as long as I am taping already and don't have a issue with it.

That makes sense, but you really should make the distinction between mouth breathing and mouth leaking. If you can breathe fine through your nose, and the only problem is you mouth popping open and air leaking out of, then you're a "mouth leaker" and taping should be no problem.

Do read carefully what Pugsy and robysue wrote.

Your chart shows a small number of obstructive apneas, a small number of snores, but many hypopneas.
I agree with Pugsy: the first step is to stop the EPR.