Cheyne Stokes Respiration ?

[Mal777]

I turned off ramp, and reduced pressure from 10-15 to 8-11. Arousals were down :-)

Unfortunately my AHI went up to 7.33 (usually from 1 to 2) and CA was 2.83.  Also my respiration rate was up

When I first started therapy I had noticed when ramp was off, I was getting much higher AHI's. Have you seen this before? 
 
I was thinking possibly trying  pressure to 8-12 and ramp to auto, or is it a lost cause until I trial the bilevel?

Screen shot from last night attached. 

thanks again Sleeprider

[Geer1]

During ramp the machine will not flag breathing events (apneas, hypopneas etc), you are still having them but the machine just ignores them. You can see this in your old data as it was not flagging any events nor flow limitation during ramp periods because it knows it is not even trying to provide sufficient treatment. In your specific case you undergo a periodic breathing period when transitioning to sleep and that is what was primarily being flagged in that last day of data you just shared, most of this data would have been ignored when ramp was on and set to 30 min which is why your AHI was higher.

Hopefully that makes sense, the attached file shows what data would have been ignored (not flagged as apnea events) if you had your previous 30 min ramp setting still on. As you can see your AHI would have been significantly lower even though your breathing would not have actually been better.

As you noted you didn't have as many arousals on these settings, your pressure only barely bounced off maximum a few times and your flow limitations weren't significantly increased. I think you should stick with the current settings for a while to give your body time to adapt to them (unless Sleeprider or someone else more knowledgeable says to try changing something).

[Mal777]

Well that is very interesting. I was not aware that the machine does not flag events while in ramp. I was always confused as to why my AHI's were so much better if I used ramp.  I will not use it again.
All my early oscar reports showing many AHI's at the start of therapy, (and also the periodic breathing events) were likely when I was awake trying to sleep. Once I got to sleep and ramp was off, therapy started and my AHI's were excellent. In fact when I'm awake and relaxing in a chair, I often feel like I have depressed breathing.....or almost forget to breathe.
It is all starting to make sense

thanks for your assistance

[Mal777]

Hello again Sleeprider and Bonjour
Last night I had a very restless night, and this morning my report showed Cheyne Stokes breathing again. I presume (hopefully) that this is periodic breathing like before. As previously discussed, I see my sleep physician in 3 weeks to see if a change in machines to bilevel or ASV would be better for me, but in the meantime could I have your opinion/suggestions please on this CSR possibility

Ive tried various pressures, but have now gone back to 11-14  or 10-15, since I no longer use ramp
Ive included a zoom in on the CSR part

thanks once again
Mal

[Geer1]

I would be curious if this periodic breathing would go away with reduced EPR which would imply that these are central apneas being induced by the CPAP treatment (I don't know that I believe the obstructive flag for these). They could be being caused by the increased pressure as well as it seems you might be more prone to these events at higher pressures.

You mentioned you feel it is harder to breath with reduced EPR. What you could try is turning ramp back on, setting it to auto, start pressure to 8 cm and EPR to ramp only. This will help you fall asleep and then once you do the EPR will turn off.

[Sleeprider]

The apnea are mostly obstructive and end with recovery breathing which argues against CSR and for PB. The events are real enough that a better solution should be found. On the charts, we really don't need Tidal Volume or Resp Rate, but the Flow Limit chart needs to be expanded so we can see if the events are arising out of restricted breathing. Could you please make some adjustments?

[sheepless]

I'm no expert by any stretch but this doesn't look like csr to me. besides the incomplete not very sinusoidal pattern, most events are obstructive. I don't want to harp on periodic leg movement but I suffer from it so I suggest ruling it out in your case. I don't know if everyone's respiratory response looks like mine and your image doesn't look like my typical plm flow rate pattern but it is periodic & it does look like the new pattern I've had lately that I speculate is a quieter response to quieter plm as a consequence of taking ropinirole for it. plm may or may not be the source of your periodic breathing but something to keep in mind.

[Mal777]

The apnea are mostly obstructive and end with recovery breathing which argues against CSR and for PB.  The events are real enough that a better solution should be found.  On the charts, we really don't need Tidal Volume or Resp Rate, but the Flow Limit chart needs to be expanded so we can see if the events are arising out of restricted breathing.  Could you please make some adjustments?

Thanks for your advice everyone

Geer1 .   Good suggestion but I will wait till after my sleep physician appt as I want an accurate indication of AHI's and ramp was not showing these as you kindly pointed out previously

 Sheepless.   I am not aware of periodic leg movement

Sleeprider I have attached 2 new screen shots of flow limit

[Sleeprider]

Mal777, I think the periodic breathing is not a particularly important issue, but the shape or your flow rate, for example from 00:15 to 0045 looks extremely flow limited and unusual. The same pattern of higher expiration flow seems to occur frequently. I can't promise I will be able to help, but it would help to look at a 2 minute zoom of breathing outside this PB period. I suspect we will see flat-topped inspiration and a rapid exhale leading ot near zero flow ahead of the next inspiration. You have a relatively long inspiration time 2.2 seconds vs expiration time 1.74 seconds. Finding out why that is happening might be a key.

[Mal777]

Mal777, I think the periodic breathing is not a particularly important issue, but the shape or your flow rate, for example from 00:15 to 0045 looks extremely flow limited and unusual.  The same pattern of higher expiration flow seems to occur frequently.  I can't promise I will be able to help, but it would help to look at a 2 minute zoom of breathing outside this PB period.   I suspect we will see flat-topped inspiration and a rapid exhale leading ot near zero flow ahead of the next inspiration.   You have a relatively long inspiration time 2.2 seconds vs expiration time 1.74 seconds.  Finding out why that is happening might be a key.

Thanks  Sleeprider
Screen shot as requested attached.

 I might try to tolerate my cervical collar tonight to see if that helps my flow limitation. I do tend to drop my head when sleeping.....