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My sleep results. Is ASV in order?
#1
Question 
My sleep results. Is ASV in order?
Hi all

Thought I'd share some of the results off my sleep study, so maybe you can tell me what I can expect during my follow-up meetings.

First, I failed it. The study was 7 1/2 hours long, of which I slept 3 hours 3 minutes. Part of that was just the new surroundings and wires. I had 33 awakenings after sleep onset. Sleep latency was 55 minutes and REM latency was 218 minutes. 94 stage shifts in sleep patterns.

I didn't have a mask on until 12:30 am. During the no-mask period, I had 42 respiratory events consisting for 15 apneas (3 obstructive, 1 mixed, and 11 central) and 27 hypopneas. I can't figure out the difference between a central apnea and a hypopnea. ??? AHI was 35.5 and CAI (central apnea index) was 9.3. REM AHI was 0.0. non-REM AHI was 35.5 and arousal index was 34.6. Average oxygen 92.0% and minimum oxygen saturation of 80.0% YIKES! I was below 90% about 10 total minutes. Supine the entire time.

Then they put an Eson 2 on me. Only minor leaking. About 5 hours on the mask. Snoring was eliminated at 6 cmH20. 52 respiratory events (more, but it was a much longer time) consisting of 43 apneas (0 obstructive, 0 mixed, 43 central (100%)) and 9 hypopneas. So, there I am with my mask on, and the average oxygen saturation was 95.0% with a low of 84%. I was under 90% oxygen for about 3 minutes. What gives with that??

No arrhythmias. no movements with arousals.

The diagnosis from this first study is two part:
G47.33 (severe) Obstructive sleep apnea
G47.37 Treatment emergent central sleep apnea
 (I disagree with the "treatment emergent" part as this was one of my complaints to the doctor that led to the study. See avatar name. But I understand that it can also apply to CPAP persistent central sleep apnea.)

There's a note that the baseline AHI is probably higher because of my inability to maintain REM sleep during baseline portion of the study. There's a second note that they never normalized my AHI at the tested PAP settings (fixed CPAP levels of 5,6,7,8,9) due to residual events and the presence of central events raising concern for complex sleep apnea. They suggest the centrals were maybe due to lack of acclimation to PAP even though I mentioned it while they were putting the mask on me.

They are Recommending a 2nd study for full night titration starting at 10 cmH20 and during which there should be a low threshold for transitioning to bilevel if central events are observed, which they will be.

Oh boy! That's a ton to type. I think I'm going to be on a machine moving forward, n'est-ce pas?

What does all this mean to you?? I'm just a little scared and hopeful. Should I push for Adaptive Servo Ventilation? Will they be able to learn what they need from just a bilevel?

Thanks!!! Thanks
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#2
RE: My sleep results. Is ASV in order?
Your diagnosic portion had more Central Apnea than Obstructive Apnea 11 to 3. Hypopnea are partial Apnea, that's what they are period. What they don't say is Central or Obstructive Hypopnea. With 11 CA to 3 OA, there's got to be some Central content in that 27 Hypopnea.

They have gone Central blind hence you have Obstructive Apnea. There's a bit of sarcasm for ya. NOTE This is not treatment emergent Central Apnea. You didn't have a mask on!

43 CA to 43 OA during the titration, no surprise.

Several things, CPAP, APAP might be ok to avoid centrals. BPAP without backup absolutely NOT.

Request the full diagnosic and titration reports.

You will need ASV. Let the fight begin.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#3
RE: My sleep results. Is ASV in order?
Your comment about being a shallow breather has me concerned.  Have you seen a pulmonologist?  COPD and several other things can make you a shallow breather.  What is causing this MAY, only may, influence machine choice.  Hypopnea can be as simple as shallow breathing.

BiLevels such as the ST 
ST (Spontaneous/Timed) Augments any breaths initiated by the patient but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS), and other respiratory conditions
Basically, an increased Pressure Support (PS) is the difference between inhale and exhale pressures, provides deeper breaths, or if you prefer improves shallow breathing.

Without question an ASV will resolve any central apneas that you have, but what about the underlying condition?  I suspect that despite the fact that I dislike the ST for apnea use it may be a better choice for you.

We, and I suspect you, need to know and understand more about this shallow breathing.  

Look for a pulmonologist that works with shallow breathing and is aware of sleep apnea.  If you have more info on this please fill us in.  This is IMPORTANT.

Also as a shallow breather, you are not flushing out much CO2. Higher CO2, the need to flush it out provides our main drive to breathe.  This flushing increases dramatically on PAP use resulting in Treatment-Emergent Central Apnea. Thus the included diagnosis of G47.37 Treatment emergent central sleep apnea is spot on.  So much so I suspect that you will see a real train wreck of Centrals from ANY PAP use.

Bottom line, you, and we, need much more info on your shallow breathing.

No matter what stick with us.
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#4
RE: My sleep results. Is ASV in order?
Quote:NOTE This is not treatment emergent Central Apnea. You didn't have a mask on!
 
Oh my word!  I don’t know how I missed the that. Thank you thank you!!
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#5
RE: My sleep results. Is ASV in order?
Let me clarify my response.
To my knowledge, there is no shallow breathing-induced central apnea diagnosis.
Shallow breathing will affect your CO2 levels and Treatment-Emergent Central Apneas are very much CO2 induced, thus I agree with the diagnosis.
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#6
RE: My sleep results. Is ASV in order?
Ask your doctor for your full sleep study report and then post a redacted version (remove any personal info for you/doctor). We might be able to make a couple more inferences based on the detailed data/report.

It seems like centrals are an issue and ASV is likely indicated. ASV is a form of bilevel but it isn't clear if that is what they would attempt to use if centrals are present. A titration study is only as good as the tech running it and for some reason too many places waste too much time trying different pressures and pressure supports when both Resmed and Philips Respironics recommend ASV if central apnea for more than 20 minutes.

From Philips Respironics titration guide.

"If central apneas are observed consider decreasing pressure for 20 minutes; if still present consider switching to BiPAP autoSV protocol"

https://philipsproductcontent.blob.core....3de0e6.pdf

Resmed titration protocol.

"Decrease CPAP by 1 cm H2O and wait 20 mins. Consider ResMed’s ASV if centrals persist and patient meets criteria"

https://document.resmed.com/en-us/docume...er_eng.pdf

Based on your explanation of what has already been done I feel that ASV use should be considered almost immediately, I would hope they wouldn't spend any more than 1 hr trying other settings before switching especially considering you had trouble sleeping in the first test. I would ask the company what their titration procedure will be if centrals are present and if ASV will be used. If they seem hesitant to try ASV for some reason I would consider looking elsewhere.
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#7
RE: My sleep results. Is ASV in order?
Gideon does have a point. Get the shallow breathing diagnosed. Get your doc's attention and get a test. This will probably be a PFT, pulmonary function test.

If in fact this disqualifies you from ASV, ST-A possibly is your next best choice, dependant on the shallow breathing issue. The specifics will point you too a certain machine.

Last, get the low oxygen issue addressed. This too can be a bigger issue than it first appears.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#8
RE: My sleep results. Is ASV in order?
I will add that except for the shallow breathing this presents very clearly as central apnea and likely to an ASV in the future.
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