Periodic Breathing

I have a Remstar Auto A Flex - Phillips- pressure settings 6/12...I've been changing the pressure settings to get my AHI's down, and they are now pretty consistantly below 5/hr. But, my Periodic breathing has been all over the chart...last 3 (1) day readings were 2.4% - 6.2% - and 11%.....my 90% reading has been below 11% each night....

All readings taken from the machine.

I've read the definitions of Periodic Breathing, but don't really understand them...can anyone explain what they are and if you thing the percentages are of concern??

Thanks!!! Great Board!!

Would really need to see the wave form associated with the PB times along with AHI breakdown and the timing of the PB and know if you were awake or not to have any idea if the PB warrants concern.
For that you need the software reports for us to see. Can't tell just by the numbers off the machine.
Or you can contact your doctor and have him/her take a look at the data to see if he/she thinks there is something to be alarmed about.

Periodic Breathing is just a breathing pattern that waxes and wanes. We read about Cheyenne Stokes Respiration pattern here and it is a form of Periodic Breathing but it isn't the only form of periodic breathing.

If I consistently saw over 5% of the night in PB...I would probably want my doctor to evaluate things.

I agree completely with Pugsy's wording.

"Periodic breathing," generally speaking in the context of sleep breathing as I understand it as a patient, is unstable breathing during sleep that shows up as a regular pattern of underbreathing and overbreathing. Because it involves the breathing drive, it is a term often associated with non-obstructive breathing problems, BUT it is a common component of obstructive sleep apnea, too, for some people.

If someone has had trouble with severe obstructive apnea for a long time before starting PAP therapy, it can take a while for breathing to stabilize after several weeks of effective PAP therapy--so a little residual instability in breathing may be normal for some people when first starting out. However, if significant breathing instability remains, and especially if it is accompanied by sleepiness and exhaustion, that is useful info for the sleep doc to know. I am unaware, however, of a line in the sand that dictates a certain percentage as reported by a home machine that would be considered significant, since the home machine doesn't know wake from sleep, for example. The significance, or insignificance, may relate to a particular patient's circumstances overall medically, I would think.

It looks like there is continuing research going on to find ways of dealing with it when it causes the patient problems and it doesn't go away, according to this link I found in an old post by -SWS:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3014238/

What they said.

I, too, have periodic breathing in the form of Cheyne-Stokes.

The difficult thing about this is my AHI shows zero most nights when using the Resmed Adapt machine. But under a close observation of the breath by breath waveform, I can see the "suppressed" wax and wane patterns. Without the ASV machine, these patterns would usually degrade into full blown central apneas. But the paced breathing keeps ventilation going and produces these semi-periodic waveforms. These are OK since my Ox blood % levels stay above 94% all night and the breathing never stops, though it can get shallow at times.

How to we make it better? I've found for my own situation that by reducing the epap minimum to as low as possible, still allowing for OSA, I was able to dial in the lowest hypopnea events and then the lowest periodic breathing event levels. This takes many nights of trial and error and it's really a pressure compromise optimization between obstructive events and periodic breathing events.

These days, I wake up and look at the overall AHI, periodic breathing and then look over the overall breathing waveforms. Zeo helps too. These optimum settings will drift over the days due to our own varied health patterns, so we need to settle on a best choice and let it run.

The bottom line is we may try to have a perfect, constant "sinewave" breathing pattern all night, not missing a breath. But being human, we can never achieve this gold standard - nor must we to be healthy.

That said, you might ask your doctor about a ASV machine for your periodic breathing. They are designed for this problem as well as handling OSA.
T

Thanks for the info. It's very helpful. What effect, if any, would wearing a chin strap have on periodic breathing?

ms21117 wrote:I have a Remstar Auto A Flex - Phillips- pressure settings 6/12...I've been changing the pressure settings to get my AHI's down, and they are now pretty consistantly below 5/hr. But, my Periodic breathing has been all over the chart...last 3 (1) day readings were 2.4% - 6.2% - and 11%.....my 90% reading has been below 11% each night....

All readings taken from the machine.

I've read the definitions of Periodic Breathing, but don't really understand them...can anyone explain what they are and if you thing the percentages are of concern??

Thanks!!! Great Board!!

Reply,

If you have periodic breathing, even by getting it at hi elevation, it means that you have CSAS (central sleep apnea syndrome) and any AutoCPAP machine is bad for you. So why do you stick to it?

p.s.

1) I am surprised that jnk gave you above a link to that silly report about added dead space and not this one which jnk usually gives:

http://emedicine.medscape.com/article/304967-overview

2) Mis. P. posted above that: Periodic Breathing is just a breathing pattern that waxes and wanes. We read about Cheyenne Stokes Respiration pattern here and it is a form of Periodic Breathing but it isn't the only form of periodic breathing.

But, imo, Periodic breathing does not need to show waxing and waning of the waves patterns but repeating patterns. CSR, on the other hand, does show the waxing and waning.

PB: CFLOW patterns repeat.





CSR: CFLOW waves waxing and waning.

Hmmmm... U r above my head now...I had 2 sleep studies, both indicated I had mild to moderate sleep apnia...I have been working with my pressure settings to get my ahi down from 10 to less than 5... So far that is working and I am feeling better...I used to be exhausted by 2 pm and now I am not...my 30 day average periodic breathing had been 5.3%...last few days it has been 6-11%...11% when I wore a chin strap...so based on that...do u still think I should not be using a Cpap? Thanks!!!

Please disregard what Avi123 has said about not using APAP. He can't have any idea what your diagnosis is based off the machines % of time in PB.

Without seeing your software reports we have no idea what is going on with your PB and we cannot offer any constructive ideas.
Call your doctor or DME and report what you are seeing on the machine and let them address the situation and your concerns and advise you on what to do.

Your doctor is the one that you should be talking to for final advice. At the best all we can do is offer ideas or explain things but without seeing your reports we can't explain anything.
While it may be nothing at all...the % of PB that you are seeing is more than I would be comfortable with seeing unless my doctor told me not to worry. I see PB sometimes myself but always less than 1% of the night. Yours is a lot more and warrants a discussion with your doctor.

IMO, the Periodic Breathings repeating throughout the night might be an issue. But, reducing the AHI to below 5 is not. Read the report on my signature line. At this point since you would not get your Doc soon and DMEs know nothing about it, even if you show PB graphs for Pugsy to interpret, I would discontinue using the AutoCPAP mode, and use it in CPAP mode instead, in the meantime.

Pugsy wrote:Please disregard what Avi123 has said about not using APAP. He can't have any idea what your diagnosis is based off the machines % of time in PB.

Without seeing your software reports we have no idea what is going on with your PB and we cannot offer any constructive ideas.
Call your doctor or DME and report what you are seeing on the machine and let them address the situation and your concerns and advise you on what to do.

Your doctor is the one that you should be talking to for final advice. At the best all we can do is offer ideas or explain things but without seeing your reports we can't explain anything.
While it may be nothing at all...the % of PB that you are seeing is more than I would be comfortable with seeing unless my doctor told me not to worry. I see PB sometimes myself but always less than 1% of the night. Yours is a lot more and warrants a discussion with your doctor.

It's obvious that Pugsy is giving you excellent advice and is always cautious when doing so. Good luck and keep us posted.

To Shekh Tom:

Cheyne Stoke Respiration (CSR) on Remsed S9 Elite machine in ResScan:





Periodic Breathing (PB) on S9 Elite in ResScan:

AVI,

Referring to the periodic breathing chart above: It's amazing how the sequence of left side page of wavelets and the right side page repeat closely in frequency and amplitude. This is amazing considering we are biological machines. I would expect a mechanical machine to repeat this regularly as it goes through the same sequence of gears over and over. I see why it's call "periodic" breathing.

My breathing definately resembles the Cheyne-Stokes pattern you posted. The only difference is my centrals were from 45-95 seconds in length. Some of my CSR repeats in a periodic manner, though at times we could called "aperiodic."


BTW, that periodic breathing sure is nasty looking. Those patterns remind me of class E amplifier waveforms, except the ones shown here are randomly biased to way below cut-off at times.

Looking at both charts, it's easy to see why the CSR is harder to treat since there are three cycles running through. When they are all out of phase, we get no breathing. The periodic does not contain that slowest cycle. Thus, the ASV machine is needed for more complex reinforcement or subtraction.

T

Pugsy wrote:Please disregard . . . about not using APAP. . . . While it may be nothing at all...the % of PB that you are seeing is more than I would be comfortable with seeing unless my doctor told me not to worry. . . . warrants a discussion with your doctor.

Words of wisdom, all.

ms21117 wrote:I have a Remstar Auto A Flex - Phillips- pressure settings 6/12...I've been changing the pressure settings to get my AHI's down, and they are now pretty consistantly below 5/hr. But, my Periodic breathing has been all over the chart...last 3 (1) day readings were 2.4% - 6.2% - and 11%.....my 90% reading has been below 11% each night....

All readings taken from the machine.

I've read the definitions of Periodic Breathing, but don't really understand them...can anyone explain what they are and if you thing the percentages are of concern??

Thanks!!! Great Board!!

PAP pressure “raises the gain” of our breathing control system. If you will, we have sensors in our body which monitor the O2 and CO2 levels which result in signals from our brain to our muscles to breath. The PAP pressure kind of upsets this by making it easier to breath in – so more air tends to be used.

If that “gain” gets just above one oscillation results (Periodic Breathing). The system is kind of searching for the right level. Breath too much for a bit – system says slow down – oops, too far, too far – breath too much of a bit – repeat until stability is re-established.

To look at this in broader view, some model our breathing control systems as a servo system whose gain needs to be less than one. If more than one the breathing seems to “take off” resulting in over breathing. The over breathing will likely cause arousals which will also stimulate the central nervous system and so raise the breathing gain (+loop …!). The irritation (drier, colder) caused by the over breathing can cause more AHI which will stimulate the central nervous system and raise the breathing gain (+loop …!). If the gain becomes high enough periodic breathing will result. If the gain goes a bit higher hypocapnic central apneas (such as Cheyne-Stokes respiration) will occur. As all of this occurs many cells will not get O2 when they need it, the heart will strain, the brain is particularly sensitive to the O2 / blood gas issues – well – simply – after reading a lot about what does happen I am more afraid of unstable breathing than I am of Obstructive Sleep Apnea.

You say you are adjusting your pressure. Please be very careful about that!!! If the pressure is too low your OSA is not well treated. If your pressure is to high the unstable breathing could bring you closer to stroke or heart attack and is doing harm. In my case I was forced (cannot find the medical care I need!!) to adjust. I have only reduced pressure and only (save a very short test) in CPAP mode. I gather at least a week of data (sometimes two) before I consider keeping the result or going for another change. And, it has only been reducing pressure. I am glad I have, for that matter. 8 cm/H2O is much easer to deal with than 15 cm/H2O – which was causing unstable breathing due to recent weight loss and conditioning! My AHI is lower AND I have seen no Periodic Breathing or use of large volumes of air for many days.

The short list of things I have also found help with this:

Reduce Stress!!!
Aerobic and especially interval training exercise
Less violent media.

May we find good health!

Todzo

jnk wrote:

Pugsy wrote:Please disregard . . . about not using APAP. . . . While it may be nothing at all...the % of PB that you are seeing is more than I would be comfortable with seeing unless my doctor told me not to worry. . . . warrants a discussion with your doctor.

Words of wisdom, all.

Question,

Since when most Docters know how to treat central sleep apnea syndromes? You can see in this case that Der Docter loused up.