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Very confused about apnea
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msmcintosh Offline

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Post: #1
Very confused about apnea
I'm a Veteran and have been getting all my health care from the VA for the last 1.5 years. I have chronic pain and have been treated with opioids (Morphine and Oxycodone) since 2006. Last summer, I told the Nurse Practitioner I've been seeing at the Mental Health Clinic that I haven't been sleeping well. I figured on account of the pain and I've never been a good sleeper most of my life. She asked if I wanted to go for a sleep study, so I agreed.

The sleep study came back that I had:

Severe obstructive sleep apnea (327.23) with mild associated hypoxia.
Mild underlying central sleep apnea (327.29) with worsening demonstrated while on PAP therapy
Inability to correct sleep related breathing disorder on CPAP due to significant appearance of events while on CPAP and Bilevel therapy.

Baseline Central Apnea Index 3.3 AHI 51.7 (unassisted)
5/5/0 Central Apnea Index 60 AHI 4.5 (CPAP)
9/7/0 Central Apnea Index 78.6 AHI 0.0 (CPAP)
0/0/2 O2LPM Central Apnea Index 6.5 AHI 1.2 (Oxygen)

I had no idea I had sleep apnea. No one has explained the report to me. They are blaming my apnea on my opioid pain meds, which at the time of the study, I was taking 45mg - 30mg of Morphine SR x 3 and 5mg Oxycodone x 4. They believe that taking these meds away will solve the problem.

This is what the doctor from the sleep clinic wrote to my pain management doctor:

"He did his best with oxygen alone (at the time of the study, CPAP was not effective). This may have been attributable to his medications at the time (opioids). If he has successfully, weaned off the opioid medications, and remains symptomatic, I would repeat the sleep study (can be done with portable home T3 study). This study should be done without supplemental oxygen to determine whether or not he continues to have significant respiratory events (off medications). If so, CPAP might then be helpful, if not he may be able to eliminate the need for interventions."

Would taking the opioids cause such a high AHI? The plan seems kind of flimsy. My pain management doctor has already had my wean off of most of my opioids and it is painful. Can anyone tell by the numbers I entered what it means? There was a recommendation to try PAP with Auto PAP, but apparently they don't want to do that.

Thanks


Attached File(s)
.pdf  Sleep Study_data.pdf (Size: 18.79 KB / Downloads: 323)
(This post was last modified: 01-30-2013 03:54 AM by msmcintosh.)
01-30-2013 03:42 AM
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Moriarty Offline

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Post: #2
RE: Very confused about apnea
Hi msmcintosh

I can't help much with an explanation but I am interested to know your approximate age.

A 'simple' Auto PAP will probably not help a lot with Central Apnea. CPAP and its APAP variant do not do any more than splint the airway open to prevent obstruction -( ie Obstructive Sleep Apnea or OSA). Central Apnea is more a neurological issue where there is no obstruction of the airway - rather a lack of impulse to breath. This requires more than PAP to overcome.

I hope some one can offer more detail for you.

Cheers

David
(This post was last modified: 01-30-2013 05:16 AM by Moriarty.)
01-30-2013 05:15 AM
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Moriarty Offline

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Post: #3
RE: Very confused about apnea
Post 5 in http://www.apneaboard.com/forums/Thread-Stop-Breathing is probably relevant.
01-30-2013 05:20 AM
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msmcintosh Offline

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Post: #4
RE: Very confused about apnea
(01-30-2013 05:15 AM)Moriarty Wrote:  Hi msmcintosh

I can't help much with an explanation but I am interested to know your approximate age.

A 'simple' Auto PAP will probably not help a lot with Central Apnea. CPAP and its APAP variant do not do any more than splint the airway open to prevent obstruction -( ie Obstructive Sleep Apnea or OSA). Central Apnea is more a neurological issue where there is no obstruction of the airway - rather a lack of impulse to breath. This requires more than PAP to overcome.

I hope some one can offer more detail for you.

Cheers

David

I am 55.
01-30-2013 10:47 AM
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zimlich Offline

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Post: #5
RE: Very confused about apnea
I'm in a similar situation, but my apnea is not as bad as yours. Do not give up your pain meds. You won't sleep at all without them. I take 10 mg methadone and oxycodone three times a day. There is a difference in respiratory depression which is what we get and not regular apnea- it looks like central apnea, and I guess it presents as central apnea. My machine regularly reports that my respiratory rate is from 4- 12/minute during the night. If I didn't take the meds I would not sleep at all and if I did it would not be the good, restorative sleep. I also take psych meds. My life is not worth living, not to be dramatic, without my meds. I am a serious manic depressive
and have chronic, severe back and leg pain. I've never had a doctor try to wean me off the meds. What I did was ask for a sleep test with an ASV machine. ASV worked for me. The backup RR was auto, but I changed it to 10 or 12. If you can wrangle an ASV which is the treatment for central apnea I think you would be pleased.
It really bothers me when doctors don't realize that chronic pain has to be dealt with to ensure quality of life. Please don't let the doc bully into giving up your meds, just get treated appropriately. My AHI is in the high 20's t and 4-8 with ASV.
01-30-2013 10:56 AM
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PaulaO2 Offline
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Post: #6
RE: Very confused about apnea
(01-30-2013 03:42 AM)msmcintosh Wrote:  Severe obstructive sleep apnea (327.23) with mild associated hypoxia.
Mild underlying central sleep apnea (327.29) with worsening demonstrated while on PAP therapy

Those numbers are probably the diagnosis codes.

Quote:Inability to correct sleep related breathing disorder on CPAP due to significant appearance of events while on CPAP and Bilevel therapy.

I think this is saying that despite having both a CPAP and a Bilevel PAP, your apnea events were not decreased but rather increased.

Quote:Baseline Central Apnea Index 3.3 AHI 51.7 (unassisted)
5/5/0 Central Apnea Index 60 AHI 4.5 (CPAP)
9/7/0 Central Apnea Index 78.6 AHI 0.0 (CPAP)
0/0/2 O2LPM Central Apnea Index 6.5 AHI 1.2 (Oxygen)

An apnea index is taking the number of events and dividing it by the number of hours.
CAI is central apnea events and only includes the central events
AHI is Apnea Hypopnea Index and includes central and obstructive events as well as hypopnea events. This is the total number of events per hour.

The first line is without any xPAP at all. You had a CAI of 3.3 but an AHI of 51.7
The second line, I'm not sure what the 5/5/0 is. You can see the CAI increased dramatically with the introduction of pressure.
The third line is basically the same.
The fourth is where they introduced oxygen, no machine, and your events improved dramatically.

Looking at all three of those beginning numbers, I'm going to guess that they are pressure at inhale, pressure at exhale, and oxygen given. So the first would be the CPAP at at 5 in, 5 out, and no oxygen. The next would be the bilevel at 9 in, 7 out, and no O2. The third would be no pressure but with 2 litres of oxygen per minute.

Quote:Would taking the opioids cause such a high AHI? The plan seems kind of flimsy. My pain management doctor has already had my wean off of most of my opioids and it is painful. Can anyone tell by the numbers I entered what it means? There was a recommendation to try PAP with Auto PAP, but apparently they don't want to do that.

Thanks

Yes, a lot of medications can cause apnea events. Any medication that effects sleep would. And opioids do. My suggestion would be to fight to get O2 at night. You could request it be done on a trial basis to see how you feel. You could also suggest an oximeter be used to monitor your blood O2 levels. The number of events dropped dramatically just with the application of supplemental oxygen. That alone should show your doc that you need it.

As for coming off the meds, the idea is to keep the patient as healthy as possible. You and your doc need to decide which is healthier for you: lower pain meds with increased pain but "better" sleep; or keep the pain meds and get "lesser" sleep. From my personal experience, you are going to get worse sleep without the pain medication. Your entire daily life is going to be screwed. This is why at least trying the supplemental oxygen at night is important. It may also help with your pain levels as you would be getting better sleep.

Good luck and please keep us posted!

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
01-30-2013 11:45 AM
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msmcintosh Offline

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Post: #7
RE: Very confused about apnea
I don't have a choice as to what happens since I am going to the VA. All the services are in one place, the sleep clinic, pain management, mental health, my records, they share everything. Everything happens so slowly. I had the sleep study on 10/17/2012 and it wasn't until 12/13/2012 before I heard anything about it. That was when my pain management doctor said I would have to wean off my opioids. I had to beg my PCP to get a copy of the study report. When I saw my pain management doctor again on 1/23/2013, I told him every time I stopped taking my opioid pain meds it hurt too much. He said it was imperative that I do so and gave me a new plan to wean. All I know is that my pain has gotten much worse and I have no idea where my apnea stands. I have an appointment at the sleep clinic on 02/28/2013, but I don't know what for. It's not a sleep study. On 03/05/2013, I have an appointment to get a home oxygen machine to use while weaning off my opioids. Too bad I will be off of them by then. I am so frustrated with this whole process.
(This post was last modified: 01-30-2013 11:57 AM by msmcintosh.)
01-30-2013 11:46 AM
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trish6hundred Offline

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Post: #8
RE: Very confused about apnea
Hi msmcintosh,
WELCOME! to the forum.!
I am sorry you are having such a rough time of things right now and I hope you can get some resolve, soon.
Best of luck and hang in there.

trish6hundred
01-30-2013 12:17 PM
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msmcintosh Offline

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Post: #9
RE: Very confused about apnea
In the link in post 5 it mentions a device.

I'm not sure I understand. Is there a machine that would control my obstructive sleep apnea without producing a lot of central sleep apnea?

I don't know why the CPAP machine helped my OSA, but increased my CSA dramatically.Well, they are blaming it on my opioid pain meds, but could there be another reason?

The VA does not like to prescribe opioids to Veterans. They look for any reason to take them away. I most likely will never get them back. And no, I don't sleep well. I'm tired all the time.
01-30-2013 01:57 PM
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Ugly Offline

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Post: #10
RE: Very confused about apnea
(01-30-2013 05:15 AM)Moriarty Wrote:  Hi msmcintosh

I can't help much with an explanation but I am interested to know your approximate age.

A 'simple' Auto PAP will probably not help a lot with Central Apnea. CPAP and its APAP variant do not do any more than splint the airway open to prevent obstruction -( ie Obstructive Sleep Apnea or OSA). Central Apnea is more a neurological issue where there is no obstruction of the airway - rather a lack of impulse to breath. This requires more than PAP to overcome.

As un-helpful as my resp therapist has been, she did indicate that and the required apparatus would cost much more than the government will pay for. Some of us are just S.O.L.
01-30-2013 02:26 PM
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