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Cheyne Stokes isn't always heart related
#31
RE: Cheyne Stokes isn't always heart related
Don't forget to include leaks when evaluating tidal volume or minute vent.
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#32
RE: Cheyne Stokes isn't always heart related
I am teaching virtual class this week (Mon-Thur) 7 hours a day, so I am HOPEFUL I don't have big issues. They aren't expecting a zombie....

After that, I have some weeks to experiment with EPR, etc.
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#33
RE: Cheyne Stokes isn't always heart related
I wonder what your flow rate looks like masked up awake during the day? do you normally breathe shallowly?

now we know the reason for your username! with cold feet, low pulse rate, dreams of feet being beaten: maybe you should take this up with your GP. I have no knowledge of what must be a variety of things that could cause circulatory problems; some might be serious (?). are you diabetic? have a heart condition? arterial sclerosis? pulmonary issues? (just brainstorming here; I have no particular reason to think they apply to you.)

in my experience BP meds can drive pressure too low. I checked my BP 3 times a day for several months and was surprised to learn it was highest in the early morning, then after taking a 2nd med in the evening (first one in the morning) my before-bed BP was so low I felt faint. I found mild exercise most effective in reducing high BP (along with meds) and some strains of cannabis that I use(d), ostensibly to help sleep through plm, also significantly lowered my BP (I thought it would raise it).

anyway, the point is that you may have internal or external things other than apnea going and that you might be wise to ask your doctor to evaluate your complaints.

another kind of way out there question in my mind, although I have never heard of it, is whether such shallow breathing is somehow related to the cause of your periodic breathing and ca.
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#34
RE: Cheyne Stokes isn't always heart related
Smart idea. I should mask up during the day and try it for five minutes and then switch to the shallowest I can breath without distress for another five. Then I could dig into the charts (I'll wear the ring as well).

I don't have diabetes (had my annual physical), heart work up done last year says things are ok. I have a slightly enlarged Aorta (the number 4.1 comes to mind??) that was discovered when I went to the emergency room last year. I have Costochondritis (inflammation of the cartilage in the sternum) and when it flairs up (stress, excessive physical activity, etc.) it can mimic the chest pain of a heart attack. What was stressful in 2020 that could have triggered that....

The enlarged aorta sent me for the workup. Heart Dr. said it wasn't an issue (sometimes ER folks and specialists disagree on what is an issue) and the expensive tests were fine. I reported the cold feet to the heart Dr and my GP. Neither seem to feel it was worth investigating, I presume because I could just wear socks to fix it.

My meds aren't for BP, but they have the side-effect of lowering BP. I am going to head to a neurologist about the occasional burning sensation in my feet. Sort of feels like the cool feeling when you put on a menthol rub, but it happens when socks and shoes on!

Looking back I can kick myself for not pushing the issue of the cold feet and legs harder with the Drs. That might have uncovered the SBD five years ago.
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#35
RE: Cheyne Stokes isn't always heart related
I am back....  and I've learned a lot.

I have been able to adapt to my N30i nasal mask but still struggle with large mouth leaks. My attempts to control those leaks scared me. I had a tight chin strap and a molded mouthguard and it definitely helped on major leaks, but I started to have front tooth pain so I STOPPED THAT IMMEDIATELY! If I can control the mouth leaking, my AHI is about 2-4. As we all know though, this number can deceiving. My usual pattern is a rash of CAs in the last 1-2 hours of the night that are an AHI of 15-20 over that time but averages out to 2-3 over the night (such a bogus way to measure things for bean counters at the insurance company).

Are these late CAs related to REM sleep? Isn't most of the REM typically in the last part of the night? My CAs start with cyclical breathing that starts to take on the look of CSR and then it breaks into a string of 10-15 CAs over a period of 15-45 minutes.

I have tried the F30i (small and medium)on three different occasions and I can't get a good seal with my nose. That really frustrates me because it is a minimal mask. I tried the F20 again last night (with the memory foam) and it is cumbersome, but I was able to get it to seal ok and wore a neck collar to keep my chin up. I woke a couple of times in the night but my chart is brutal. My AHI jumps to over 10 every time I have tried a full face mask. I've attached my chart.

I limited my pressure to near 10 and I am wondering if I have to up my pressure because a face mask can't apply enough as much pressure in nose and mouth as just nasal?  My OAs with the face mask (almost gone with a nasal mask at 10) were substantial.

I am thinking I change the limits to 8-15 and try the F20 again tonight.


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#36
RE: Cheyne Stokes isn't always heart related
about half your ahi might be reduced with a soft cervical collar. if you're already using one, try a different size, style, fit. use just one low profile pillow. if oa stays high after that, you probably do need higher pressure but of course that's likely to increase ca. you can play around with pressures to find the best balance between oa and ca but I'd take that mess of a chart to my doc and demand better, i.e., asv. meanwhile, I still see hints of plm in your flow rate. it's worth ruling plm out or getting treatment for it because it really screws up pap treatment whether apap, bilevel or asv.
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#37
RE: Cheyne Stokes isn't always heart related
(04-15-2021, 04:01 PM)sheepless Wrote: about half your ahi might be reduced with a soft cervical collar. if you're already using one, try a different size, style, fit. use just one low profile pillow. if oa stays high after that, you probably do need higher pressure but of course that's likely to increase ca. you can play around with pressures to find the best balance between oa and ca but I'd take that mess of a chart to my doc and demand better, i.e., asv. meanwhile, I still see hints of plm in your flow rate. it's worth ruling plm out or getting treatment for it because it really screws up pap treatment whether apap, bilevel or asv.

Thanks for the speedy reply.

I was wearing a 3" collar to keep my chin up so the mask stayed tight across my chin and mouth.

Is the plm from struggling to breath? I am curious how flow limits are related. I was thinking flow limit related to a constriction of the flow (approaching an OA).

Is treatment for plm something like Ropinorole? All my Dr. offered is Modafinil for sleepiness and he said my numbers looked good. (I HATE how everything is reduced to 'your AHI is good enough'.)

I've attached a chart from the night before with my n30i and chin strap (no mouthguard). I've been wearing the chin strap for over two months and I just can't seem to train my mouth to stop leaking (even when I put my tongue on the roof of my mouth whenever I wake). Those large leaks are mouth because I get low leak rates with the chinstrap and mouthguard.

I let my wife wear the O2 ring (she was asking) so I don't have pulse data but added Tidal Volume to the chart.

I'll try collar, F20 and 8-15 range tonight to see what happens....


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#38
RE: Cheyne Stokes isn't always heart related
this all night chart looks a lot better than the last; stick with whatever you did that night!

fewer oa and not so clustered. the hairbrush look suggests a lot of arousals though. leaks are a bit high. right click the title at left of graph, click dotted lines/upper threshold to see how much is over the red line. a collar helps me minimize my lip leaks. flow limitations are a bit high too. I think you reduced epr and pressure to deal with ca. alternatively, increasing epr and pressure will help with oa and flow limitations. that's the dilemma you face with apap.

the zoom shot is pretty ugly. I'm not sure it's plm but it's close enough it could be. if so, it'll improve with plm treatment. if not, asv is likely in your future.

I forget whether plm it showed up in your full (not necessarily summary) report from your sleep test. if so, seek treatment for it or it'll continue to wreak havoc with pap therapy. if not, try to confirm or rule it out. best method besides polysomnogram is video or witness reports.

some say that disordered breathing can produce plm. maybe so but that's not been my experience. apnea events aren't so uniformly timed which makes me think the disordered breathing might trigger movement, but not plm. I used to thrash mightily in the struggle to breathe before pap but it was random, chaotic and involved my entire body. plus, I'd wake up aware of doing it. I have no awareness of plm.

still, it could be what's going on with you. hence the utility of confirming or ruling out plm.

I'm not entirely sure how flow limitations and plm are related. one of my theories is that I respond vocally to the insult in the form of a grunt/groan/moan/verbal complaint/swearing/whining and so on which expels air, closes the throat and maybe is interpreted as a flow limitation. hard to tell at the 36 minute view of your last screenshot but those really dark areas may be snores or the grunts I'm talking about. either way, probably flow limitations. I don't see them flagged very often in the middle of my plm episodes but we know the machine reporting of flow limitations is far from perfect.

ropinirole is one med that's commonly used. there are others. some get away with supplements like iron and magnesium if deficient. I only really know my own experience and that is that you have to try things to find what works. I don't know if your doc will prescribe anything without at least some anecdotal evidence though, like statements from someone witnessing it.

modafinil helps us get through the day but it's antithetical to our goal of better sleep. obviously it's better to solve the sleep problem than mask it with stimulants. I have no idea if true but intuitively I'd suspect central nervous system stimulants could produce central apnea.
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#39
RE: Cheyne Stokes isn't always heart related
Thanks sleepless. I need to look into some magnesium supplements.

Interesting idea of chicken and egg. Grunt/move and have flow limit or flow limit and then struggle.

Uploaded chart from last night with F20 (memory foam) mask and cervical collar (too hot - need holes for air). Reduced the pressure range to avoid the leaks and I have one of the best leak rates I've ever had. It doesn't fit my nose/forehead area well and it is hurts a bit, but I will get used to it. I arranged a large, long pillow to my back while laying on my left side. This prevented me rolling over. My OAs were much better and pressure never went above 11, but even with an EPR of 3 that is too much exhale resistant for me because my costochondritis acts up. (I've been using CPAP for 3 months so I should expect my breathing effort to have adjusted right?)

My CAs are my struggle and I guess PAP can't deal with that. OAs seem to be able to be managed with staying off my back, max pressure around 10-10.5 and a full face mask to avoid mouth leaks. Seems like a BiPAP could let me set a much lower exhale pressure to reduce my straining.

I am going to work with the F20 for a while to see if I can get it to be comfortable. I hate chin straps so I am better with the F20 and it doesn't disturb my nose.

So now I know what I need the new Dr (still looking) to address: costochondritis (perhaps with lower exhale pressure) and CAs.


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#40
RE: Cheyne Stokes isn't always heart related
as you know, ahi of 4 is acceptable to your doctor. if your ca stays at this level and you don't feel awful, it's fine. of course ca is inconsistent; if you see it continue to rise and fall, you may prefer to stop trying to reduce your ahi since that's pretty much all providers look at.

unless you can find a source of your periodic breathing, like plm, you might start organizing your case for asv to take to the doc. this might sound a little deceptive but the system is designed to make getting asv difficult so we have to play their game. and that is that you would be better off going back to the doc with ahi >5 with ca predominant. maybe use initial prescribed settings for a month if that returns worse results. don't titrate out your oa so well and use settings that let the ca run wild. document your physical complaints and don't take no for an answer (shop for an open-minded doctor if necessary). I haven't seen csr in your charts and I think you said your heart checked out okay so insurance should be your primary obstacle to asv. of course I know nothing of your other conditions so maybe they'll have to be taken into consideration and/or your providers will know of other means of treatment besides asv. but while ahi of 4 is good if it stabilizes at that level, if it continues to fluctuate, apap isn't working well for you. bipap is good for obstructive issues, the need for higher pressure (not an issue for you apparently) and having a wider range between epap and ipap. it's not designed to handle ca but ca can often be reduced with a trigger setting of high or very high, in the resmed anyway. asv will handle both obstructive and central apnea, and periodic breathing (unless plm induced). another option while you're building your case and waiting on your providers is to borrow, rent or buy a used vauto and/or asv. you can buy from a private party. you may or may not be able to buy from one of the suppliers on the AB list without a bilevel or asv prescription. you can resell these if they don't work out but the only way to really know is to try them.
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