central sleep apnea - what does it take to make a diagnosis?

OK, so I went to a second sleep study the other night. First one I went to, they had left the remote machine set on timed cycling - and it was a short time cycle, too. Pressure had been 10, they decided I needed a 17.

Now, I have had a sleep study fail - I simply could not get to sleep. They titrated me and came to the 10 - but they titrated me in an hour.

So now I stay up the night before and then sleep for three hours in the morning. Then I try and stay awake all day.

So, I was being restudied last night and I fell asleep sitting up. Probably napped for three hours - I was no longer tired and did not expect to fall asleep. They told me to take sleep meds if I was used to them. I took 6 mg of Sonata.

I supposedly went to sleep very quickly - then, after 20 minutes I thought I heard a sound like a buzzer, and bam - i was wide awake. Took another sonata and finally got back to sleep (after the tech kicked all the wires out).

She finally got the 2.5 hours of recording time she wanted and noted an apnea rate of 14 per hour - well, I have insomnia and daytime tiredness so that will get me past medicare.

Then into the mask. It was blowing constantly this time. She said that the same pressure was needed (17) and that she noted that I was having central apneas as well as obstructive apneas.

So, Q1: Could central apneas be caused by Sonata?

Q2: If the tech could not reduce central apnea with CPAP, does that mean that I need a second study with BiPap or is it just accepted that once there is a diagnosis of central sleep apnea that can't be reduced with CPAP that I should be prescribed a BiPAP?

If your diagnosis based on a sleep study, indicated only centrals, then an xPAP is not likely to be the ideal therapy device.

The main issue with Centrals is determining if a person has only Centrals (i.e. as in Stokes-Cheynes Breathing (one def="A type of respiration characterised by periodic breathing that alternates with hypopnea or apnea. ")) or has mixed Apnea (Centrals and Obstructive Apnea).

The likelihood of having only Centrals is the more rare situation & often associated with some other pre-condition or trigger event (such as a stroke).

If somone is determined to have mixed apnea (centrals and obstructive) then the issue becomes what is the primary cause of each. That can get quite complicated to determine as there are so many different factors influencing each (weight, health, pre-conditions, etc:).

Good luck

brasshopper wrote:She said that the same pressure was needed (17) and that she noted that I was having central apneas as well as obstructive apneas.

Q2: If the tech could not reduce central apnea with CPAP, does that mean that I need a second study with BiPap or is it just accepted that once there is a diagnosis of central sleep apnea that can't be reduced with CPAP that I should be prescribed a BiPAP?

Central apneas mixed with obstructive apneas often result at higher pressures. However, this is also often a transient condition and central apneas often go away after one gets accustomed to xPAP. Others have posted here that their health care providers often aren't very concerned when they see mixed centrals and obstructives during a titration.

A BiPAP is common at that pressure. Also, if they think your centrals require more than a BiPAP they may put you on an S/T machine.

Regards,
Bill

Hi, a lot of people have some central apneas when tested, but they're not necessarily numerous, or harmful unless there are really a lot and they dominate the study. I was worried too, but I think your DME tech might have worried you needlessly by not elaborating on how many there really were, or anything else. It's really quite rare to have 'central sleep apnea' itself, and unless your MD or testing, etc. has shown other problems that would point to CSA being a serious thing, you probably could just relax until further notice.

See if you can get the obstructive component handled via a combination
of the Pillar procedure and use of a Dental Device, or alternatively
through the use of a BiPap machine. If you have a true Central problem,
it will still be there after a couple of months. However, if you are like
most folks; you will have 2 or 3 centrals per night (either right when
you are falling asleep, or right as you are waking up). So Sleep on your
side, try Melatonin, try different masks, be adventuesome and look at
your nightly data. See an endocrinologists to get your blood and urine
levels checked out. Things like Uric Acid, Cortisol, various Hormones, etc.
See a cardiologist for a full workup to look for underlying cardiac
problems. All of this assumes you have outstanding health insurance.

Hi Brasshopper. Glad you threw out the question about the centrals because I'm trying to understand them better also. My neuro doc expressed real concern at the possibility of me having mixed sleep apnea. That's part of the reason he's sending me to Cleveland Clinic for a consultation (along with probable Narcolepsy). On the night I got my cpap, I had a few centrals (more with increased pressure), which the sleep doc didn't find signicant enough to mention but the neuro doc did. I will ask for more info about centrals while in Cleveland and post their doc's response by the weekend.

P.S. Sorry about leaving the chat room so abruptly the other evening while you were looking at my organ donor awareness items. I accidentally logged out and you were gone by the time I got logged back in. Didn't mean to be rude.

I'll try to be clearer:

I have had a long standing diagnosis of OSA. I was diagnosed in the late 1980's, and I have been using a CPAP (same one) since then. My compliance rate is very high - I normally do not sleep without the CPAP, ever - maybe one night in 30 I used to fall asleep in a lounge chair. In the late 1980's, I was diagnosed with OSA by a pulmonologist who saw an enlarged primary pulmonary artery on a radiological study, which he thought indicated long term apnea. He ordered the sleep study, which confirmed it. I had been a snorer since at least the early 1970's - I used to wake myself up with the volume of my snoring when I was in the Navy and I had a reputation for loud snoring - although at least I did not moan in my sleep like one guy did. Back then we thought we had no issue with snoring other than volume and bothering people in their sleep. We thought.

This was a retest - one, to get the new recording needed for medicare, since my original study had been an in home study (one eeg channel, tech came to my house and hooked me up, one night for diagnosis and one for titration) and home studies are not accepted by medicare, and a retitration, since I was starting to feel like sleep was not restful, and like my pressure of 10 was "not enough". Last time I thought my pressure was not enough, I was retitrated and they increased me from 7 or 8 to 10. This was the one hour study from several years ago where I could not sleep for most of the night.

I had gone to the same sleep study place in Fort Myers, FL a few days ago. They had left the machine set to timed cycling (bipap, but not needing a clue from me to shift - in fact, laying on the bed it pulsed at the same rate) and when I pointed that out to them they agreed that it was a mistake and scheduled me for another study.

This study's sleep pattern was, "almost immediate sleep, awake after about 20 minutes". (I thought that I might have dreamt hearing a buzzer, probably because I was not using my CPAP and I have trained myself, over the years not to sleep without the CPAP and to wake if I am not wearing it). At that point I had trouble going back to sleep and I took another sleeping pill. When I asked the tech to get me the pill from my bag, she kicked out half my wires and it was a mess to get them reattached. They used a paste that washes off with water to anchor the hair leads instead of the acetone dissolving stuff I remembered from past studies. It is easy to dislodge the leads - first night I did not dislodge any, and slept like a rock. This night it was a mess, I felt like I had no sleep at all in the morning. Constant reconnections.

Anyway, this time I "slept" (that is, I woke 14 times an hour until roused without remembering waking up) until about 2:30, when they switched me on to cpap. Because the tech knew about the pressure I had before, she jacked me to 17 quickly. This pressure stopped the OSAs and the tech saw some CSAs. I am slightly worried that she has given me too high of a pressure but I am hoping to get an APAP through medicare to replace my nearly 20 year old machine, so that should "fix" the pressure.

The sleep tech was clear when she talked to me, although I was not. She cautioned me that she was not qualified to read sleep studies and that I should wait for the report, but because I had reasonable knowledge she felt comfortable talking to me. She also did not suggest a diagnosis, she just talked about what she saw.

But I knew she had to know what an apnea was to titrate. She said that there were plenty of OSAs, and they were resolved with the 17 pressure. There were a "couple" of CSAs (and I was not near either when I went to sleep or when I would have normally have awoke) when I was titrated and sleeping at a pressure of 17. I assume the details will be in the report.

Given that I have spent years using CPAP and, at least, the last 6-7 years at a pressure of 10, it is not like I am a brand new CPAP user, although the pressure is significantly higher than what I am used to.

The "10" pressure never bothered me - 17 did. I could feel it and it was not as easy to breathe out.

I have also switched from a nose mask, the sort that they were making 20 years ago, to a Resmed swift, in just the last couple days, which might have been a bad idea because of the higher pressure.

I had dental surgery last year. I went to a cardiologist for a pre-operative clearance. The cardiologist did a complete workup, including stress EKG and technium scans to show that my heart was picking up gases properly. He said that I have as good a heart as I can expect at my age, better than I should expect given my weight and exercise amount. I have regular blood work due to diabetes and all tests are more or less normal. There were no abnormalities and the technium uptake was complete (no blocked areas).

I have secondary insurance but it generally only kicks in if medicare refuses to pay for something.

Or if I am out of pocket for more than 3k in a year. It also covers prescriptions, which is very important to me. I use a couple thousand dollars of prescription meds every month.

Anyway, it sounds like I should (1) be sure I get a machine that can record so that I have something to discuss with the sleep doctor (2) should get an APAP because I don't quite trust the pressure (3) talk about the CSAs with my pulmonologist but I should not expect them to worry about them since they are common with the increase in pressure and (4) expect a prescription for a CPAP, not a BiPAP, and I might well want the Respironics that lowers the pressure for a moment at the start of exhalation for comfort.

I guess no one has heard of sonata causing CSA. The obvious answer for "cause of OSA" would be my weight, except that I was quite thin when I was waking myself up with the volume of my snoring. I've gained weight ever since then because of my pain issues and the associated inability to exercise. I suppose it is possible that surgery could stop the apnea, but, frankly, I'd rather wear the CPAP than do the surgery - I've seen someone do apnea surgery before, the pain was tremendous. Pillars might be easier, but, well, I generally like breathing through my nose as I sleep and I can't nose breathe while sleeping without the CPAP. I'm a person who actually prefers the CPAP, at least at my old pressure. I've also never used a humidifier before. I expect that I will use one now.

brasshopper wrote: (4) expect a prescription for a CPAP, not a BiPAP, and I might well want the Respironics that lowers the pressure for a moment at the start of exhalation for comfort.

Brasshopper, you might want to consider the BiPAP-auto, unless you'd just prefer a CPAP-auto (don't know why you would though). At your high pressure BiPAP's are routinely prescribed rather than CPAP. Compare the BiPAP-auto vs the other machines on CPAP.com here:
https://www.cpap.com/cpap-compare-chart/all-BiPAP
[EDIT: The chart states that the BiPAP-auto doesn't do CPAP, but that it incorrect. My BiPAP-auto does CPAP very nicely.]

Unlike APAP's which are often difficult for folks to get, nobody has come here with a story about the BiPAP-auto being hard to get, probably because it's very close to the same price as a regular BiPAP. The BiPAP-auto also provides the same detailed recording capabilities (hint: get the software) as the Remstar-auto along with Bi-flex which may ease the transition to higher pressure even more for you.

Sounds like you have things under control. Hope this change in xPAP therapy works out to your satisfaction.

Regards,
Bill

I second NightHawkeye's idea. If you were correctly titratred at 17cms then a bi-level machine where you can set a specific reduced pressure on exhalation will make breathing out a whole lot easier.

It is not unusual for an individual to have some central apneas periodically during the night. Experiencing occasional central apneas is not the same thing as the rare diagnosis of Central Sleep Apnea.

There are a number of reasons that a person may have a “central apnea” during sleep. Central apneas occur when there is no effort to breathe (no movement of the chest or abdomen). Most of the time these central apneas—not to be confused with central sleep apnea—are normal hysiologic events.They often occur after we sigh or when we take a larger than normal breath and lower the level of carbon dioxide in our blood.They are more apparent when we are sleeping because there are fewer overriding factors controlling breathing when we sleep.We frequently see central apneas in the period of transition between being awake and being asleep, either when you first fall asleep or after any awakening during the night. It would not be unusual for you or your wife to notice apneas at these times. In central sleep apnea, an uncommon form of sleep apnea most often seen in individuals with heart failure or stroke, the central apneas occur frequently throughout the night. In addition, there are some individuals who have what is termed “idiopathic central sleep apnea” because their breathing center is overly sensitive to slight changes in carbon dioxide in their blood.
If you are sleeping well and are not sleepy during the day, and if your “apneas” occur only occasionally, it is unlikely that you have anything to worry about. If you have any concerns, however, you should follow up with your sleep specialist.

Kathe Henke, Ph.D.,A.B.S.M.,
Sleep Disorders Center of Virginia,
Richmond,Virginia

Central sleep apnea usually occurs in people who are seriously ill. For example, it can occur in people with a variety of severe and life-threatening lower brain stem lesions. The brainstem controls breathing. As a result, any disease or injury affecting this area may result in problems with normal breathing during sleep or when awake.

Conditions that can cause central sleep apnea include:

Bulbar poliomyelitis
Encephalitis affecting the brainstem
Neurodegenerative illnesses
Stroke affecting the brainstem
Other causes include complications of cervical spine surgery, secondary radiation in the region of the cervical spine, severe arthritis and degenerative changes in the cervical spine or the base of the skull, or primary hypoventilation syndrome.

There is a form of central sleep apnea that commonly occurs in people with congestive heart failure. Finally, idiopathic central sleep apnea is when the apnea is not associated with another disease.

http://www.nlm.nih.gov/medlineplus/ency ... 003997.htm

Medicare calls Bipaps breathing assistive devices. They don't consider them simple alternatives for CPAP, they won't allow them to be prescribed simply because the doctor thinks that compliance will be better, or because the patient complains that the pressure was uncomfortable. You actually have to fail, which, means, I guess that at month three (or perhaps earlier, but medicare requires a compliance audit between day 61 and day 90 to pay month 4), you go to your doctor and say, "I am not using the damn thing because it is too uncomfortable - it wakes me up because of the effort of breathing out against it."

You do not qualify for a bipap if you have simple OSA, unless you fail with CPAP. If you get a diagnosis of CSA or mixed apnea, you can get a bipap - and it can be with or without a backup timer, at the physician's choice, based on medical opinion. But there has to be a study that shows that BiPAP will be effective if BiPAP is prescribed as a first device for mixed or CSA. There are other indications for BiPAPs, COPD, thoracic problems, etc. They don't apply to me. I definitely have OSA. Other diagnoses will wait for the physician to review the tests.

From what everyone has said here (and I appreciate the effort people have put into the answers) I may or may not get a diagnosis of mixed apnea, and it will depend on what my pulmonogist considers significant.

If my pulmonologist decides that I have mixed apnea, then they will have to study me again (or ressurrect the first study - if the bipap that they mistakenly used during that study turns out to be effective in stopping the CSA, then they might be able to write it up). As I read the medicare regulations, (hard to find for BiPAP, search for DME, then for L5023 Respriatory assist devices in the resulting list). CPAP is listed under that name, BiPAP is listed as a Respriatory Assist Device, you might need up to three studies to comply if you have CSA. First, a diagnostic study which determines sleep apnea, second, a titration study which fails because of CSA and third, a BiPAP study.

Section 280.2 is where Medicare does not cover white canes for the blind because they are not devices that make a meaningful contribution to their treatment. I found that oddly amusing. The point is that there are lots of little laws about this and the DMEs that deal with Medicare know how to deal with the maze, and I doubt that many others do. I am fairly sure my doctor does not. I found one copy of the Medicare regulations that said that 2 hours of recorded sleep were required and other regulations that said that 2 hours of recording were required - I think that applied in some other states, in Florida I may need two hours of actual sleep recorded. And now I'm worried I'm a few minutes short.

[quote="brasshopper"]I'll try to be clearer:


I have secondary insurance but it generally only kicks in if medicare refuses to pay for something.

Or if I am out of pocket for more than 3k in a year. It also covers prescriptions, which is very important to me. I use a couple thousand dollars of prescription meds every month.

I guess no one has heard of sonata causing CSA.

I've gained weight ever since then because of my pain issues and the associated inability to exercise.

It appears the issue isn't the machine's usefulness for you, but Medicare's policy. Any doctor could write you a prescription for a bi-level right this minute (Bipap is the Respironics trademarked name for their version) and you could have your machine within a week. But Medicare won't pay for it so you would have to buy it out of pocket? That's terrible! If you don't purchase it on your own, you have to wait. You have to play by Medicare's rules and get lousy treatment for 3 months. I guess 3 more months isn't that big a deal, but how frustrating.

On this forum it seems a lot of people have purchased bi-levels because of high pressure requirements for ease upon exhalation. I wonder if this means they all bought their machines out of pocket because they didn't qualify for it under their insurance rules and regulations. Or is this just a Medicare issue?

I only had a few central apneas at my PSG, which they said was normal, so I don't have Central Sleep Apnea requiring a bi-level with timed backup, but my pressure is high so I'd like the exhalation relief of a bi-level. I have been looking at the Respironics Bipap Auto with Bi-Flex for myself. It is $1330.00 at https://www.cpap.com which is about 1/4 the cost of what my DME charges. More and more I'm seeing why so many people just forego their insurance altogether and buy online. I'm saving up.

Hi,

Don't have a lot of answers for you (wow, am I impressed about how much people on this site know!), but I can tell you that I had some CA's mixed in with my OSAs. My sleep md is great and he never mentioned them, so I'm guessing he wasn't concerned.

I do suggest that you talk to your sleep dr, not the tech. I know techs know a lot (a LOT!), but my sleep center seemed to be very careful about having them give me any info other than what they were going to do in terms of the sleep study. So, I suggest you talk to your dr -- and push until you get the information you need. Sleep studies are very expensive and highly profitable -- so every one of us deserves the answers we need on important questions. Ask, ask, ask!! (I'm lucky, my dr lets me ask ad finitum)

feelinfab wrote:Hi,

Don't have a lot of answers for you (wow, am I impressed about how much people on this site know!), but I can tell you that I had some CA's mixed in with my OSAs. My sleep md is great and he never mentioned them, so I'm guessing he wasn't concerned.

Me too. Only my sleep md did discuss the CAs because I asked about them. He said, despite the number, they were typical and insignificant. Now that I've read about how rare and serious central sleep apnea is, I am even more relieved than I was then when I didn't realize the full importance of the diagnosis. I never thought I'd be happy that I just have OSA with some centrals thrown in, but knowing what I know now, I feel lucky!