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[Symptoms] Report. Displays elevated AHI including Central
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PaytonA Online
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Post: #11
RE: Report. Displays elevated AHI including Central
100 total apnea and hypopnea events in one nights sleep, assuming 7.5 hours of sleep would give you an AHI of 13.33 events per hour. AHI is the number of apnea events (both obstructive and central) per hour. So your AHI for the night is 100 (the total number of events) divided by the hours slept (I assumed 7.5 hours). AHI of 13.3 is high but not all that high.

There is some other information as mentioned previously if we are to make any suggestions.

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PaytonA
06-14-2014 06:04 PM
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justMongo Offline

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Post: #12
RE: Report. Displays elevated AHI including Central
If your pressures are truly in the 23 range that's on the high side compared to most people.
Many machine cannot run above 20 -- Payton's and my machine can go to 25.
High treatment pressures can induce central apneas.

1) Keep the appointment you made.
2) When you can, more information on your type of S9 machine, your prescribed pressures, and perhaps some screenshots from Sleepyhead.
3) Try not to worry.

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06-14-2014 06:32 PM
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mdeehl Offline

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Post: #13
RE: Report. Displays elevated AHI including Central
Then I agree with you. I am able to see a daily report before 12;00 noon, it gives me that night info. Yes, I see 60-70 total ahi and total central 25-35 ahi. My pressure have been changed by the sleep doctor in the past. Currently it's at 24 and 23. That is the most I can take!

There is also a report I can view. I can select day, week, month, three months six months and one year. That reports averages the info over what ever period of time frame I want to see.

I use a ResMed Quarto full face mask. My leaks are almost none. I have to tighten it down and adjust often to keep the seal. Especially by sleeping on my back helps with air leaks.
I don't know what else to tell you but this is my situation. The sleep doctor and I are meeting often to try to bring these numbers down. I am taking another sleep test this coming week to.
06-14-2014 07:16 PM
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robysue Online
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Post: #14
RE: Report. Displays elevated AHI including Central
(06-14-2014 07:16 PM)mdeehl Wrote:  Then I agree with you. I am able to see a daily report before 12;00 noon, it gives me that night info. Yes, I see 60-70 total ahi and total central 25-35 ahi.
As you already know, these numbers are way, way too high. Why they are so high is something that you and your doc will need to investigate. More on this in a bit.

Quote:My pressure have been changed by the sleep doctor in the past. Currently it's at 24 and 23. That is the most I can take!
We need to know the exact model of the Resmed S9 you are using. The standard S9 CPAPs and the S9 AutoSet (APAP) can only deliver up to 20cm of pressure. So if your pressure(s) are 24 and 23, then you must already be using an S9 VPAP of some sort. The question is what S9 VPAP are you using?

When you look at your S9, what does it say just above the on/off button to the left of the LCD:
[Image: jimmye4golf-s9_zpsad01e74c.jpg]
My guess is that you are either using an S9 VPAP S with EPAP = 23 and IPAP = 24 or you are using an S9 VPAP Auto with PS = 1 and the 95% pressure levels are IPAP = 24 and EPAP = 23. But that's only a guess, and it would be very useful if you could confirm whether either of these are correct.

Quote:I use a ResMed Quarto full face mask. My leaks are almost none. I have to tighten it down and adjust often to keep the seal. Especially by sleeping on my back helps with air leaks.
You may want to check your leak data in ResScan or SleepyHead as well as the 95% leak rate reported on the S9's LCD.

If your leaks are consistently below 24 L/min, then there's good reason to believe the data is accurate and you really are having a whole bunch of apneas each night.

Quote:I don't know what else to tell you but this is my situation. The sleep doctor and I are meeting often to try to bring these numbers down. I am taking another sleep test this coming week to.
You should get copies of the full report of your sleep studies, including the summary graphs.

Some questions:

1) Was your diagnostic study done in the lab? Or was it a home study?

2) What was your diagnostic AHI? What was the break down of events? Were CAs a big problem on the diagnostic study? Or were all the apneas OAs?

3) Did you have a titration study done in the lab? Or were you given an APAP for a while and then switched to your current machine?

In your first post you write:
Quote:Also, my personal condition is complicated because I have a implanted medical device (Pain Pump) which drips morphine directly into my spine. The doctor feels this is mostly the cause of the large number of nightly events. I. Question this because I have had this pain pump for over 10 years and the volume of medication is very low. I am able to drive a automobile and do most anything.
So clearly using the Pain Pump predates the sleep test by a lot of years. Which means: If the centrals were being triggered by the morphine, then centrals should have been present on your diagnostic test and/or your titration test. Was that the case?

If your diagnostic sleep test showed a lot of centrals, then it's reasonable to assume that the morphine may be the cause of the centrals, even though it causes no problems with doing your daily activities. But if your diagnostic test show few or no centrals, then the theory that the CAs are related to the morphine is much more questionable. And it's worth asking the doc some very direct questions about whether your diagnostic sleep test showed centrals or not.

But there's another piece of the puzzle that has to be dealt with: The number of OAs scored by your S9 seems to be at least as high as the number of CAs. My guess is that that's why you have either been prescribed such a high pressure OR why your machine (if it's an auto VPAP) is giving you such a high 95% pressure level.

Typically the response by sleep docs (and posters here) when they see a lot of OAs in the machine data is to say: You need more pressure. And the doc will authorize a pressure increase. In a typical case, the higher pressure does bring the numbers down. But you are NOT a typical case.

And when super high pressures do NOT bring the number of OAs down, then it's reasonable to back up all the way to the start and ask a very pertinent question: Are all the OAs scored by the machine really OAs?

Some new PAPers develop problems with emergent central apneas once they start PAP therapy. In other words, all the apneas and hypopneas scored on their diagnostic sleep test were indeed obstructive, but after starting PAP, the patient starts to experience really high numbers of CAs. The CAs often come in long chains lasting 20 minutes or more. And the CAs often come at very regular intervals in those chains. In other words, the breathing pattern has a certain "periodicity" to it: Sharp inhalations are followed by gradually decreasing breaths, which are often followed by a central apnea or hypopnea, which ends with some more sharp inhalations and the pattern starts over.

The thing that drives these long chains of CAs is instability in the CO2 levels in the blood. The sharp inhalations lead to blowing off too much CO2, which reduces the urge to breathe, which depresses the size of the breaths (sometimes until an CA happens). The decreased breathing leads to not blowing off enough CO2 in each exhalation, which eventually triggers the sharp inhalations, and the CO2 overshoot/undershoot cycle starts again.

These kinds of centrals are thought to be pressure induced. In other words, once the pressure reaches a (patient-dependent) critical point, the CO2 overshoot/undershoot cycle starts, and that's what leads to the long chain of CAs. It's estimated that 10-15% of new PAPers wind up developing some problems with pressure induced CAs, and the problem is more common for folks at higher pressures. For many new PAPers with moderate problems with pressure induced centrals, the problem will resolve itself in a month or so as the patient's body adapts to sleeping with PAP every night. The unlucky PAPers who continue to have problems with CAs are often diagnosed with Complex Sleep Apnea (CompSA). And folks with CompSA are often switched to either a bi-level ST machine (the S9 VPAP ST) or an ASV machine (the S9 VPAP Adapt SV)

Now back to your problem: You have a whole lot of CAs scored every night. And a whole lot of OAs scored events scored every night. And you are already close to the maximum pressure your machine can deliver. And you are taking a medically necessary drug that can induce central apneas. Add to this potent mix of things, one more fact: As good as it is, the S9's FOT algorithm for classifying apneas as OAs or CAs is far from infallible. It makes mistakes. And it is much more likely for the machine to mis-score a real central apnea as an OA than it is for the machine to mis-score a real obstructive apnea as a CA.

In other words, it's possible that the high pressures you are currently using are part of the problem. They may be increasing the instability in your night time breathing, but the machine may be mis-scoring the unstable breathing pattern as OAs instead of the more correct CAs.

When you meet with your doctor, you should ask him to download the high resolution data as well as the regular data. Ask him to take a look at a typical night's data on a breath-by-breath basis. (You can do that yourself in either ResScan or SleepyHead if you want to.) And ask him if it is possible that some or most of the OAs might be misscored central apneas.

If you see the doc before the sleep test is scheduled, ask the sleep doc exactly how he wants the tech to run the test: Does he want the tech to start over at low pressures and redo the whole titration? Or does he want the tech to gather data about what's really happening when you are sleeping with the really high pressures that are currently prescribed.

When you do the next sleep test, it's important to find out whether the tech is starting from scratch and titrating you from a very low pressure or whether the tech is going to use the pressures you are currently set to use as the starting point. Be sure the tech knows you use a Pain Pump and be sure to use the Pain Pump as normal during the night of the test.
06-15-2014 03:40 PM
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mdeehl Offline

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Post: #15
RE: Report. Displays elevated AHI including Central
My machine is a VPAP-S.
(06-14-2014 06:32 PM)justMongo Wrote:  If your pressures are truly in the 23 range that's on the high side compared to most people.
Many machine cannot run above 20 -- Payton's and my machine can go to 25.
High treatment pressures can induce central apneas.

1) Keep the appointment you made.
2) When you can, more information on your type of S9 machine, your prescribed pressures, and perhaps some screenshots from Sleepyhead.
3) Try not to worry.

(06-15-2014 05:55 PM)mdeehl Wrote:  My machine is a VPAP-S.

I am using VPAP -S
(This post was last modified: 06-15-2014 05:57 PM by mdeehl.)
06-15-2014 05:55 PM
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vsheline Offline

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Post: #16
RE: Report. Displays elevated AHI including Central
Hi mdeehl,

You may have a misunderstanding of AHI and CAI.

For example:

if AHI = 70, this is the Apnea Hypopnea Index, which is the average combined number of all apneas and hypopneas per hour.
if CAI = 34, this is the Central Apnea Index, which is the average number of central apneas per hour. This makes up part of the AHI.

You don't add the AHI and CAI together to get a total of 104. The AHI ALREADY INCLUDES all the central events.

If you slept 10 hrs with an AHI of 70 and a CAI of 34, this would mean during the 10 hrs of sleep you had 700 events, of which 340 were central apneas and the rest were obstructive apneas and hypopneas.

Take care,
--- Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
06-16-2014 01:15 AM
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robysue Online
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Post: #17
RE: Report. Displays elevated AHI including Central
(06-15-2014 05:55 PM)mdeehl Wrote:  My machine is a VPAP-S.
So your current VPAP is the fixed bilevel PAP in the Resmed line.

And you write:
(06-14-2014 07:16 PM)mdeehl Wrote:  Then I agree with you. I am able to see a daily report before 12;00 noon, it gives me that night info. Yes, I see 60-70 total ahi and total central 25-35 ahi. My pressure have been changed by the sleep doctor in the past. Currently it's at 24 and 23. That is the most I can take!
What were the pressures that you started out with?

How many times has the doc raised the pressure? And what did he base the need to raise the pressure on? Has he looked at any of your detailed daily data? Or did he decide to raise the pressures based on the summary data indicating that the OAI was too high? [Note: You can compute the OAI from the LCD data: OAI = AI = CAI]

You also say that the plan is to switch you to a different VPAP. With all the centrals, you may not see much improvement with a VPAP Auto. You may need a VPAP Adapt SV, which is designed to treat central apnea problems as well as OSA.
06-16-2014 01:45 AM
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vsheline Offline

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Post: #18
RE: Report. Displays elevated AHI including Central
(06-14-2014 05:00 PM)mdeehl Wrote:  I was so alarmed when I realized this I am now scheduled for a new sleep study which will be completed at a sleep center in my local area tomorrow. After that I will be getting a new auto VPAP.

Hi mdeehl,

An S9 VPAP Auto will not help very much at all, because it cannot treat central apneas at all.

Only a machine with a "backup rate" (backup breathing rate) feature, such as an ASV machine (S9 VPAP Adapt or PRS1 BiPAP autoSV Advanced) or an ST machine (S9 VPAP ST or PRS1 BiPAP ST) or (best of all in your case, I think) an ST-A machine (S9 VPAP ST-A or PRS1 BiPAP AVAPS) can treat central apneas.

The problem with ASV machines, however, is they are limited in the how much EPAP they can use. The S9 VPAP Adapt cannot have EPAP higher than 15. The PRS1 BiPAP autoSV Advanced can adjust EPAP higher, but how well central apneas can be treated will be limited if EPAP is much higher than about 15-17, because Pressure Support needs to be at least as high as 8 or 10 to be able to fully treat central apneas. Both machines are limited to a max inhale pressure of 25.

Better in your case would be an S9 VPAP ST-A machine or a PRS1 BiPAP AVAPS machine, because the treatment pressure during inhale on these machines can go as high as 30, if needed, allowing EPAP to be perhaps as high as 20 or 22, if needed. (Which you are likely to continue to need, I think.)

For a machine which can treat central apneas, I think you would need a special type of bi-level titration which is NOT the standard bi-level titration you would need for an VPAP Auto machine.

I suggest you ask for an ST-A titration which will use the S9 VPAP ST-A algorithm. I think you will probably need special pre-authorization for an ST-A titration, and, also, you may want to search for a titration center with experience in that type of titration (or at least has the ABILITY to perform an S9 VPAP ST-A or PRS1 BiPAP AVAPS titration).

And as robysue posted, it may be essential that precise instructions are given ahead of time to the technician who will be doing the titration, specifying the starting pressures to use, and the titration plan or protocol to be followed.

Take care,
--- Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 06-16-2014 02:09 AM by vsheline.)
06-16-2014 02:01 AM
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robysue Online
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Post: #19
RE: Report. Displays elevated AHI including Central
(06-16-2014 02:01 AM)vsheline Wrote:  Hi mdeehl,

An S9 VPAP Auto will not help very much at all, because it cannot treat central apneas at all.
I agree

Quote:The problem with ASV machines, however, is they are limited in the how much EPAP they can use. The S9 VPAP Adapt cannot have EPAP higher than 15. The PRS1 BiPAP autoSV Advanced can adjust EPAP higher, but how well central apneas can be treated will be limited if EPAP is much higher than about 15-17, because Pressure Support needs to be at least as high as 8 or 10 to be able to fully treat central apneas. Both machines are limited to a max inhale pressure of 25.

Better in your case would be an S9 VPAP ST-A machine or a PRS1 BiPAP AVAPS machine, because the treatment pressure during inhale on these machines can go as high as 30, if needed, allowing EPAP to be perhaps as high as 20 or 22, if needed. (Which you are likely to continue to need, I think.)
Here, however, I disagree. I think it is jumping the gun to assume that mdeehl will need an EPAP of 20+ or even 15+.

We don't know:
  • what the baseline AHI was and what comprised it;
  • what the intitial pressure settings on the VPAP-S were; and
  • how many times the doc simply raised the pressure.

The thing is: The extra high pressure could be the cause of the unstable breathing patterns. And at very high pressures (such as those mdeehl is using), the FOT can be less reliable. The doc really ought to be looking at a couple of nights worth of mdeehl's detailed data on a breath-by-breath basis and do some serious analysis of what's going on rather than just assuming all the "OAs" scored on the machine are OAs. Given the patient's history and the high pressures, there's a real chance that some or all of these OAs are actually mis-scored CAs and more pressure is making things worse, not better.

Things that ought to be looked at the whole history of what happened with each pressure increase: If the pressure increases have made things worse in the sense of total AHI, there's a good chance that the problem is breathing instability made worse by too much pressure.



Quote:For a machine which can treat central apneas, I think you would need a special type of bi-level titration which is NOT the standard bi-level titration you would need for an VPAP Auto machine.
I agree

Quote:I suggest you ask for an ST-A titration which will use the S9 VPAP ST-A algorithm. I think you will probably need special pre-authorization for an ST-A titration, and, also, you may want to search for a titration center with experience in that type of titration (or at least has the ABILITY to perform an S9 VPAP ST-A or PRS1 BiPAP AVAPS titration).
I'd start with requesting just an ASV titration; if the tech cannot control the obstructive events with an ASV titration, they can move on to the machines that deliver even more pressure.
06-17-2014 07:46 AM
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