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Cheyne Stokes -Should I be concerned
#1
Cheyne Stokes -Should I be concerned
Hi, 

I'm having CSR show up in my data every three nights or so, and both the sleep doc and my GP are pretty dismissive of my concerns, should I be pushing harder to get this looked into?  

I haven't had a stroke or congestive heart failure that I know of, though the frequency and % of time in CSR jumped up significantly and has stayed up after an OD with lorazepam and oxycodone last summer (I still take lorazepam to help sleep, oxy I haven't had since).

Thanks for taking the time to look.


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#2
RE: Cheyne Stokes -Should I be concerned
It could very well be from the meds you are taking. Discuss that possibility with your doctor.
If he still dismisses you, ask for a referral to see a cardiologist and have some tests run.

It’s worth having peace of mind.
OpalRose
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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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#3
RE: Cheyne Stokes -Should I be concerned
if that was my chart, I'd be looking for guidance from my providers, not dismissal, if only to bring my ahi down to an acceptable level. I wouldn't hesitate to ask for a good reason why csr and ca shouldn't be concerning. as OpalRose said, it could be the meds but don't you deserve to know?
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#4
RE: Cheyne Stokes -Should I be concerned
A lot of people come to the forum with periodic breathing that is labeled CSR, but yours looks to be real. Clearly, we do not want to see CSR due to it's close association with congestive heart failure, however there are other reasons it may be present. You are having a considerable number of central apnea that CPAP cannot treat. It would help if you did not include the monthly calendar so that more respiratory and settings information could show up on the chart. While your settings are not included, it appears you are using EPR. I'm going to suggest you turn off EPR and we might also consider dropping the pressure setting a bit. Let's start with the EPR and see if turning that off stabilizes the CA events and CSR.
Sleeprider
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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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#5
RE: Cheyne Stokes -Should I be concerned
I agree with SleepRider, this CSR looks real.  
Let's work on trying to minimize this, IMHO it is likely significant.
It is likely that an ASV is in your future, but we need to work with what you have.

Just to supplement info here.  You have 2.45 hours of CSR (assuming the machine correctly captured all of it) over 29 % of the 8.33 hr night with a net CAI of over 5.
The above qualifies for a diagnosis of CSR. (But that is up to your doctor)

Some of the article is outright scary.

Etiology
Cheyne-Stokes respiration is a specific form of periodic breathing (waxing and waning amplitude of flow or tidal volume) characterized by a crescendo-decrescendo pattern of respiration between central apneas or central hypopneas. The American Academy of Sleep Medicine (AASM) recommends to score a respiratory event as Cheyne-Stokes breathing if both of the following criteria are met:
  • There are episodes of at least three consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds).
  • There are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of two hours of monitoring.
https://www.ncbi.nlm.nih.gov/books/NBK448165/

Unlike obstructive sleep apnea (OSA) which can be the cause of heart failure, Cheyne-Stokes respiration is believed to be a result of heart failure. The presence of Cheyne-Stokes respiration in patients with heart failure also predicts worse outcomes and increases the risk of sudden cardiac death. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options.

Treatment / Management
The main cornerstone of management of Cheyne-Stokes respiration is optimizing the treatment for the trigger factor, congestive heart failure (CHF), or stroke. The American Academy of Sleep Medicine recommends that positive airway pressure should be considered for all patients with central sleep apnea. The two main modalities of noninvasive treatment for Cheyne-Stokes respiration are continuous positive airway pressure (CPAP) and adaptive servo-ventilation (ASV).[8][9][10][9]

CPAP delivers continuous positive pressure and has several mechanisms of actions. The positive pressure keeps the upper airway splinted during the central apnea, leading to stabilization of respiratory drives and improvement in oxygenation and ejection fraction. The positive pressure will also reduce the preload by reducing the venous blood flow to the right atrium and afterload by increasing the intrathoracic pressure, thereby improving the ejection fraction. In a clinical trial, CPAP therapy in patients with Cheyne-Stokes respiration showed improvement in nocturnal desaturation, Left ventricular function and six-minute walk distance, but there was no improvement in survival.

Adaptive servo-ventilation is the newer modality of noninvasive treatment which is effective and well tolerated by patients. This mode of noninvasive ventilation can counteract hyperventilation during the hyperpnea phase and prevent hypoventilation during the apnea phase. It delivers constant continuous pressure and can recognize apnea or hypopnea and adjust pressure support with backup ventilation if needed to deliver preset tidal volume. During the hyperventilation phase, the pressure support is reduced, depending on the patient to prevent large tidal volume. Adaptive servo-ventilation is more effective than conventional noninvasive ventilation therapies like continuous positive airway pressure and bilevel positive airway pressure therapy and has been shown to improve the functional class, cardiac functions, exercise capacity and brain natriuretic peptide (BNP) levels. However, in a recent large clinical trial involving patients with systolic heart failure and Cheyne-Stokes respiration breathing, the addition of adaptive servo-ventilation to guideline-based medical therapy did not improve outcome and increased the risk of cardiovascular death.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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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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#6
RE: Cheyne Stokes -Should I be concerned
I am dealing with a more severe case of CSR in this thread http://www.apneaboard.com/forums/Thread-...ice?page=3 where the patient has a recent history of cardiac infarction. There is little doubt in my mind, that his heart injury need to be reassessed to evaluate whether it has moved to congestive heart failure, and to screen him for use of ASV therapy. In responding to his concerns I came across recently released preliminary data from the 2018 ADVENT-HF study which is reevaluating the use of ASV in heart failure patients, and seems to be finding no additional risk in the use of ASV https://www.mdedge.com/chestphysician/ar...-no-safety Should this study hold constant, then it may well be that the limitation on using ASV in CHF cases with reduced left ventricular ejection fraction will be overturned, however, results here are preliminary, but promising.

Meanwhile, I encourage you to try reducing EPR on your CPAP to see if that helps. Due to the presence of CSR breathing patterns and plenty of CA events, you do need to be evaluated for the central apnea, and more importantly to be sure nothing has happened to your heart. If you have been feeling at all sick, fatigued or have other symptoms, please consider going to the emergency room for an EKG and for a blood test to check if Troponin levels are normal. Troponin is a very sensitive indicator of heart injury and can detect if you may have had a silent heart attack or infection that resulted in the change in your health. The emergency room will not ignore you, and can save your life or provide a lot of peace of mind. Either way, it can quickly move you to a higher priority to address the centrals and CSR. No doctor should dismiss these symptoms.
Sleeprider
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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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#7
RE: Cheyne Stokes -Should I be concerned
Thanks for all the feedback everyone, really appreciate it.

Hi Sleeprider I attached more settings etc info from another night with a lot of CSR, and also an overview for the last couple of months, like I said I don't see it every night.

I'll try lowering the EPR setting tonight and see what that does, and go down another notch in a few days.

I have an appointment with another doc in a week, regarding something else, I'll see if he can do a req for some testing, or give me a referral.

Thanks again


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#8
RE: Cheyne Stokes -Should I be concerned
Well, the centrals have been going on for a while, so this is not a sudden acute issue. We can see where EPR takes you, but assuming good heart health, the ASV is going to be in your future. You will do great with it! Your respiration statistics are exactly what they should be, other than your have this central apnea, and apparently it sometimes evolves into CSR. This may well be idiopathic (without known cause). You should not tolerate a doctor dismissing a potentially serious condition, and poor therapy results.
Sleeprider
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www.ApneaBoard.com

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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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