CSA and periodic breathing

[Herbert0815]

Dear all,

Unfortunately  I have a very complex case to share with you. I hope that some of you have made similar experience or are professionals able to help me to better understand my situation and options.

I'm male, 35y and generally completely healthy. Nevertheless due to sudden episodes of afib after covid in 2021 I was also diagnosed with severe mixed apnea.

My initial AHI during sleep study was 58 with 1/3 central apnea, 2/3 hypopneas and 0 obstructive events. There's supposed to be an obstructive share in all of this, since somehow they recorded lots of snoring while my wife of 10 years never heard me snore ever. First strange thing about my diagnosis.

During 2nd night I was tested under CPAP in different pressure modes. It turned out 7 was the best of the 4 tested (5-8). It reduced my AHI to 3. Second strange thing, as usually cpap shouldn't do anything against centrals.

Meanwhile after 5 months of CPAP I'm down to an AHI of 2 on average. Oxygen average is 97% with lowest of 93%. 

Despite those quite good results, I'm still very worried, because of the periodic breathing pattern I show almost every night for a certain amount of time. Sometimes more, other times less... Also I still feel tired most days.

Could you maybe take a look on my reports. I will attach them here. I also got them on sleephq but im not allowed to post links as new member... Please let me have your thoughts.

PS: Heart and brain are said to be healthy. I had MRIs and several other tests done by the doctors. also I'm not using opiods and I'm not living in the mountains.

Thank you!!!

[chewielotuses]

Hey Herbert, I have alot of periodic breathings throughout the night and like you, I dont have any heart issues nor am I living on elevated terrain. Am curious to know how to go about solving this issue

[Herbert0815]

Hey Chewie, 

since nobody ever answeeed my Post here, I will not be able to provide any answer to you, I'm afraid. I will continue my CPAP Rherapy and maybe have another study in lab this year

Whats your plan?
BR

[Sleeprider]

Herbert0815, sorry we missed your thread asking for help with complex sleep apnea. Hopefully you are still following this thread. Your Oscar graph shows that you have a lot of central apnea and periodic breathing. This is mainly focused at the beginning and end of the night, but there are some event through most of the night. It would he helpful to know if you had a diagnostic study, and what the results of that were. A CPAP is not generally going to be an effective treatment device for this kind of apnea. Your breathing in the segment posted, shows periodic fluctuations of volume and flow, and this is often happens when starting CPAP therapy before you adapt to the improved ventilation, which flushes more CO2, affecting respiration.

If you have any information on diagnostic sleep studies, or can post some additional Oscar charts, including full-night views so we can see if this is typical, we can hopefully think of something useful you might try. I think we may need to experiment with some alternate settings to see how you respond with improvement. Your machine provides EPR (exhale pressure relief) and I'm tempted to have you try EPR on at a setting of 1. Normally we try not to use EPR with central apnea because it can make the problem worse, but it has occasionally helped. If you are willing to try it, all we can do is observe if it improves the problem or makes it worse. Central apnea often improves as new CPAP users adapt to the therapy, and when it doesn't, the best alternative is to try Adaptive Servo Ventilation (ASV) which is specifically designed to treat periodic breathing and central apnea and hypopnea.

[Sleeprider]

Hey Herbert, I have alot of periodic breathings throughout the night and like you, I dont have any heart issues nor am I living on elevated terrain. Am curious to know how to go about solving this issue

Chewielotuses, I have noticed you are posting about this problem in other member's threads.  If you would start your own thread and post some graphs, perhaps we can help.

[Herbert0815]

Hi Sleeprider,

thanks for your reply. I did one in lab and two home studies. For the home studies I never received a written report, but those only showed a moderate result (around 15 AHI). But the in lab study showed a devastating result, which I personally did not expect at all. I will post the screenshots attached and provide a short translation of the result box, as it is in german.

In lab study first night:
"Slept restlessly, many hypopneas with mild desaturations, breathing partially paradox, on his back central apneas in the morning, medium snoring"
   

In lab study second night with CPAP treatment:
"Slept restlessly, woke up several times, breathing partially periodic, some hypopneas and reras with mild desats, few central apneas, partially restless legs, no snoring"
   

And last but not least the control night after 3 months in the same lab:
"Nice sleep structure, CPAP well tolerated, few hypopneas and reras with no relevant desats, very good oxygen levels of 95% in average, no snoring"
   

On a first look one could say I came from a catastrophic state to a very well treated one. But some things don't add up. I still have periodic breathing - I still wake up a lot - I still do not feel very well rested.

So your estimation on my situation would really be appreciated. Also maybe you can have a guess on the root cause of my distroted breathing at night. As mentioned according to the doctors besides the sleeping issues and occasionaly afib (probably covid related) I should be completely healthy...

[Sleeprider]

With this we know that your central apnea issues are not "therapy onset", but were present prior to starting CPAP. It is common to see improvement in overall central sleep disordered breathing with CPAP, but it rarely achieves what we consider "efficacy" or a level of treatment and restful sleep that is satisfactory. There are many exceptions and individual responses. As you have found, the apnea may be improved, but many people treated for CA with CPAP remain fatigued and dysfunctional in their lives due to the many arousals that come from unstable respiration. Your follow-up tests with CPAP show varying levels of efficacy similar to what you are experiencing now. I think you have concluded it is better than no treatment, but not good enough to function normally.

I don't know the availability of ASV in Germany, or whether it is feasible to pursue that mode of treatment through your health system. If you have adequate financial resources, many of our European and Asian members have acquired ASV by purchasing from Supplier #2. The current price of a lightly used but guaranteed low-hour ASV from Supplier #2 is $1799 USD, and new is $2599 USD. There may be shipping and taxes on top of this. ASV is the absolute best therapy you can get for your problem, and it is very easy to optimize to get effective results. Is this an affordable option for you?

[Herbert0815]

Luckily basic insurance in Germany (which I'm on) usually covers all acknowledged treatments, in case the doctors prescribe it. So far I just didn't ask for it, but even asked to avoid it and remain on CPAP since I'm scared of asv for two reasons: First it feels like another escalation level and way more serious/invasive than CPAP which is sufficient for most cases. I just couldn't admit to myself that as a healthy mid 30 need something like that. Secondly I'm really scared of the thought of getting air 'forced' down my throat when having an apnea. The whole concept just sounds way more uncomfortable than cpap to which I adapted quite well so far. Also pressure would probably be much higher than right now, as now I operate between 5-7 cmh2o.

Could I really expect a big difference not only in AHI but also in periodic breathing and thus in my quality of sleep on asv?

And what do you think of additional O2 instead of asv? my sleep doctor said this would be the next step in order to check if ot would resolve my periodic breathing. but I'm not too convinced about this proposal.

[Sleeprider]

It might help to learn more about ASV by reading this clinical titration protocol that shows how it works https://document.resmed.com/en-us/docume...er_eng.pdf

We have many members with similar problems. I am always surprised when a young, healthy woman with good fitness and low body-weight joins the forum and complains about her apnea therapy. As you can imagine, nearly all of these cases are people with central apnea being treated for obstructive sleep apnea. The correct way to think about your condition is that it is "idiopathic central sleep apnea" which means it does not have an identified cause. It does not arise from a neurological or cardiac comorbidity, but probably due to the fact your respiratory drive is very sensitive to the increases and decreases of CO2 Respiratory drive is very complicated, but in simple terms, when sleeping, your respiration rate is regulated by chemo-receptors on carotid bodies. Many people with central apnea and periodic breathing experience a feedback-loop in this chemical interaction that results in alternating hypoventilation (hypercapnea) and hyperventilation (hypocapnea). The condition is self correcting, but due to a lag in the feedback loop the fluctuations in breathing volume and apnea result in a pattern you are very familiar with. This is not a health problem other than you can't sleep without arousals from the adrenalin response during periods of hypercapnea (high CO2).

How's that for "simple"? LOL! Anyway, don't feel stigmatized by pursuing the appropriate therapy in ASV. The way it works to target your normal breathing rate and volume, and allow you to breathe spontaneously. As the algorithm detects increases or decreases in respiratory volume, it makes adjustments in bilevel pressure support (the difference between inhale and exhale pressure) to make respiration more constant and maintain the minute vent rate. This keeps the user from experiencing the periodic breathing, leading to the apneic loop that leads to central apnea. In most cases a central apnea does not occur, but if it does, the machine just continues to adapt the pressure support to maintain breathing volume. If it "shoves air down your throat" something is wrong. Most ASV users adapt to the pressure changes and become very comfortable with it. You can always stop using the therapy and you will go back to your untreated state of over 50 events per hour. You really do need this instead of using an obstructive sleep apnea therapy to treat a central sleep apnea problem. I hope this helps you understand the problem in different terms and just what "central" means. It's simply a chemical imbalance that people without the problem do not experience because their chemo receptors (carotid bodies) are less sensitive. Most of the members on this forum using ASV are younger and healthier (less obese) than the cohort of CPAP users.

[Sleeprider]

Herbert, I think ASV is the right therapy in your case, but there is one other technique we can use to stabilize the CO2, and that is by adding enhanced expiratory rebreathing space (EERS). This is simply blocking the vent at your mask, adding a short section of tubing and relocate the vent farther from the mask. This causes you to breath a small part of the air you exhaled in the last breath, increasing CO2. Increasing the respired CO2 increasing respiratory drive by keeping PCO2 higher, and buffers the effect of periodic breathing. http://www.apneaboard.com/wiki/index.php...ace_(EERS)

This technique is mostly experimental but has been used successfully by several members.