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AF, OSA, CA, PLM & PAP experiments...
#1
AF, OSA, CA, PLM & PAP experiments...
Hi All. Long time member, first time poster, new patient.

Was sent for sleep study by my cardiologist after a persistent AF episode (now not in AF). Diagnosis was moderate OSA overall (AHI 20.7/hr), severe in spine sleep (35.2/hr). There is also PLM (23.6/hr) and a number of Central and Mixed events (avg 2.9+1.4/hr, higher in supine REM sleep - 6.8+4.1/hr).


.pdf   SleepStudy-20200609_Redacted.pdf (Size: 896.24 KB / Downloads: 12)

As we have a spare CPAP at home (wife has well treated OSA and 2 machines) I've done some experiments with some (hopefully) conservative settings to see how I respond before seeing a Sleep Specialist in a couple of weeks.

The ResMed autoset 10 (which I managed to borrow for one night only) reported a lot of CA and some clusters of OA. I suspect some of the OA is due to jaw retraction with the FF mask I was using (F30):
   

The Respironics System One (50 series) was also reporting quite a few OA's but this has reduced after switching to a nasal mask. It's also reporting a lot of variable breathing (30-46%) and some periodic breathing (1-6%):
   

Any thoughts on how to optimize this? Given my low pulse (now often 42-45 during sleep with beta blockers) I wonder if some of the CA apneas are due to (relatively) slow circulation, with a few deep breaths dropping CO2 and landing in a delayed feedback loop, but presumably some of the thinking from the cardiologist is that OSA/CSA has somehow led to the AF.

Thanks,
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#2
RE: AF, OSA, CA, PLM & PAP experiments...
You have a complex apnea as documented by your sleep study and may ultimately need ASV. I think your results on the Respironics and Resmed Autoset both indicate that the CA events identified in your diagnostic study may increase with positive pressure therapy. With the PRS1 we see a lot of flow limitation leading into your events which suggests a need for some pressure support to avoid hypopnea and RERA which are present behind the CA events. With the Autoset at 5 to 10 cm pressure with EPR 1 you had a lot more CA events, flow limitation is present but not as severe, and OA events show strong clustering which may be a positional apnea (chin tucking) that may respond to a soft cervical collar. The CAI is probably exacerbated by the EPR which is effectively the same as bilevel pressure support of 1.0 cm. Interpreting any chart will be complicated by your frequent leg movement and PLM which will often cause arousals and sometimes will show up as CA events on a CPAP.

I don't think CPAP is your best option from what we see in your diagnostic chart and confirmed in CPAP data. I think when you see the doctor, this information should be discussed and you should not accept the usual diagnosis of obstructive sleep apnea, instead you have complex or mixed sleep apnea and should be evaluated in a titration that is able to move from CPAP to bilevel and ASV to determine what therapy will actually work for you. Based on what you have presented, you are a candidate for ASV therapy which would treat the entire spectrum of problems by stabilizing your airway against OA, provide pressure support for comfort to avoid hypopnea and RERA and treat central apnea by providing pressure support to create a breath when you do not spontaneously maintain your breathing rate. Approval of ASV can be difficult as they are more expensive machines and doctors and suppliers don't enjoy the battle with insurance to get this therapy. To understand better what you're up against, you may want to read the Justifying Advanced PAP wiki http://www.apneaboard.com/wiki/index.php...P_Machines

Next time don't wait 4 years to post. Nice to see you at last.
Sleeprider
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#3
RE: AF, OSA, CA, PLM & PAP experiments...
(07-06-2020, 07:58 AM)Sleeprider Wrote: To understand better what you're up against, you may want to read the Justifying Advanced PAP wiki 

Next time don't wait 4 years to post.  Nice to see you at last.

Thanks for the detailed response Sleeprider. Being in Australia I don't have the problem of justifying a particular machine to my insurance... I just have to reach deeper in to my own pocket after the small $500/5y contribution my health insurance will kick in. Avoiding expensive detours is my main objective.

I was here originally to glean more information around my wife's treatment and never really expected to be a sleep patient myself, but I guess it's better to have some background (and easy access to machines to trial) rather than to start cold.

I was seeing a lot of OA's on the Respironics as well before switching masks. For example, with flex off:
   
Some of these are OAs are mixed (rightmost, where my pulse and flow response disappear after the second machine pulse) and others misclassified as you can see a significant flow response to the pressure pulses as well as my pulse. I found something that said that Respironics classify CA using "Pressure pulse few seconds into apnea but if larger than expected breath at end of apnea, event is defined as obstructive" (from 'Johnson, Karin Gardner, and Douglas Clark Johnson. “Treatment of sleep-disordered breathing with positive airway pressure devices: technology update.” Medical devices (Auckland, N.Z.) vol. 8 425-37. 23 Oct. 2015, doi:10.2147/MDER.S70062').

I suspect ASV may be on the horizon... just hope my sleep physician will be energized rather than frustrated by my enthusiastic analysis and preparation... I do have some experience nursing egos in IT tech support (where I need them to catch up rather than start from the basics) so hopefully that will help  Bigwink
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#4
RE: AF, OSA, CA, PLM & PAP experiments...
I see the ASV in the future as well. It does sound like there's less of a fight there in Oz to get one than over here. I do recommend the ResMed as the choice if at all possible. Best to you on the journey.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: AF, OSA, CA, PLM & PAP experiments...
The OA’s in this graph


Are more likely mis identified centrals more pressure will not help looking at the wave flows you need an ASV machine. If this is the case and your treatment is mainly out of pocket get a prescription and contact Supplier #2 and import a lightly used ASV unit they are not cheap, but there is no point incurring extra costs for an Autoset machine then a BiLevel without a backup rate and associated sleep study costs.


[Image: attachment.php?aid=24284]
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#6
RE: AF, OSA, CA, PLM & PAP experiments...
all sound reasoning except for not taking the plm into consideration, which complicates matters. your experience may not be like mine but:

I have mixed apnea and plm.

I moved from apap to asv which reduced my ahi to less than 1 but I was still not feeling as rested as I'd like.

resmed machines raise pressure / pressure support against flow limitations.

plm, in my case anyway, produces flow limitations (and sometimes hypopnea, oa and ca) between movements.

these plm flow limitation triggered pressure swings cannot overcome plm induced flow limitations and can be quite disturbing (even though I was never directly aware of them) causing arousals, leaks and aerophagia

I'm now using a bilevel (vauto with trigger set to very high for ca), and getting higher ahi, but pressure swings are avoided by more or less fixed epap and pressure support. consequently I feel better rested than with apap and asv.

your mileage may vary; just another factor to consider as you proceed.
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#7
RE: AF, OSA, CA, PLM & PAP experiments...
Thanks for your post sleepless it reminds me that every person is different and have different solutions
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#8
RE: AF, OSA, CA, PLM & PAP experiments...
no worries jaswilliams. good to have a variety of takes. meanwhile, apart from the potential for plm to cause problems, I agree that asv looks to be a better choice for the OP.
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#9
RE: AF, OSA, CA, PLM & PAP experiments...
(07-06-2020, 12:52 PM)sheepless Wrote: all sound reasoning except for not taking the plm into consideration, which complicates matters.

Thanks for the responses all... Lots to consider here.

I have experimented with a soft cervical collar. It helps with the full face mask maintaining a seal but doesn't really make any difference to any of the flow limitations or the number of events. I feel as if there are restrictions with my nostrils, particularly on the left, which can vary a lot. I've switched to a Respironics Pico mask which we had and that seems to be the most comfortable.

I've been collecting data on my leg movements. I have acquired a bluetooth 9-axis accelerometer (WIT901BLECL 5.0) that wear on my ankle to measure orientation and movement (similar to what 2SleepBetta describes in the software support forum recently). This is synchronized with the cpap data and collects at 5Hz, so picks up even pretty small twitches. In the graphs below Orientation is ~180 for back, ~270 for right, ~90 for left and ~0/~360 for prone (with some variation due to leg rotation relative to torso). Inclination measures movement (acceleration + rotation) on a log scale (with gaps when comms are lost). Clearly I move around a lot!
   

And a zoom on a 18 minute window (fairly typical of the high AHI periods) which shows breathing variation associated with movements...
   
It looks to me as if many of my breathing events are PLM related so finding some way to address the plm may be better than trying to conform the breathing...?
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#10
RE: AF, OSA, CA, PLM & PAP experiments...
The events marked as OA in your last chart appear to be CA with a slow transition into and out of the apnea rather than an abrupt restriction followed by recovery breathing which is typical for OA. That just takes us back the the likely need for ASV. We haven't talked about it, but if you are in good physical condition and of normal weight, that makes CA far more likely than OA.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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