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central apnea concerns
#1
central apnea concerns
I have been using a Philips System One for three months. Being aware of my apneas, I had tried the machine prior to a sleep study. Those early trials on auto 4-14 pressure presented AHI of around 16 and often greater than 50% central apneas.
  I did a home sleep study two months ago. The results did not show any central apneas. It did show 124 total obs apneas and 139 total hypopneas. I requested a histogram and a secretary sent me the raw data. On those data sheets I noticed the respiratory effort chart (chest band) was flat lined. I called and spoke with a doctor at the sleep study company. I asked why there were no centrals indicated. He said to not worry about it because they only affect 5% of people with sleep apnea. I pointed out the flat line for the chest band. At that point he was upset that I had access to the raw data, but he admitted there was probably a broken wire in the chest band lead. They offered another test and that one shows  an AHI of 34 ( 39 obstructive, 228 hypopneas, and 9 central).  The central ratio is 3%.
  After my conversation with the sleep study company, I was not, to say the least, pleased with their product and have no faith in the usefulness or validity of the results. My OSCAR data is often showing more than 50% clear airway events. I have tried various interventions I have gleaned from posts on this forum, but my results remain the same. To attempt to reduce the centrals I have tried a fixed 7 and have tried auto 4-14. I continue to have most days with an AHI of 16-26, and I’ve had a few days with nice lows of AHI 4. All variables remain the same except pressure settings.
  I am attaching a typical daily chart. I am also attaching a zoomed chart of a very common flow pattern I have with clear airway events. It shows the typical Cheyne Stokes pattern. I have a long history of afib, but I’ve had a few ablations and I do not currently have afib. Other than that, no heart issues.  Should I try to get an in lab sleep study done and see a sleep specialist (it’s at least a two month wait in my area)? Can you give me any other info or recommendations regarding my OSCAR data?


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#2
RE: central apnea concerns
I had two home sleep tests done, and was told I quit breathing 42 times in one hour. When I saw my Pulmonologist (with a facility for lab sleep studies) for my lung issues, he asked "what's new". I told him about the home sleep studies and their result. The next words out of his mouth were "I hate when they do that". Before I could ask why, he said "Let's get you into our sleep study". That's all I needed to hear. With the home sleep people I don't know if they're doctors or not -- I feel they're more Salesmen than anything.
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#3
RE: central apnea concerns
Wow, that is a BEAUTIFUL example of central apnea related periodic breathing right there.

I feel like you may have been misdiagnosed. You definitely have some obstructive stuff going on (though they didn't (and CPAPs don't) differentiate between hypopneas being central or obstructive, I'm guessing) that may be positional (chin tucking) by the clustering. But that looks HUGELY like you might have either predominantly central sleep apnea or mixed/complex sleep apnea instead.

Do you have the actual sleep study reports? Would you be willing to post them (redacted as necessary)?

Yes, it's normal to have the ODD central, but if you having that many, then you have central sleep apnea and it's absolutely something that should be treated. Do you have any details about pulse oximetry during your studies (or own a recording pulse oximeter that you can use overnight)?

I would definitely say that you need a decent sleep study ASAP if they've not marked any central events because either you have treatment-emergent apnea that hasn't improved in the normal timeframe, or you have (more likely from just what's in your first post) misdiagnosed central/mixed/complex sleep apnea and a CPAP won't fix that. By two-three months, that's when we'd normally expect to see treatment-emergent centrals improve. Your pressure is not super high, but that huge run of centrals happened at around 10 or so - so if it WAS related to the pressure, you'd have to keep it below that level. It may be worth trying, to see if it helps, but it depends if that's controlling your obstructive symptoms (or if they are mostly positional anyway) and you spend most of the time on the lower end anyway. If you have EPR on (I think A-flex or C-flex on Philips machines) then you might want to switch that off (or down) and see if it helps in the interim.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#4
RE: central apnea concerns
I agree with Ratchick. The CA events are real and a concern. The appropriate therapy for central sleep apnea or complex apnea in your case, is to use an Adaptive Servo Ventilator (ASV). We can perhaps mitigate the centrals by narrowing the range of pressure you have through the night, and try to avoid higher pressures that seem to be where your CA is more prevalent. To do this, I'd like to see you change your pressure settings to a minimum of 7.0 and maximum of 7.0, or use the CPAP mode at 7. Central apnea is often the result of hypocapnea (low CO2) as a results of increased ventilation from CPAP. Your events seem to be triggered by an initial obstructive event (hypopnea or OA) then progresses into CA as a result of recovery breathing. The mechanism is the initial apnea increases CO2 and respiratory drive resulting in deeper faster breathing which dirves down CO2 and suppresses respiratory drive resulting in CA. As you go back and forth between not breathing and hyperventilation, the periodic pattern becomes a feedback loop that you can't break. ASV can fix that, but I think it may be worth trying fixed pressure first.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
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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.
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#5
RE: central apnea concerns
Agreed with the others. A few things that can be tried with the PAP you've got now, at or near straight CPAP pressures, do not use Ramp or Flex. But the usefulness of this PAP will expire pretty quickly due to your Centrals.

And one more item, the starting pressure of 4 is default, a lazy doctors answer. This will need to go upward. Your 95% pressure was 13.6 while the median was 10.6.

I imagine the move towards straight CPAP pressure would be one to bring that 4 up to about 8-11 area. I think this low pressure of 4 is to blame for a lot of the Obstructive based events. This Philips machine is inherently slow to respond. It missed events due to this slowness.
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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#6
RE: central apnea concerns
Thanks so much for all of your input. You guys are providing a tremendous service and education.  I tried to post a redacted full sleep study report but posting was not allowed. Anyway, I copied the oximetry data and it is as follows:

Mean O2: 90 % Highest O2: 96 % Lowest O2: 82 % Number of Desaturations: 200 Desaturation Index 34.2 Time under 88%: 12 % 42 min Mean Pulse Rate: 57 bpm

SpO2 Levels by Time: 95 - 100: 1 % 4 min 90 - 94: 59 % 207 min 85 - 89: 40 % 140 min 80 - 84: <0.5 % <0.5 min 75 - 79: 0 % 0 min 70 - 74: 0 % 0 min Under 70: 0 % 0 min 

Following your recommendations I will try a fixed 8 w/o flex for at least three days. Also, I will get on the long waiting list for an in-lab sleep study.
 
Thanks again.
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#7
RE: central apnea concerns
You should look at getting a pulse oximeter too. Seems like you're spending FAR too long under 88% and if the CPAP hasn't helped that, then you need to be chasing up ASAP for either a much faster sleep study or supplemental oxygen in the interim. You're spending over 40% of the night under 90% SpO2 and 12% of the time under 88%. Those are both FAR too long.

Have a look at the post in my signature (my comparison of the watch-style pulse oximeters) though any of these will work (Contec CMS-50D+, CMS-50-E, CMS-50E, CMS-50F, CMS-50H, CMS-50I, and pretty much any Viatom/Wellue product including VisualOxy CheckMe O2, SleepU, O2Ring, and probably the Lookee rebranded Viatom products).

Generally, I prefer the Viatom/Wellue products (especially the wrist-worn ones) because I find the sensor more comfortable and far more reliable than the normal style ones. They are a little more expensive and if that's an issue, then the CMS50F is probably the least expensive option, but any of the above will do the trick. I think it's really necessary to see how bad your oxygen levels are at night right now because if they're anything like your sleep study, they need effective therapy ASAP.

Re: the upload - I suspect that you tried to link to an external source? That's not possible for very new accounts, but when you get to 5 or 6 posts, you should be able to do so.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#8
RE: central apnea concerns
With regard to an in-lab sleep study, you should be seeking a titration study that transitions from CPAP to ASV, not just another diagnostic. The point is you either have idiopathic complex sleep apnea, or therapy onset central sleep apnea. A diagnostic study is unlikely to reveal a primary central sleep apnea problem, and that puts you right back on CPAP. A conventional titration study will attempt to find an optimum CPAP pressure, and since your apnea is consistently inconsistent in time and frequency, it may find a pressure that works. The needed study is actually one that titrates CPAP, moves to bilevel and ASV to demonstrate efficacy with ASV. This all starts with a discussion with your doctor expressing concern for the persistent central events that continue to be present with CPAP, combined with your known low SpO2. You can help your case by wearing a recording oximeter and documenting if you oxygen levels still fall below acceptable thresholds with CPAP. I'm not confident in the level of concern or professional competence of most sleep specialists. Many are in this game as an easy way to increase their income without having to deal with patients. You will have to judge for yourself, but your primary physician might be the person to manage your care and assessment of sleep disordered breathing if you have a good relationship where he or she listens and respects your insights on health care.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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.
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#9
RE: central apnea concerns
Yes, agreed, and I've been there, so it's the correct plan to go with.

To get the ball rolling with doc, note all the symptoms and complaints with Centrals, and lack of comfort, and any other applicable issue. Tell the docs office often, it's not helping, and why it's not, what it's not doing, the issues it creates. Make doc's ears bleed with all the complaints.
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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