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Pugsy wrote:

icipher wrote:If that is the definition, than any of us who have central apnea were all CSR breathing every night before treatment. I don't remember being told I had CSR at my sleep study.

Not all centrals (either full or hyponea central in nature) cause the CSR pattern...it can of course cause CSR pattern but doesn't always cause CSR.
There's more involved to making that diagnosis than the one line in the definition makes it appear to be.
CSR is not something that we normally see noted on sleep study reports as far as I have seen on sleep studies even with people who have straight up central sleep apnea on the diagnostic sleep study.

Interesting. I find it somewhat odd that the sleep study reports wouldn't indicate CSR. Seems like an important thing to catch.

icipher wrote:Interesting. I find it somewhat odd that the sleep study reports wouldn't indicate CSR. Seems like an important thing to catch.

I interpreted Pugsy's statement as "CSR is rare, even in those with diagnosed central apnea", not "most sleep studies don't report CSR". All of my sleep study printouts had fields which showed % time in CSR, how many CSR periods happened, etc. (Even though I had centrals, there were no CSR periods, and it was still on the report.)

shortcake wrote:

icipher wrote:Interesting. I find it somewhat odd that the sleep study reports wouldn't indicate CSR. Seems like an important thing to catch.

I think Pugsy may have meant that CSR is rare, even in those with diagnosed central apnea, not that most sleep studies just don't report it. All of my sleep study printouts had fields which showed % time in CSR, how many CSR periods happened, etc. (Even though there were none, it was still on the report.)

Ahh i see. Thanks for clarifying. That would make sense.

For what it's worth, I had occasinal 1% PB when I was on Bipap for a month. Now that I am on ASV my PB registers as 0% on my machine, but in my reports I see anywhere from 0% to 0.5%.

While talking about CSR here are some MOST LIKELY underlying medical conditions:

Conditions Associated with Cheyne-Stokes Respiration

Cardiovascular:
Congestive heart failure
Coronary heart disease
Hypertensive cardiovascular disease

Neurologic:
Cerebrovascular disease
Subarachnoid hemorrhage
Trauma
Cerebral tumor
Meningitis
Encephalitis
Narcolepsy

Miscellaneous:
High altitude
Sleep
Prematurity
Elderly status
CO2 narcosis
Uremia

Source: THE YALE JOURNAL OF BIOLOGY AND MEDICINE 65 (1992), 39-50
Cheyne-Stokes Respiration in Congestive Heart Failure
CHARLES LIEBER, M.D.,a AND VAHID MOHSENIN, M.D.b

icipher wrote:For what it's worth, I had occasinal 1% PB when I was on Bipap for a month. Now that I am on ASV my PB registers as 0% on my machine, but in my reports I see anywhere from 0% to 0.5%.

Do you have the Respironics ASV? I think the machine display may round to the nearest % and not include fractions. I've noticed the same thing... PB in Encore shows 0.4%, machine displays shows 0%.

shortcake wrote:

icipher wrote:For what it's worth, I had occasinal 1% PB when I was on Bipap for a month. Now that I am on ASV my PB registers as 0% on my machine, but in my reports I see anywhere from 0% to 0.5%.

Do you have the Respironics ASV? I think the machine display may round to the nearest % and not include fractions. I've noticed the same thing... PB in Encore shows 0.4%, machine displays shows 0%.

I do have the respironics 960 ASV. Do you ever see PB flagged on yours?

The PR S1 may have a minimal PB % that needs to be met before reporting it on the LCD screen. I have never seen that number documented but it may be that we need 1% (or some other %) of time in PB to get the LCD data off 0.0.
That likely accounts for the discrepancy between LCD data and report data.
Also it might be related to when the machine updates the LCD data...it doesn't do it automatically when the machine is shut off (though it does write to the SD card immediately) so in theory maybe when a person is checking the LCD screen data in relation to GMT noon is when the LCD screen gets updated.

icipher wrote: I think Pugsy may have meant that CSR is rare, even in those with diagnosed central apnea, not that most sleep studies just don't report it. All of my sleep study printouts had fields which showed % time in CSR, how many CSR periods happened, etc. (Even though there were none, it was still on the report.)

Yes, that's what I was trying to say.
Not all central breathing equal CSR breathing.
It may not be noted on a sleep study simply because it didn't occur for whatever reason.
A person has to have more than a handful of centrals on the diagnostic study to even have the centrals worthy of mention.

Pugsy wrote:Where are you located that you get a one month trial before purchasing a machine?

I am in Ontario, Canada. Elevation 70 m (230 ft). The one month trial appears to be part of the standard that doctors in this province follow although I've seen evidence in this forum of the same practice from other provinces.

Pugsy wrote:What are your pressure settings?

CPAP Mode with a pressure of 8cm H20. At this point, as far as my doctor knows from laboratory sleep and titration studies, I don't meet the specific criteria for APAP. There are defined standards for each class of machine.

Pugsy wrote:You know you did have that one perfectly acceptable AHI of 2.93..so it can happen...we like to see AHI less than 5.0..some of the other nights you were close.

Exactly. So I figure my brain is in WTF mode and adjusting to the therapy. I only have a small data sample from the beginning of this trial. I think more data is needed before any real conclusions can be made. I am prepared to be told I'm in mortal peril and to seek help immediately. I just thought some data of my airflow appeared to be PB.

Pugsy wrote:Some things to talk to doctor about when you see him.

I have a month to collect data and will certainly highlight areas of "cyclic crescendo and decrescendo change in breathing amplitude". That phrase sounds beautiful. Will definitely work it into more conversations today.

The sleep doctor and I reviewed my breathing patterns. No specific syndromes other than OSA were brought to my attention. The trial phase of the therapy is probably meant to uncover complications of applying the therapy itself so the doctor needs a chance to review. I didn't ask for a printed report of my sleep study and was just too ignorant to even know what questions to ask. Thanks to your help I will be better prepared for the next meeting.

Pugsy wrote: ... you will be seeing the doctor next week I don't advise any dial a winging stuff. Best leave this to the pros for now.

Absolutely. Too many cooks spoil the broth!

As of now I am preparing myself as best I can. Really I am just protecting against potential apathy from the DME and/or doctor. The standard of care thus far has been excellent. I want to ensure it stays that way.

SleepWrangler wrote:CPAP Mode with a pressure of 8cm H20.

Thought you might be in Canada as they go about the titration thing differently.
Since you are using fixed pressure then we can't blame them on APAP running wild and since your 8 cm pressure is really rather mild we can't blame them on higher pressures.
Not sure what to blame them on at the moment. Are you using EPR and if so at what setting? Sometimes with a few rare people EPR will trigger those centrals and the CSRish looking breathing pattern.

Your obstructive type of events seem to be well controlled with your current 8 cm pressure..some things to talk about with doctor might be a slightly lower pressure to see if there is threshold where below it you can keep the obstructives well controlled and not trigger the centrals (assuming that they are pressure driven which they may not be)...you appear to have some wiggle room for lowering the pressure a little or talk with him about EPR maybe.

EPR..is normally considered a comfort feature and usually no one gets all upset if we go messing with it.
There's 2 ways to maybe have it impact the centrals..
If not using EPR..maybe add it at a setting of 2 or 3 to see if the slightly lower average pressure impacts things...sort of making the machine work like a bilevel machine which sometimes is sufficient for central prevention.
If using EPR then maybe turn it off as there are a few cases (rare) that EPR triggers the breathing pattern with centrals.
Don't see this often but it can happen.
So you might discuss that with him also...or play with EPR yourself if you have a mind to.

Finally it may just be a matter of time getting your body used to cpap therapy and the centrals might go away on their own.
From what I have read...6 months or so...and that is why I am mentioning all the other stuff as ways to reduce it.
We would hate for you to buy this machine and 6 months from now still have problems and need that high dollar machine.

Sorry OP if I have hijacked your thread but you can definitely see what looks like PB!

Pugsy wrote:Not sure what to blame them on at the moment. Are you using EPR and if so at what setting? Sometimes with a few rare people EPR will trigger those centrals and the CSRish looking breathing pattern.

EPR is set at 3.

Here is a really dense set of CA events. As you say, there are some nights that are good except for a few too many CA events per hour so the treatment isn't completely ineffective and thus gives me confidence. I will have questions for my doctor about my titration. I suspect an EEG may show that I am awake during these periods. Not alert but not sleeping either. If I am awake I don't remember. Regardless, this has to go away with time or get fixed.

Pugsy wrote:Finally it may just be a matter of time getting your body used to cpap therapy and the centrals might go away on their own.
From what I have read...6 months or so...and that is why I am mentioning all the other stuff as ways to reduce it.
We would hate for you to buy this machine and 6 months from now still have problems and need that high dollar machine.

Yes. I keep my grubby fingers off the shiny knobs and dials until the professionals tell me "see you in six months". At that point if I believe there are additional gains to be had I will apply the ideas you've outlined.

I appreciate you taking time to mentor me. Much appreciated.

SleepWrangler wrote:Here is a really dense set of CA events.

EWW...ugly for sure just make sure to go over all this with your doc next week.
There's a thing called sleep onset centrals which are relatively normal except when we have a truck load of them and they keep bouncing us out of sleep only to go back to sleep and have another and get bounced out again. Have no way of telling if that is the case here and you likely would benefit from a real in lab sleep study with a live person in attendance to have a better idea what is going on here and the best way to proceed. Personally unless I was having more good nights than bad nights...that is what I would push for and I wouldn't buy a machine until these things are sorted out. I wouldn't have a whole lot of faith in "time" fixing all of those.

Good luck to you and when you find out would you let me know....I am curious as to what they find as it helps me learn.

Pugsy wrote:Good luck to you and when you find out would you let me know....I am curious as to what they find as it helps me learn.

I had my first post-CPAP meeting with my sleep doctor. She was was very interested in how I felt and to review any ResMed charts with me. Back on March 9th, within a week of starting therapy, I had one of the most miserable nights ever with CPAP. I woke with headaches, tired, eyes sore and red, and still needed a granny nap to make it through the day. During the first few weeks I had the same symptoms although progressively getting better. Fewer horrible nights as illustrated in the following flow graph.



A more recent annotated flow graph as of April 20th is shown below. A vast improvement with no changes to the prescription (8cm H20 CPAP). Some of the clear airway events appear to have happened while awake but only an EEG can be conclusive. Lately I have been waking because of leaks blowing air into my face and tear ducts, and because my mouth is open and completely dry. Today I wake headache free, rested, eyes are clear, slight energy dip in the early afternoon but don't granny nap at all. My expectations are being met. I still want improvements but would rather make small tweaks and adjustments on my own.



The doctor was not concerned with the BP, her words when I showed her the ugly flow graphs, and said it was my brain rejecting the sudden change of sleep environment as a result of CPAP. Given the turn-around after a few weeks she was confident that CPAP is working as it should. I agree with her. She was more concerned with my limb movements, particularly my legs. During the study I moved 13 times per hour, and 11 times after titration at 8cm H20. I think things have improved because my bedding no longer looks like a tornado strike in the morning. I didn't pursue the offer because with good sleep hygiene and CPAP it doesn't appear to affect my sleep.

She signed a prescription for a follow-up sleep study in November (to be used at my option). Having a prescription means the procedure is completely funded by the national healthcare system.

Now on to the dial wingin, mask adjustments, and fine tuning to see if I can consistently achieve AHI<2!!!

SleepWrangler wrote:The doctor was not concerned with the BP, her words when I showed her the ugly flow graphs, and said it was my brain rejecting the sudden change of sleep environment as a result of CPAP. Given the turn-around after a few weeks she was confident that CPAP is working as it should. I agree with her.

Thank you for the follow up.
Given the marked improvement with just time...your doctor is most likely spot on. Some people do get centrals after starting therapy and they go away as the body gets used to this therapy. Some people either can't or won't wait to see if time fixes things. Some don't go away..so that's why I think that having a doctor at least be aware of them so that something can be done if the need arises.
Things are looking good and you are feeling good and that's what is important.

Pugsy wrote: Thank you for the follow up.
<snip>
Things are looking good and you are feeling good and that's what is important.

I am willing to let the process go where it may and have the doctors do their thing. It's only possible to let that happen knowing I have your expert help, and others on this forum, by just posing a message for help. Thank you for your support. Yes, I am so glad to have energy again. The best things in life are not things.