CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Eldad Wasserman · Post by **Eldad Wasserman** » Tue May 04, 2010 6:54 pm

I Know that also the price is important, so I want to share this information with you...
This is the ecommerce with the most attractive price for any Contec products, include the CMS-50E.
Only 116 us$ (need to add shipping fee) for the excellent Oximeter CMS-50E.
www(dot)Contec-Products(dot)com for your best products best price...

-SWS · Post by **-SWS** » Tue May 04, 2010 7:03 pm

Below is one interesting and perhaps relevant article, Blizzardboy:
http://www.sleepreviewmag.com/issues/ar ... -06_03.asp

Stephen E. Brown, MD, DABSM wrote:we found that sometimes it was difficult to determine during a titration whether a real event has occurred as the rapidly responding pressure support may terminate a near-event just before the 10-second mark. In one patient, we initially overtitrated the EEP, increasing the pressure for respiratory effort-related arousals (RERAs) that were, on formal scoring, demonstrated to be spontaneous arousals. In another patient, undertitration occurred as the technologist adjusted the EEP for apneas and hypopneas, but did not adequately increase the pressure for residual RERAs. Our experience suggests that some of the early failures with ASV may be inadequate SDC/technologist experience, and not necessarily a problem with the device.

Note the above account documented the original Adapt SV model having a factory-limited EEP of only 10cm.

How is the above possibly relevant? Recall from this post, Blizzardboy, that you still managed to present significant flow limitations at pressures above 10cm:

blizzardboy wrote:Here's my data from last night during which I slept in the recliner to see the effect of sleeping inclined on my ASV results (e.g. reduce silent GERD):

http://users.adam.com.au/sixsome/ASV/0410/042810/

seems to be the most stable breathing on the ASV to date. What do y'all think?
Obstructive patients sometimes elect to sleep upright to lessen the severity of upper-airway occlusion. Since gravity's vector changes its relative angle in physiology by sleeping upright, in many cases obstruction becomes less severe.

I suspect your recliner-chair experience mentioned above and especially your S9 data reveal that your obstructive component is under addressed by your current EEP of only 8cm. BTW, that 8cm EEP was the correct obstructive-addressing value according to your sleep study that found 8cm adequately addressed your snoring and obstructions. But again, your S9 data very strongly hints that 8cm EEP is not sufficient to address your airway occlusions on some nights. I'll explain below:

--------

S9 April 9th:
Let's examine the handful of obstructive events that occurred between hours 02:00 and 03:30 on April 9th:
http://users.adam.com.au/sixsome/S9/S9_trial_11.JPG (bottom graph)

Next, let's see what pressure the S9 was running during that time frame: (bottom graph)
http://users.adam.com.au/sixsome/S9/S9_trial_09.JPG

Now let's see what your snores and especially (obstructive) flow limitations were up to on April 9th at those pressures:
http://users.adam.com.au/sixsome/S9/S9_trial_12.JPG (top and bottom graphs)

CONCLUSION: Pressures above 10cm did not completely address your obstructive component on April 9th.

------

S9 April 10th:
Let's examine that denser cluster of apneas that occurred on April 10th between the hours of 01:15 and 02:00:
http://users.adam.com.au/sixsome/S9/S9_trial_08.JPG (top graph)

As in the first example, let's see what pressure the S9 was running during that time frame:
http://users.adam.com.au/sixsome/S9/S9_trial_06.JPG (top graph)

Now let's see what (obstructive) flow limitations were up to on April 10th at those pressures:
http://users.adam.com.au/sixsome/S9/S9_trial_09.JPG (top graph)

CONCLUSION: Pressures above 10cm did not completely address your obstructive component on April 10th either.

---------------------------------------------------

ADAPT SV CONCLUSION: An EEP pressure of only 8cm is probably insufficient to address your obstructive component. An EEP pressure of only 10cm might be insufficient as well.

While those slight flow limitations can negligibly impact volume targeting and an ongoing baseline, they can have a devastating impact on sleep architecture and following-day symptoms for some patients who are arousal inclined. The point being that it's entirely possible to adequately address volume-based targets as well as AHI, but still have suboptimal treatment results based on RERA's (flow limitation based).

blizzardboy wrote:When I showed him my Tidal Volume plots he commented that "Instability begets instability"...Hypersensitivity to CO2 levels contributing to oscillation between hypoventilation and hyperventilation. Approved of increased Epap and gradual increases to PS_min.

Loop gain theory supports that view:

David P. White wrote:Simply put, loop gain can be mathematically defined as the response to a disturbance (hyperpnea) over the disturbance itself (apnea or hypopnea):

If loop gain is less than 1, a respiratory disturbance will lead to a response, but it will be sufficiently small such that ventilation relatively quickly returns to a stable pattern (Figure 4). If loop gain is greater than 1, a respiratory disturbance will lead to such a large response that ventilation will wax and wane indefinitely (Figure 4).

http://ajrccm.atsjournals.org/cgi/conte ... 72/11/1363

So the idea is to do whatever you can, blizzardboy, to minimize introducing respiratory perturbations that might serve as catalyst for the above loop-gain dyscontrol scenario. If under-addressed flow limitations cause RERA's that, in turn, cause stimulus/response hyperpnea, then the above state of oscillatory dyscontrol might commence. If unaddressed pain happens to cause stimulus/response hyperpnea, then the above state of oscillatory dyscontrol might once again commence---thereby causing that unsteady breathing you see on your ASV charts. If silent acid reflux events happen to cause stimulus/response hypernea, then the above state of oscillatory dyscontrol can once again commence.

I would suggest that you try to keep all candidate sources of respiratory perturbations (potential loop-gain catalyst events) in mind as you experiment toward increased breathing stability and improved daytime symptoms. I think the sleeping wedge experiment is a great idea in light of how well you slept in the recliner.

Good luck.

Muse-Inc · Post by **Muse-Inc** » Tue May 04, 2010 7:46 pm

jnk wrote:...THS was 4.98 back in 2004...

Waaay too high!!! By the time TSH is 4.2, there is at least a 20% rise in LDL cholesterol. Thryoid affects/interacts with everything in the body it seems!

blizzardboy · Post by **blizzardboy** » Wed May 05, 2010 12:03 am

-SWS wrote:So the idea is to do whatever you can, blizzardboy, to minimize introducing respiratory perturbations that might serve as catalyst for the above loop-gain dyscontrol scenario. If under-addressed flow limitations cause RERA's that, in turn, cause stimulus/response hyperpnea, then the above state of oscillatory dyscontrol might commence. If unaddressed pain happens to cause stimulus/response hyperpnea, then the above state of oscillatory dyscontrol might once again commence---thereby causing that unsteady breathing you see on your ASV charts. If silent acid reflux events happen to cause stimulus/response hypernea, then the above state of oscillatory dyscontrol can once again commence.

I would suggest that you try to keep all candidate sources of respiratory perturbations (potential loop-gain catalyst events) in mind as you experiment toward increased breathing stability and improved daytime symptoms. I think the sleeping wedge experiment is a great idea in light of how well you slept in the recliner.

I concur wholeheartedly. My strategy at present is to reduce any influence that might destabilise my system. Here is what I have done so far:

1. Chosen a mask selection that minimises leaks and pain/injury to my face
2. Purchased a papcap to hold my chin up to minimise leaks
3. Purchased a pad-a-cheek anti leak strap to minimise leaks
4. Purchased a pad-a-cheek bridge protector to reduce pain/injury on my bridge
5. Purchased a 7" bed wedge to gently elevate my head to reduce EEP required to treat OSA and to contain any reflux associated with aerophagia/silet GERD
6. Taking PPH medication to reduce the effects of any reflux that I might be experiencing
7. Visited an experienced sleep dentist today to discuss the use of a MAS to assist in treatment of OSA by the Adapt SV. My thinking here is that the addition of a MAS might reduce the EEP required to treat my OSA, which in turn would hopefully improve the stability of my system through decreased aggravation of CSA, respiration, aerophagia, reflux, stimulation, leaks, etc. The dentist and I agreed that I would discuss the MAS idea with the new sleep doctor when I visit next week - its good because the dentist and the doctor are part of the same sleep study group. I think I may have already had my first taste of the benefits of a multidisciplinary approach to SDB management.
8. Joined a forum filled with people of the most helpful kind!

Let's see where it all takes me.

p.s. -SWS Ref 21 in Treating the "Untreatable": http://chestjournal.chestpubs.org/conte ... 5.full.pdf looks like a good review of CSA

Cheers,

dsm · Post by **dsm** » Wed May 05, 2010 4:24 am

BB

As you can see this cpap therapy can be extraordinarily involved

Lets hope it keeps going well.

Cheers

DSM

jnk · Post by **jnk** » Wed May 05, 2010 7:04 am

Muse-Inc wrote:
jnk wrote:...THS was 4.98 back in 2004...
Waaay too high!!! By the time TSH is 4.2, there is at least a 20% rise in LDL cholesterol. Thryoid affects/interacts with everything in the body it seems!

Here's an interesting and fairly recent article on OSA and the endocrine system. It is one of the best overviews I've ever read on OSAS:

http://www.spendocrinologia.org.pe/publ ... 0Apnea.pdf

-SWS · Post by **-SWS** » Wed May 05, 2010 8:50 am

blizzardboy wrote: p.s. -SWS Ref 21 in Treating the "Untreatable": http://chestjournal.chestpubs.org/conte ... 5.full.pdf looks like a good review of CSA

I agree that's an excellent review. And Figure One (on PDF page 5 of 15) demonstrates "an experimentally induced arousal leading to central apnea"---a very interesting and potentially helpful demonstration IMO. I suspect many practitioners focus almost exclusively on mitigating central dyscontrol after the fact----or even ignoring significant numbers of post-arousal central apneas---when they should consider also addressing potential loop-gain catalyst events with diverse proactive management techniques.

Blizzardboy wrote:Let's see where it all takes me.

More and more of this I think:

blizzardboy wrote:I was feeling quite energetic today - definitely no hint of sleepiness. I managed to fly kites with the kids, play wrestles with the kids, play on the trampoline for a long while with the kids and have some joking and laughing with the kids - and then vacuumed the house. One of them commented that I was the most fun ever.

-SWS · Post by **-SWS** » Wed May 05, 2010 8:57 am

jnk wrote:
Muse-Inc wrote:
jnk wrote:...THS was 4.98 back in 2004...
Waaay too high!!! By the time TSH is 4.2, there is at least a 20% rise in LDL cholesterol. Thryoid affects/interacts with everything in the body it seems!
Here's an interesting and fairly recent article on OSA and the endocrine system. It is one of the best overviews I've ever read on OSAS:

http://www.spendocrinologia.org.pe/publ ... 0Apnea.pdf

Thanks for that, Jeff. And my thanks to those who have added thyroid information to this thread as well.

dsm · Post by **dsm** » Wed May 05, 2010 4:13 pm

BB

Did you manage to try varying the PS to 3.2 ?

Cheers

DSM

blizzardboy · Post by **blizzardboy** » Wed May 05, 2010 6:38 pm

-SWS wrote:
Blizzardboy wrote:Let's see where it all takes me.
More and more of this I think:
blizzardboy wrote:I was feeling quite energetic today...

I have definitely been improving since my EEP was increased. I am looking forward to getting the chin strap so I can stabilised my lower jaw. Maybe no need for an MAS, but the scientist in me just wants to give it a try. I mean, people spend more money changing perfectly good wheels on their car for fancy alloys than I would on a MAS! An adventurous spirit can often drive discovery (BB 2010.)

blizzardboy · Post by **blizzardboy** » Wed May 05, 2010 6:42 pm

dsm wrote:Did you manage to try varying the PS to 3.2 ?

Last night I dropped EEP to 9.4 and increased PS to 3.2->8.2. I woke up somewhere in the night and in a sleepy-state switched them back to 9.6/3->8. I'll post the results tonight if I get time. I know, I know, varying too many things at once. I think I might make myself a more structured pressure testing regime or, as sagely suggested by echo, just sit back and enjoy the ride for a while to let my body settle into the groove.

dsm · Post by **dsm** » Wed May 05, 2010 7:00 pm

blizzardboy wrote:
dsm wrote:Did you manage to try varying the PS to 3.2 ?
Last night I dropped EEP to 9.4 and increased PS to 3.2->8.2. I woke up somewhere in the night and in a sleepy-state switched them back to 9.6/3->8. I'll post the results tonight if I get time. I know, I know, varying too many things at once. I think I might make myself a more structured pressure testing regime or, as sagely suggested by echo, just sit back and enjoy the ride for a while to let my body settle into the groove.

BB

Fair comment.
Re dropping EEP, might be a good idea to not try that any lower. It may be that in time the suggestion is to step it up rather than down but if 9.6 is holding well stay with it.

Yes it is good to get settled with a particular band esp if the current data shows it appears to be doing a good job and if your daytime shows good results.

Cheers

DSM

Muse-Inc · Post by **Muse-Inc** » Wed May 05, 2010 7:13 pm

BB, I don't about your body and brain but my brain doesn't like changes; it takes my brain a long time to adjust to changes. Typically, no one here recommends making changes more often than 4-5 if not 7 days unless it's obvious the latest change is not working. Could be you need to need to just settle in with one batch of settings and sleep with 'em for a bit as the brain-body adjusts-acommodates-acclimates-relaxes with those settings.

dsm · Post by **dsm** » Wed May 05, 2010 7:44 pm

Muse-Inc wrote:BB, I don't about your body and brain but my brain doesn't like changes; it takes my brain a long time to adjust to changes. Typically, no one here recommends making changes more often than 4-5 if not 7 days unless it's obvious the latest change is not working. Could be you need to need to just settle in with one batch of settings and sleep with 'em for a bit as the brain-body adjusts-acommodates-acclimates-relaxes with those settings.

Caution re changing settings is well advised but is inherently complicated by how a brand allows changes. The Respirronics ASV only allows 1 CMs changes in pressure and in PS support changes which is actually quite a significant jump. Changing say epap and PS at the same time on one of them needs great caution.

The Resmed ASV allows 0.2 CMs changes & doing just one 0.2 change is normally not any major comfort or life threatening issue. But changing a couple of settings at the same time greatly expands the complexity of measuring the results (hmm which type of change altered the results ?)

Cheers

DSM

blizzardboy · Post by **blizzardboy** » Wed May 05, 2010 10:27 pm

Muse-Inc wrote:BB, I don't about your body and brain but my brain doesn't like changes; it takes my brain a long time to adjust to changes. Typically, no one here recommends making changes more often than 4-5 if not 7 days unless it's obvious the latest change is not working. Could be you need to need to just settle in with one batch of settings and sleep with 'em for a bit as the brain-body adjusts-acommodates-acclimates-relaxes with those settings.

Hi Muse-Inc, Yes good advice. We are after all dealing with body i.e. a complex biological system with multiple feedback mechanisms and variable loop gains...not electrons and molecules (think very small time frames) as I deal with in my work. Easy goes it. Gently Bentley.

From the literature and comments provided in this thread by Muffy and -SWS and others, I think I currently suspect my self as having the following physiological sleep characteristics underlying my CSA:

1. Overall hypoventilation (under breathing; increases blood CO2) with periodic hyperventilation (over breathing; reduces blood CO2) and subsequent ceasing of respiration (i.e. CSA) due the blood CO2 dropping below the level required to stimulate the central control system to initiate breathing
2. Hypercapnia (CO2 level in blood higher than normal) resulting from overall hypoventilation
3. High plant gain - i.e. only a small increase in resp rate is required to rapidly lower blood CO2 from hypercapnic levels to the level of eupnea (normal breathing) resulting from hypercapnia
4. High control gain - i.e. small difference in blood CO2 between hypercapnic and eucapnic levels as a result of my brain setup
5. Unstable respiration due to continuous oscillation between hypo- and hyper-ventilation due to these states being too close to eucapnic state in terms of resp rate and blood CO2.

Any thoughts or comments?

CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Yes you are right

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Re: CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?