Sleep wake transition disorder

After 3 months of treatment I'm worried that my physician might be grasping at straws. With CPAP I have not been able to get my AHI much lower that 12 and my sleep is crummy. There are no obstructive apneas at my current pressure of "7" just central and hypopnea apneas. Most of these apneas occur during the first hour and last hour of sleep. During my sleep studies I did not have these. When I raise the pressure the centrals go up. When I raise the pressure even more the centrals go way up.

I asked if I should try a switch from CPAP to Bipap for treatment and the physician said "no, that would not be appropriate in my case because your centrals only occur during the beginning and end of sleep."
The Dr. explained to me that carbon dioxide levels are different when you are asleep vs. when you are awake. As these carbon dioxide levels transition between wakefulness and sleep your brain will sense that difference and may (as is theorized in my case) send and alarm to your system that wakes you up.
I asked if I could rent a device that would measure my oxygen saturaturation during the night, but the Doctor did not feel that this would prove beneficial.

I am a little savier since I started reading this forum (thank you) so I asked about my initial sleep study. The data showed that while I slept on my right side my AHI dropped to 2.7 and there were no Central Apneas. So 2.7 is a heck of allot better than my current AHI of 12 (with all these Centrals) right? Wouldn't it make more sense for me to just stop using the CPAP and sleep on my side?
The Dr. said "No, that would be dangerous. Without the CPAP on there would be no way of knowing what the situation is. I would be essentially unmonitored and could get in serious trouble."

He wants me to lower the pressure down to 6 and see if anything improves. If not, he will prescribe lorazepam (Ativan). I don't like taking drugs.
Sorry for the long rant, but you are the only one I have to talk to.

Hmmmm.... I am just a newbie, but in reading your post, I wondered why you don't just sleep on your right side while using the cpap? A pressure of 7 is fairly low and moving down to 6 seems barely therapeutic.

Are you having any leaks from your mask?

I think investing in an oximeter would be a good idea. There has been quite a bit of discussion in the last week or so on this topic here. Read through this one and also do a search: viewtopic/t54776/please-recommend--good ... cards.html

More veteran and experienced members will be along soon to offer some advice.... hang in there!

If you (unknowingly) end up mouth breathing while sleeping, a trial of a full face mask would be in order because what you do otherwise is lose all the cpap air and get no real therapy.

Underdog don't feel like the Lone Ranger. I have the same thing. Most of my events happen while I am trying to go to sleep or during the time I awake in the morning. All of them centrals. There will be a few during the night but I suspect they happen as I wake up for just a moment to turn over to another position. If I happen to go to the bathroom in the middle of the night there will be anywhere from 3 to 6 centrals before I go back to sleep. There will also be 2 to 6 hypos during the night.

The s9 has done a good job of eliminating the obstructives. My settings now are 9.4 - 11.0 and my AHI averages under 5. I am happy about the AHI but all of those centrals on the event chart sure does look ugly but I don't know what else to do about it.

Julie wrote:If you (unknowingly) end up mouth breathing while sleeping, a trial of a full face mask would be in order because what you do otherwise is lose all the cpap air and get no real therapy.

Thanks for this. I'm on my third mask and "finally" have the leaks (and I mean the small leaks too) under control. My "average leaks" range from 19 to 23. And I think that is within the range of the new nasal mask. I would like to get my hands on a full face mask now that cold season is just around the corner.

snoresliketrain wrote:Underdog don't feel like the Lone Ranger. I have the same thing. Most of my events happen while I am trying to go to sleep or during the time I awake in the morning. All of them centrals. There will be a few during the night but I suspect they happen as I wake up for just a moment to turn over to another position. If I happen to go to the bathroom in the middle of the night there will be anywhere from 3 to 6 centrals before I go back to sleep. There will also be 2 to 6 hypos during the night.

The s9 has done a good job of eliminating the obstructives. My settings now are 9.4 - 11.0 and my AHI averages under 5. I am happy about the AHI but all of those centrals on the event chart sure does look ugly but I don't know what else to do about it.

Snoresliketrain, good to know (for me anyway) I'm not alone. During the initial sleep study the obstructive events climb into the low 70's (AHI) when I was sleeping on my back. So while I'm not questioning a need for treatment (and I did feel even worse before I started with CPAP). I do wonder if an alternative like Resmed's VPAP Adapt SV™ (adaptive servo-ventilator) is worth trying before lorazepam. Did your doctor ever suggest a drug therapy or VPAP?

If people using a PR System One or ResMed S9 machines notice handfuls of "clear airway apneas" or "central apneas" appearing on their data, it can be reassuring to check out some of these "Links to Centrals" discussions:

Links to Central Apnea discussions
viewtopic.php?p=22702

_________________________________


viewtopic.php?t=18117
On page 2, from a post by StillAnotherGuest:

"Assuming that the obstructive events are properly managed, then the likelihood of these being sleep-onset centrals is fairly high (you'd need PSG to be 100%) and those things are pretty much a normal event."

________________________________

viewtopic.php?p=428835#p428835
DreamOn quoted this passage from the book:
"Sleep Apnea: The Phantom of the Night" by T. Scott Johnson, M.D, et al.

"Small numbers of central apneas are seen in virtually every normal and abnormal patient that is studied in the sleep lab and are usually a normal part of the transition to sleep.
....
"We have an automatic breathing control system that maintains the carbon dioxide in our blood at a stable level. This system helps to control the rate at which we breathe....During the day when we are constantly overriding our automatic breathing, most people maintain their carbon dioxide level at a fairly low level. With the onset of sleep, however, the sensor mechanism that detects levels of carbon dioxide in the blood becomes slightly less sensitive and accepts higher levels of carbon dioxide....This change in sensitivity occurs quite suddenly as we drop off to sleep from a normal awake breathing state, and we suddenly do not have enough carbon dioxide in our blood to drive regular breathing during sleep. For this reason, at sleep onset and after arousals there is often a pause in the effort to breathe that may last as long as 10 to 15 seconds. These events may be normal."

________________________________

viewtopic.php?p=457468#p457468

JohnBFisher wrote:

"Here's an article that discusses how central sleep apneas occur during sleep onset:"

Ventilation is unstable during drowsiness before sleep onset
http://jap.physiology.org/cgi/reprint/99/5/2036

________________________________


viewtopic.php?p=47781#p47781

christinequilts (who was diagnosed with almost pure Central Sleep Apnea -- severe case) wrote:

6 centrals is not a lot- less then 1 per hour, and is perfectly normal. Everyone has central apneas- take 3 or 4 very slow & deep breaths right now, then count how many seconds after the last inhale until you feel the need to inhale again. Was it more then 10 seconds? If it was, you just had a central apnea. Next time you sigh take note how long before you inhale again....yep, another central apnea. Yawn? same thing can happen. Pick up a heavy box or weight- did you remember to breath? if you didn't, then you had another central apnea. Think of what you hear exercise trainers lecture about breathing while exercising- its human nature to not breath when we exert themselves.

Of course all of these are awake apneas- but any time you don't breath for 10 seconds, you technically have an apnea. While sleeping, you can have similar things happen- you can take several deep breaths and not need to breath for several seconds. During transitions between sleep stages, it is common to have central apneas because the acceptable levels of O2/CO2 are different for each stage...sort of like when you're still going 55MPH as you enter the 35MPH zone. When you turn over at night, it is common to not take a breath- just like when you lift something or exercise when awake. In people with OSA, they don't consider centrals a problem until they are well above 5 per hour- central apneas can be a symptom of OSA, just like snoring, arousals, etc. A few centrals are nothing to worry about- most sleep labs don't get concerned about centrals unless there are a lot of them.

_________________________________

More wise words from that very intelligent lady -- christinequilts:

Having CENTRAL SLEEP APNEA, as a diagnosis, is rare. Having a few central apneas during the night isn't, its very common & is completely NORMAL.

viewtopic.php?p=179463#p179463

----

More of christine's well informed comments:

viewtopic.php?p=15061#p15061
christinequilts wrote:
THink about when you exercise or concentrate hard- if your not aware you can hold your breath which is essentionally central apnea. Turning over in your sleep is basically like an exercise- you go from doing nothing to moving. If you were to have your breathing monitored while you are awake you would see a lot of 'central' events.

----

and here, where Christine was accidentally "guested":
viewtopic.php?p=6176#p6176

christinequilts wrote:
Most people- even those without sleep disorders- have a few central apneas while sleeping. A common cause is when you roll over...have you ever noticed when you're exercising or lifting something heavy that you hold breath unless you actually think about your breathing? The same thing can happen at night as you toss and turn. THere are other things that cause centrals too- there is a certain amount of variance in our breathing patterns when we sleep just like there is when we're awake.

I wouldn't worry about central events unless there were a significant number per hour

_______________________________

http://www.apneasupport.org/viewtopic.php?p=24677

In a reply titled "Nope" sleepydave (RRT, RPSGT and manager of an accredited sleep lab) responds to honda's question:

honda wrote:

Thanks for the comments, one other question though, do the 4 central apneas have any significance ?

None whatsoever.
sleepydave

sleepydave's nicknames on cpaptalk are "StillAnotherGuest" (SAG), "muffy" and "not_muffy."

My sleep problem sounds very much like yours, and were eventually solved with an auto SV machine. I have slept much better with this machine even though I don't have things these machines are usually prescribed for, like periodic breathing, or a severe central apnea problem. Part of the reason might be the prompt response of the machine to things like sleep-onset centrals, which I apparently have a lot of. The other part might be a much lower overall average pressure. If you investigate this therapy, look more at the Respironics BiPAP Auto SV Advanced than at the ResMed VPAP Auto SV unit. The Respionics machine has a much wider range of adaptation to different sleeping problems than the ResMed unit. The ResMed machine is IMHO better for people with people with periodic breathing or a (rare) true central apnea problem, who benefit from a very consistently regulated minute-ventilation. The Respironics unit doesn't control minute-ventilation quite as closely, but seems to respond appropriately to a wideer range of things like apneas, hypopnas and snoring.

But the only way to know for sure is to have a new PSG done. If you do, request that they consider all the possible therapy modalities-- CPAP, APAP, BiPAP and ASV. They found with me, for instance, that Bilevel therapy was all but useless. But autoadjusting CPAP with SV did the trick. Now, as I have learned to sleep with the machine, the SV action is a lot less common (or noticeable). But the machine can become quite busy when I am actually asleep.

Rested Gal, we are all incredibly fortunate to have you here. I can't thank you enough.

Underdog,

You haven't given us an update on your neurological symptoms, numbness, mental fogginess, etc.

If those are better, that means there's progress, no matter what the numbers say, and tinkering with adjustments could yield further improvement.

If you're still mentally foggy, then there's a big problem, and it could be your doctor. You're three months down the road, your leaks are controlled, you aren't having obstructive apneas, yet you still have symptoms. And apparently your doctor is advising you to keep doing the same thing that hasn't helped yet.

I cannot understand the doctor saying oximetry wouldn't be helpful. If, on the one hand, you have desaturations, then your diagnosis may be complex apnea and you need a different machine. If, on the other hand, you're not having desaturation, but still having neurological symptoms, it's very possible those neuro symptoms are not due to sleep apnea, which means something else is being overlooked. I would beg, borrow, or buy an oximeter.

And maybe you need a second opinion from a different sleep doc, neurologist or internist.

Did your doctor ever suggest a drug therapy or VPAP?


I take 1/2 of a 10mg tablet of Zolpidem 30 minutes before I go to bed. I don't like taking drugs either but this puts me to sleep faster which equals less central apneas. In the morning I usually awake around 6:00 or 6:30. When I wake up I get out of bed. If I lay there and go in and out of sleep for say 20 minutes there will be a pile of centrals on the events chart. They will be anywhere from 10 to 38 seconds long.

Like I said the s9 has done a beautiful job of stopping the obstuctives but I am afraid the centrals will be with me from now on.

Thanks rested gal for the information.

Thanks for these encouraging resources. I really mean thanks. These centrals really have me stumped and now I've got some good reading to do.