Cheyne Stokes isn't always heart related

[coldfeet7]

From what I can tell from researching it, Cheyne Stokes breathing can come several possible causes (heart problems being the most well known/common it seems). Apparently ASV for treatment is not appropriate with heart conditions (low ejection fraction), but is it ever used to correct CSR if not heart related?

I have felt like I experienced CSR on a few rare occasions. One time when napping caught my attention. I would be awakened to a slowly rising breathing and then I nod off as it slowly decreased. I tried to stay awake to experience the whole cycle but would only awaken as the cycle resumed with breathing. I couldn't tell if I was experiencing each cycle or just some in the sequence. It was such a strange experience that I researched it and found out about CSR. For an unrelated reason I had already had a heart work up (echo, stress test, etc.) and I am ok, so that is not the source.

A few months later I was diagnosed with severe apnea (AHI 57). Early in my treatment I saw a pattern that looked like CSR. I have read some threads here on CSR with great interest and have been impressed with the knowledge of this board. It makes sense that rhythmic breathing can be induced by certain settings.

Here are three charts of one night with a period of about 14 minutes with what looks kind of like CSR to me. Does it look like it?  The pressure was very low at 5, so I don't know if that could have been a trigger. Perhaps you would call it rhythmic breathing punctuated with CAs (but isn't that what CSR looks like)? The only thing that doesn't look textbook is the cycle is not symmetric because the increasing breaths time happens faster than the trail off of breaths.

I haven't had this happen but about two times in 6 weeks, so it doesn't seem like it is of concern.

[SarcasticDave94]

Great info on this. BTW just an add on. I've had the echocardiogram for getting an ASV. 55% LVEF in 2017. My new cardiac doc wanted the full nuclear stress echocardiogram in early spring 2020, LVEF was 63%. ASV is OK if the ejection fraction is above 45% and the sufferer of that number would likely know it already.

The ASV is really issued for Central Apnea combat. That's the ASV niche.

I'm not a very good chart guru so I can't add in on the CSR questions. So I'm guessing you're ruled out for an ASV? What stats were on your sleep study?

[multicast]

I have felt like I experienced CSR on a few rare occasions. 

Me too.  Covid visited me, guess when!  (max. AHI = 6 in the screenshot)

   




Sudden occasions of CSR.  Curiously enough, respiration rate and minute volume raised a lot, as you can see, but FL went down ... BTW: heart condition is good.

[coldfeet7]

Great info on this. BTW just an add on. I've had the echocardiogram for getting an ASV. 55% LVEF in 2017. My new cardiac doc wanted the full nuclear stress echocardiogram in early spring 2020, LVEF was 63%. ASV is OK if the election fraction is above 45% and the sufferer of that number would likely know it already.

The ASV is really issued for Central Apnea combat. That's the ASV niche.

I'm not a very good chart guru so I can't add in on the CSR questions. So I'm guessing you're ruled out for an ASV? What stats were on your sleep study?

I have seen that <45 criterion as well. My LVEF was in the mid-60s as well.

I don't think I have enough CAs to justify an ASV. Perhaps with several months more to see a pattern I can figure things out. I am only 6 weeks into CPAP treatment. There is so much to learn...  but it is interesting so I am trying to be a sponge right now.

I have felt like I experienced CSR on a few rare occasions. 

Me too.  Covid visited me, guess when!  (max. AHI = 6 in the screenshot)

Sudden occasions of CSR.  Curiously enough, respiration rate and minute volume raised a lot, as you can see, but FL went down ...  BTW: heart condition is good.

Did your Dr. mention how to handle your machine (cleaning, etc.)?  I would imagine your mask relief was releasing virus in the air and not a place someone else wanted to be.

[coldfeet7]

What I have learned is that I MUST strive to keep my mask on. I am still tired after CPAP each day, but my O2 ring proves to me it is at least helping with my O2 saturation. I have decided to not pay attention to AHI very much. I want wear time and that means reduced pressure for comfort. I can change my priorities when I can consistently wear it all night.

Last night, for some reason, I suddenly had a ton of leaks and not at much pressure. Arggghhhh....  but at least my O2 and pulse were good with CPAP. They always are - yeah! After I pulled the mask off my O2 and Pulse (second chart) showed I started back into my seesaw pattern and now my feet feel cold and will be tingling most of the day. My GP never questioned that I always wear two pairs of heavy socks to bed each evening, even in summer, or I wake with intense pain. I mentioned that several years ago and he thought it was curious/strange but that was all.

Look at the crazy rhythmic pattern to the O2 after the mask came off. I suspect I was on my back were my apnea is decidedly worse. I also suspect I have some neuropathy that acts up when my O2 swings around at night. (I don't have diabetes and think if this is some neuropathy that it resulted from my apnea for years.)

[SarcasticDave94]

The mask... Have you tried any others like ResMed P10 or any other? Redo your adjusting under therapy pressure, don't rely on the mask fit, it will drive you crazy with the grin and frown ghouls. Stick with you adjusting via you sensing leaks and OSCAR.

Lie back on the bed with therapy pressures on, hold mask in place no straps yet, tension by fingers, get leaks best as you can then add straps, adjust to mimic finger tension. Goal is minimal leaks and minimal disruptions from leaking, and not too tight.

[sheepless]

no one's commented on your csr/ca pattern yet so I'll take a stab: it's not as sinusoidal as might be expected for csr but it's close enough that I suggest bringing it to your doc's attention if you see it often, particularly after you've been using the machine for more than 90 days. it may be a one-off, treatment emergent, or a consequence of sub-optimal pressure settings. others may have settings suggestions to attempt to mitigate it.

[coldfeet7]

The mask... Have you tried any others like ResMed P10 or any other? Redo your adjusting under therapy pressure, don't rely on the mask fit, it will drive you crazy with the grin and frown ghouls. Stick with you adjusting via you sensing leaks and OSCAR.

Lie back on the bed with therapy pressures on, hold mask in place no straps yet, tension by fingers, get leaks best as you can then add straps, adjust to mimic finger tension. Goal is minimal leaks and minimal disruptions from leaking, and not too tight.

I have the N30i (small and medium mask), the F30i (small and medium mask) and the F20 with the memory foam.

The N30i medium is the most comfortable and relatively leak free but I wake too much with mouth breathing and bubbling lips (despite a chin strap). The F30i medium OUGHT to be good but I can't get a reliable seal around my nose. It seems to bunch up on the sides.  So clearly a medium N30i is not the same as medium F30i. I am finding that face and head geometry really make it challenging to get the right fit.  Add Covid, where trying on lots of them is impossible, and I can only imagine how this has impacted the industry. I found that the F20 gives a good seal on my whiskers, BUT it butts into my forehead where my nose and forehead meet. If I slide it down for comfort the seal pushes my nostril cavities shut. It is too hard to wear reliably.

Good idea Dave on holding the mask in place to test. I find that I can get a comfortable fit, but when I attach the headstrap/frame I can't get the idea fit for the F30i. That is the one I really wanted to work. The geometry of forces seems to just be off a little. 

Side sleeping with that silicon rib over the top of your head can be a challenge. I can get a good seal on my back, but the side-sleeping pushes it off to the side and the leaks start and the air rib can begin to narrow on the side by the pillow.

[sheepless]

just fyi, attached is a flow rate pattern not too dissimilar from your 'csr' pattern but without the ca (presence of ca within a sinusoidal flow rate pattern is an important indicator of csr). in this case the pattern is a variant of my periodic limb movement pattern. sometimes punctuated by events, sometimes not; much more so before I got my ahi down with some fine tuning. I'm not saying yours is plm, just that there are some similarities that could be suggestive to keep in the back of your mind.

[coldfeet7]

no one's commented on your csr/ca pattern yet so I'll take a stab: it's not as sinusoidal as might be expected for csr but it's close enough that I suggest bringing it to your doc's attention if you see it often, particularly after you've been using the machine for more than 90 days. it may be a one-off, treatment emergent, or a consequence of sub-optimal pressure settings.  others may have settings suggestions to attempt to mitigate it.

Thanks for taking a stab at it....

I've attached a bizarre chart of my other CSR-like episode that went for about an hour continued AFTER I removed the mask, so that made me think it wasn't treatment induced. The reason I know it continued was I was having that same arousal pattern and then slowing to unconsciousness then arousal and it went on for a long time. I finally gave up and removed the mask and wondered if it would continue. It did. I have no idea how long that went on before I just got up.

This one wasn't marked CSR and instead resembles lots of OAs and CAs. (Does the machine classify a CA vs an OA based on the higher frequency pressure pulses it sends to see if there was an obstruction?) All I know is it had that same cyclical feeling of rising and falling.
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As far as my Dr is concerned...  He is a nice fellow, but as a pulmonologist, he is not their CPAP person. That person was also to be on my visit, but he was involved with another patient and popped his head in the door for 1 minute.

The Dr said, as y'all have predicted the Dr would, that my AHI average was under 5 and so it looks great. I told him I am often MORE sleepy than before CPAP and I would give up if I didn't know about my terrible O2 sats when off of it. Here was his solution.... Modafinil. No one looked at my charts beyond compliance and AHI. I am ALMOST at 70% and so the suggestion is to wear it reading a book or watching TV to get my 4 hours if I come up short one night. I was beyond depressed about the visit. It was just one more check box for insurance bean counters.

Having a community to work on this is SO IMPORTANT. Medicine today is screwed up. They spend too much on everything BUT time with the patient (buildings, lawyers, insurance submission, etc.). Diagnosing is an art and it takes time that they don't have.