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06-14-2023, 08:49 PM (This post was last modified: 06-14-2023, 08:50 PM by SleepyBoi97.)
High Number of Central Apneas/CSR?
Hi there,
A bit of background - I've been on an APAP without a prescription for a few months now, which has mostly entailed my own attempts to combat a these issues. However, this week I finally managed to get an actual APAP trial as the result of a sleep study. As such, I am now operating under the "initial" 5-15 pressure range with an EPR of 3 so that my doctor and sleep technician can get an adequate baseline.
Historically, I haven't ever shown an especially high AHI in sleep studies, and I've had a difficult time getting a CPAP trial since I am young and in fairly good shape. However, my most recent test did finally come back saying that I had mild OSA (7.3 AHI). I will add the caveat that every test I've had has shown an arousal index or RDI north of 20, and I suspect that is where my issue lies.
Now, I have noticed in my last few months of self-titration that my biggest struggle has been a high number of central apneas. On a typical night, my overall AHI will hover around 6-20, where 60-85% of my apnea events are centrals that occur fairly regularly during the night. I have also noticed that some of my breathing patterns (both during marked CAs and periods of "good" sleep) tend to resemble (to my untrained eye) the behavior of Cheyne-Stokes Respiration. I've also noticed that a decent number of these centrals also correlate to mask leaks, so it's possible that I am just waking up during the night and breathing irregularly as I fall back asleep. However, the oscillating nature during undisturbed sleep periods has made me a bit more curious about this behavior.
I'm hopeful that I can get some feedback from the members of this forum as I move through my official APAP trial (i.e. should I/is it worth fighting for an ASV down the line). I've included a snip of my most recent in-lab sleep study and a few screenshots from last night's sleep with a closer shot of my breathing during a series of central apneas. Thanks!
You don't have CSR. Resmed logs periodic breathing as CSR, however you are near the apneic threshold, and this may be in part due to the use of high EPR setting. In your case, I'd like you to keep settings the same, but dial back the EPR to 1. Therapy onset centrals are often the result of an imbalance of CO2 as a result of improved ventilation. CO2 is a major driver of respiration and when it fluctuates your respiration tends to follow, leading to "periodic respiration" with higher and lower tidal volumes, occasionally punctuated by a CA event. Reducing EPR often helps to resolve this.
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.
(06-14-2023, 09:00 PM)Sleeprider Wrote: You don't have CSR. Resmed logs periodic breathing as CSR, however you are near the apneic threshold, and this may be in part due to the use of high EPR setting. In your case, I'd like you to keep settings the same, but dial back the EPR to 1. Therapy onset centrals are often the result of an imbalance of CO2 as a result of improved ventilation. CO2 is a major driver of respiration and when it fluctuates your respiration tends to follow, leading to "periodic respiration" with higher and lower tidal volumes, occasionally punctuated by a CA event. Reducing EPR often helps to resolve this.
Gotcha. Thanks for the reply! I've included data from a few previous nights as well. The one from a few nights ago has EPR off, and the one before that was from when I tried self-titrating and had a rough night. Let me know if there is anything else useful in here.
Following up on this - here are a few days of results with EPR turned off after giving myself a bit of time to adjust to the machine/settings. Are these numbers of central apneas worth being concerned about?
Your sleep therapy is poor and offers a very minimal benefit over no treatment at all. The event rate seems much lower without EPR. Once you have a month in, tell your doctor it's time for a titration test including ASV if needed to figure out what works. CPAP is not cutting it. It seems you didn't show q lot of central sleep apnea during your diagnostic, but had a lot of PLM. this can sometimes manifest as CSA when we look at machine data. Whatever the cause, you either need a change in therapy or a better understanding of what is causing these events and a therapy that addresses it. Have you looked into medications to mitigate the PLM?
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.
My sleep tech responsible for my at-home titration contacted me saying I “severely needed a different machine.” I forwarded this on to my Pulmonologist, who just responded that “it’s just my body adjusting to treatment and will lessen over time,” although I had asked her if I needed a different machine. She then recommended I try to get an extra hour of sleep each night.
I haven’t looked into medications for the PLM. Only medication I’ve been prescribed in response to my sleep was armodafinil.
Following up with additional messaging from my pulmonologist -
She recommended that my nightly 8 hours was not enough, and that I should get more sleep. She said that they typically do not look into a BiPAP or ASV until at least 6 months of initial treatment.
Additionally, she said she “downloaded [my] data and it looks great on [her] end,” which is interesting to me given that my average AHI is well above 5, often above the 7 AHI reported in my initial sleep study without a CPAP. Lowest reported AHI I’ve had was 3.6.
My CPAP technician has relayed to me that she is also confused by this response and does not understand the need to wait 6 months to try a different machine. She said she is planning to discuss the topic with some colleagues to see if she can think of anything to expedite the process.
Anyone have additional advice? Should I look into getting a different doctor? I’m really struggling to stay awake at my desk at work every day.
07-06-2023, 02:56 PM (This post was last modified: 07-06-2023, 03:00 PM by SleepyBoi97.)
RE: High Number of Central Apneas/CSR?
Following up with additional messaging from my pulmonologist -
She recommended that my nightly 8 hours was not enough, and that I should get more sleep. She said that they typically do not look into a BiPAP or ASV until at least 6 months of initial treatment.
Additionally, she said she “downloaded [my] data and it looks great on [her] end,” which is interesting to me given that my average AHI is well above 5, often above the 7 AHI reported in my initial sleep study without a CPAP. Lowest reported AHI I’ve had was 3.6.
The doctor responded with the following:
“It is normal to have these events, and having them on pap is normal. Our guidelines don't recommend changes unless events are > 10/hour but even that is after several months of the body getting used to PAP.
Things look great!”
My CPAP technician has relayed to me that she is also confused by this response and does not understand the need to wait 6 months to try a different machine. She said she is planning to discuss the topic with some colleagues to see if she can think of anything to expedite the process.
Anyone have additional advice? Should I look into getting a different doctor? I’m really struggling to stay awake at my desk at work every day.
So is this pulmonologist a sleep specialist? Time for a new doctor. This is not healthcare that cares, this is an ego speaking from an altar. It seems like your sleep tech is on the same page as you. Ask for a referral or recommendation. You don't owe this pulmonologist anything. Personally, I have never spoken face-to-face with a sleep specialist, and use my primary physician, an internist.
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.
Correct. They are a certified pulmonologist with a sub-cert in sleep medicine. I got in touch with them through my medical system’s sleep medicine division. It’s a very well-regarded medical center so I’m a bit baffled by how this has all panned out… I’m more than willing to jump through whatever procedures are needed from an insurance perspective, but all of my explicit questions are ignored and given generic answers about “sleep hygiene.”
I initially hoped I would be able to get the CPAP and then make the necessary changes myself to fix the issue since my AHI was relatively low, but it appears that may not be enough. I’m at a loss.
