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Help reading husbands charts -AHI very high - have sleepy head
I so appreciate what you are saying. I realize that I will have to be pushy if anything is to be done. The pulmonary doctor just said to have him sleep on his side and it will be good. The emergency room doctor was the one who recommended the sleep study. His cardiologist does not seem to be concerned and our GP doctor has said that CPAP machines may not be needed. He indicated by his words that he feels it is a rip off. Both my mom and my brother had sleep apnea and it made a big difference for them. Regretfully they have both passed away and I did not really pay attention to what they were using and we did not discuss their treatments. When I do hear about someone having sleep apnea and I ask them what their numbers are for pressure and for AHI - I have not found one that could tell me. They just use the machine. So I just backed off and decided that I would give it time and perhaps his numbers would improve. I now realize that his numbers are worse following the last sleep study that he had after I requested one. They determined then that he needed a medium mask and a chin strap and that it his poor mask fit that was the problem. We were using a large full face mask. He tried the medium and chin strap and became very frustrated. So we decided to go back to the larger mask and no chin strap. Now what???? that is what we are searching for in an attempt to get better results.
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Your husband has a fairly wide pressure range posted in his profile. When we see some data we can suggest some fine tuning of his settings. Has he been to the cardiologist lately?

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

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Post from Imgur

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This discussion, and learning that your husband is under the care of a cardiologist is very helpful and a relief. The pattern of periodic breathing that appears in these graphs is frequently associated with congestive heart failure (CHF), and I'm relieved to hear that is not the case. A couple of positives to point out are the tidal volumes are very good when he is breathing. There is not much snoring going on. The leak rate is well controlled and does not contribute to what we are seeing. Although there is not much flagged flow limitation, there is evidence of flow limited breathing in the graphs below.

The graphs show repeated obstructive apnea throughout the night. Some nights, this is mixed central and obstructive, or even pure central. I suspect much of what is being flagged as obstructive apnea is actually CA. I say that because of the relatively low incidence of flow limitation and snores. Provided your husband is not affected by CHF he may be better served by an ASV machine (adaptive servo ventilator), however I think this needs to be evaluated professionally.

Looking at these charts, we see abundant OA and periodic breathing. The first reaction to OA is usually to increase pressure, which his machine does up to the set pressure limit of 14 cm. We don't see any improvement in apnea or periodic breathing from these pressure increases, which is another reason I think the events are actually CA, but his airway is closed. The periodic breathing suggests an open airway, and no real effort to breath, and I think this would be overcome by ASV to even-out the periodic breathing, hypopnea and the apnea. I suspect the current problem is actually made worse by increasing pressure, but that is why I wanted input from other forum members.

It is urgent that we get his doctor engaged in dealilng with this. The apnea frequently have duration over 60 seconds, and I suspect if his oxygen saturation was being monitored, the results would look equally alarming. This can't be good for a guy of his age and condition, so I think you need to get his cardiologist involved as an advocate to wake up the sleep specialist to what is going on. For that reason, I think some of these charts will be useful to show the cardiologist to motivate him to become involved in the sleep therapy.

1. This is a 69 second duration event flagged as OA. It is clearly not a a fully closed airway.

[Image: nan7w8jl.png]

2. This is a fairly typical night with numerous OA events flagged. Abundant periodic breathing is visible, even fully zoomed out. The periodic breathing pattern occurs even during periods not flagged as PB.

[Image: s84GfVAl.png]

3. Example of flagged periodic breathing.

[Image: oER7a4nl.png]

4. Periodic breathing from the most recent night of "therapy"

[Image: rYMdFhGl.png]

5. Another example of PB

[Image: cYs6z00l.png]

6. A different pattern of PB showing abrubt recovery breathing at the end of apnea, followed by diminishing respiratory amplitude.

[Image: 6rU9V6il.png]
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One more showing the very long duration apnea events.

[Image: K256c5Rl.png]
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My first inclination is that we are looking at primarily Central Apnea events consisting of Cheyne Stokes Respiration, Central Apneas and Central Hypopneas. I suspect that these events are Cardiac Condition related. I also agree that the OAs are CA related. I would try reducing and narrowing the pressure range to try and reduce the machine induced portion of the CAs. The first thing I would try would be to lower the Max IPAP to 13 from 14 leaving the EPAP at 8. I would also hope the Cardiologist will take a more aggressive approach to the diagnosis and treatment of Congestive Heart Failure. Treating the Central type events with an ASV machine is contraindicated if the LV ejection fraction is below 45%. ASV might be an option if the CHF can be better controlled.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur

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(12-17-2016, 06:26 PM)FrustratedWife Wrote: Most certainly you can share his readings. He is in the care of a cardiologist and has been for many years. He has a mitrol valve prolapse and is in constant irregular heart beat. Perhaps it does show up in his sleep pattern. It was a year ago in November that he ended up in the hospital due to a build up of fluids in his lungs because his heart ejection fraction was low and his heart was not putting out enough oxygenated blood. It was after that episode that the sleep study was done. I have felt that the CPAP has not achieved all that it could. I have recorded his readings daily and know that there have been very few days that the AHI has been in the 10 or below range. When contacting the Doctors office and inquiring, they have seemed unconcerned. His best reading was on May 30 when we were on a vacation trip to New York. He was so tired I do not think he moved once he hit the bed. I thank you and anyone else who is willing to go over his records and give us your thoughts.

I had missed this post when looking back at the thread. The low ejection fraction is likely CHF related, and ASV was recently found to have a higher risk for patients with LVEF<45% as mentioned by Rich.

I actually would set his machine at 8 cm fixed, which is his minimum pressure. There is no benefit visible from the machine increasing pressure, and that may actually be increasing the central events. Still, I think the charts we posted should be discussed with the various doctors treating him. We may not be able control the cheyne-stokes respiration and associated apnea, so the use of supplemental oxygen at night should be discussed, perhaps in lieu of CPAP. This would be very easy to evaluate by monitoring his SpO2, which I'm sure falls to very low levels at night. It's important to note, this does not mean he needs O2 during the day. He can continue to be active, but he probably needs oxygen supplemented, assuming the periodic breathing is not treatable.

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I would agree with the 8 cm H2O as well. I thought we would wind up there anyway.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur

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I decided to take a look at the therapy history, and found the best results have been on fixed pressure at 12 or 13 cm. I would suggest returning to that scheme and trying to get the doctors onboard to monitor night O2 desaturations, with the idea of determining wether supplemental oxygen would be beneficial.

A closer look at the historic data shows some of the worst results have been a fixed low pressure without Flex. The best results were fixed 13 cm with cflex at 2. No one has tried higher fixed pressures (14 or higher). The data show me that the machine should be set at 13 fixed cpap with flex at 2 or 3, and it may be worth trying higher fixed pressures. This does not eliminate periodic breathing, but greatly reduces the frequency and duration of apnea events. When pressure was changed to 8-14 without flex, the results were pretty dramatically worse.

[Image: dncrZ4Gl.png]
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I have contacted the Pulmonary Doctors office and asked them to set his pressure at 8 to test for a while. The office person I spoke to seems to feel that his problems are all related to mask leakage. The last time he had a sleep study done the tech determined that he was moving a lot, fidgeting with his mask, and that when the fit was right, there was no apnea. I do not think it is just a mask fit problem with leaking. I can hear when it is leaking and we do adjust. But she will speak to the doctor when he is back in the office and then if approved will contact the cpap tech and have them adjust the pressure. Thanks for your help. Merry Christmas to all of you and I do so appreciate your assistance.
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It's a pleasure to help, and Merry Christmas to you and your husband.

With the pleasantries out of the the way, any technician that can't recognize textbook cheyne-stokes respiration should get out of the business. There may be some leaks, but the respiratory waveform is very clear and leaks are not interfering with either the machine or my ability to see what is going on.

Based on the data you posted, he does best with a fixed pressure of 13. This is the instruction on how to change it: http://www.apneaboard.com/dreamstation-c...structions

Please understand that the "office person" and "technician" are coming between your husband and his doctor at the risk of his health. Their advice is wrong. Can I be any clearer?
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