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Please help me evaluate CSRs and what to do
#1
Please help me evaluate CSRs and what to do
I’m new to this forum having just recently been diagnosed with severe apnea.  Already this board has been one of the few blessings in this diagnosis and lifestyle change process.  I’m learning, like many of you before me, I have to advocate for myself to succeed.

I only started on CPAP a couple days ago (APAP, ResMed AirSense 11 at 6-16 cmH20, no ramp, no EPR). My diagnosed AHI 4% was 24.4, and AHI 3% (RDI) was 44.9.  My CA index was 5 (11%).

I’ve only been on the device for 3 days, and I know that’s a short amount of time.  However I would like to ask the community for feedback on a pattern I’m seeing, and have already discussed with my primary care physician.

In the first 3 nights, my AHI has been 3.9, 0.9, and 2.5 events per hour, so a massive improvement already.  That would be encouraging except for the pattern that seems to have been hiding behind the obstructions.

If you look at the screenshots from Oscar on the first night, Oscar reported Cheyne Stoke Respiration lasting 17 minutes, and what looks like a 2nd episode (unreported but visible) lasting 8 minutes. At that point, EPR was turned on and I promptly turned it off the next morning thanks to recommendations I read here on the board.

The next 2 nights show similar patterns, but either without any reported event, or a couple with a one or two hypopneas reported.

I’m 43 and, according to the last test I had (a couple years ago) my heart should be healthy;  I exercise daily.  So here’s my question.  How concerned should I be about this irregular breathing pattern?  My PCP didn’t seem too concerned.  He wanted to get a month of data and then discuss.  If there’s a cardiac condition, I don’t want to wait.  Can CSR be caused by the machine?  Perhaps I need to change settings one way or the other?

I really don’t know how to interpret data yet, or how to react to it.  I will say the consistent “football shaped” pattern seems to exist in numerous places on each day’s timeline.  It seems like it’s less frequent that it’s accompanied by a respiratory event, but the presence of the pattern alone has me concerned.  

So, how concerned/urgent should I be?  Should I try any device settings to mitigate the CSRs?  

By the way, I have 100% of the data in SleepHQ.com so you can see all of it for each recorded period.  I will happily share it with anyone privately.

Thank you for helping me through my learning curve.

   

   

   
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#2
RE: Please help me evaluate CSRs and what to do
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#3
RE: Please help me evaluate CSRs and what to do
Welcome to the forum. I can't answer your question about Cheyne Stoke Respiration but do Have some suggestions. First, please limit your daily data to show only event flags, flow rate, pressure (not mask pressure) leak rate, and flow limit. Those are the most important data to help us interpret your data and will make the charts easier to read. Also increasing minimum pressure to 7 or 8 should result in less pressure swings. Please see the link below for organizing your data and post again.
Download OSCAR

Organize Charts
Attaching Charts

Mask Primer
Soft Cervical Collar

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#4
RE: Please help me evaluate CSRs and what to do
Your CPAP machine will never adjust pressure to less than 4. So, by setting your minimum to 6 and EPR to 3, you don't get completely effective use of EPR because Pressure of 6 minus EPR 3, would be 3, and the machine won't go below 4. So choose your settings so that Pressure-EPR >= 4. With EPR=3, the minimum value of Pressure you should set would be 7 (or 8 as Melman suggested would be a good choice for you as well).

With your relatively low pressure, you probably don't need to use a ramp. All a ramp does for you is to prevent any detection or treatment during the ramp period.,
Useful links
Download OSCAR (current version is 1.4.0)
Best way to organize charts
How to attach charts to your post

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#5
RE: Please help me evaluate CSRs and what to do
(07-26-2022, 08:34 PM)GuyScharf Wrote: Your CPAP machine will never adjust pressure to less than 4. So, by setting your minimum to 6 and EPR to 3, you don't get completely effective use of EPR because Pressure of 6 minus EPR 3, would be 3, and the machine won't go below 4. So choose your settings so that Pressure-EPR >= 4. With EPR=3, the minimum value of Pressure you should set would be 7 (or 8 as Melman suggested would be a good choice for you as well).

With your relatively low pressure, you probably don't need to use a ramp. All a ramp does for you is to prevent any detection or treatment during the ramp period.,

That's my understanding as well.  I actually have ramp and EPR off for now; I'm just starting right at 6.  But I'll keep that in mind if/when I increase my minimum.

That's super helpful.  I'll go through the links and familiarize myself with everything.  I'll start with a pressure of 7 tonight and see if that helps with the CSR pattern.
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#6
RE: Please help me evaluate CSRs and what to do
(07-26-2022, 06:19 PM)Melman Wrote: Welcome to the forum. I can't answer your question about Cheyne Stoke Respiration but do Have some suggestions. First, please limit your daily data to show only event flags, flow rate, pressure (not mask pressure) leak rate, and flow limit. Those are the most important data to help us interpret your data and will make the charts easier to read. Also increasing minimum pressure to 7 or 8  should result in less pressure swings. Please see the link below for organizing your data and post again.

Thank you.  I've adjusted Oscar so future screenshots will have only the relevant data formatted as you described.

Would you say there are active forum users who tend to have CSR experience?
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#7
RE: Please help me evaluate CSRs and what to do
On CSR, ignore those words, think of it as Periodic breathing.  ResMed calls ALL periodic breathing CSR which often causes unneeded anxiety for users

EPR is for much more than comfort.  It actually gives you the best option to treat Hypopnoea, flow limits, and RERAS.  BUT it may be causing excessive flushing of CO2 likely resulting in the waxing and waning pattern of periodic breathing incorrectly labeled as CSR.

Simple explanation:
Normal/high levels of CO2 triggers our drive to breathe, the need to flush CO2 out of our system.  The higher the CO2 the deeper our breaths.  If your CO2 levels go below your apneic threshold a central apnea event occurs.  Your zoomed views.

While there is no official limit for flow limitations we like to see the 95% value <= 0.10 but consider 0.03 to be very good.  Yours are just below 0.10.
RERAS showing up at all is another indication of high flow limits.
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#8
RE: Please help me evaluate CSRs and what to do
(07-27-2022, 02:14 AM)Gideon Wrote: On CSR, ignore those words, think of it as Periodic breathing.  ResMed calls ALL periodic breathing CSR which often causes unneeded anxiety for users

EPR is for much more than comfort.  It actually gives you the best option to treat Hypopnoea, flow limits, and RERAS.  BUT it may be causing excessive flushing of CO2 likely resulting in the waxing and waning pattern of periodic breathing incorrectly labeled as CSR.

...

While there is no official limit for flow limitations we like to see the 95% value <= 0.10 but consider 0.03 to be very good.  Yours are just below 0.10.
RERAS showing up at all is another indication of high flow limits.

Hi Gideon,

Thank you for such a helpful reply.  I didn't know that the devices flagged patterns.  I knew they flagged events, but I wrongly assumed patterns (like CSR) were identified by tools interpreting data such as Oscar.

I'll take your advice and ignore CSR for now.  My real question then becomes what changes to make to get the best possible outcome.  It looks like I have periodic breathing (the football-shaped crescendo-decrescendo) every night, multiple times per night.  The attached screenshot from yesterday shows the pattern with a few CA/H events interspersed.  Would changing my minimum pressure or something similar help to address it? 

I do not have EPR enabled at the moment.  I would gladly turn it on if anyone things it would help, however I think I understand your point that it may contribute to the pattern by flushing CO2.   I suppose the CSR flagged on my first night still has me on edge - I'm not clear on whether periodic breathing should be cause for concern.

Thank you again for the helpful clarification.  Do you have any recommendations?

Much appreciated!!

   
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#9
RE: Please help me evaluate CSRs and what to do
(07-27-2022, 02:14 AM)Gideon Wrote: On CSR, ignore those words, think of it as Periodic breathing.

From what I can tell, there's a lot of PB in my data.  Is an ASV device something I should discuss with my primary care provider, or can typical CPAP and APAP devices handle periodic breathing?
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#10
RE: Please help me evaluate CSRs and what to do
(07-27-2022, 10:29 AM)nearenough Wrote: From what I can tell, there's a lot of PB in my data.  Is an ASV device something I should discuss with my primary care provider, or can typical CPAP and APAP devices handle periodic breathing?

Your periodic breathing is not a concern. And no, considering an ASV is overkill.

It is not unusual for new CPAP users to experience *some* centrals.

Now that you are using CPAP your CO2 is being washed out of your system very differently than pre-CPAP. Your brain needs to adjust to these new triggers.

Brand new users should not even look at Centrals, unless they are an absolute disaster (well into the double digits).

Get used to the CPAP, let your body adjust. There really is no point trying to optimize therapy that is still new and very foreign.
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