[Diagnosis] OSCAR: TECSA, CSR, or something else?

[Malgaras]

I first got diagnosed with OSA back in August. My pulmonologist had me do a home sleep study, came back with AHI of 34, OA 19, CA <1. 

Mid September > Mid November, I do an initial run with a CPAP, Resmed AirSense 11 APAP, 6-12 with an EPR of 3. After struggling with mask fit, rainout, and various other crap, I finally get things kinda sorted but the machine is reporting significant central apnea. I have my follow-up with the pulmonologist. He looks through the data, and says I have TECSA, and sends me for an in person sleep study to see about ASV. 

December comes around, I do the in person sleep study, and a follow up with the pulmonologist a week or so ago. The ASV appeared to do the trick, and he wants to switch me over. Fine by me. However, I was born with multiple congenital heard defects (...and you probably know where we're headed here), so I ask if there are risks associated with me going on ASV. I also ask my Cardiologist for good measure. The pulmonologist checks my echo from march of last year, and things at that point were looking good (well as good as my heart ever looks, defects, but no heart failure), and my ESF is 69%, so we should be good to go. I basically tell my cardiologist what I told you up to this point, and they say ASV should be fine. Long story short, I've been off therapy entirely since November since it didn't really seem to help, and am waiting on an ASV.

However, I've been looking around at all this crap lately for obvious reasons, and my machine is now supported by OSCAR, so on a whim, I download OSCAR and pull up some of my old data from November out of curiosity, and I see the attached, or something similar on many many days.

This... looks like textbook CSR to my admittedly untrained eyes. Am I wrong? Does TECSA just happen to present in the same way? Did the original home sleep study just completely whiff on the type of apnea?

Assuming I'm right, how urgent is this? My latest MRI and Echo looked good in march of last year, and I've got my yearly follow up with my cardiologist in just a couple weeks. I don't feel particularly different in any meaningful way since then and haven't experienced any trauma etc. Do I bring this and my SD card with me to my appointment? Or is this like, get my cardiologist on the phone tomorrow?

[Malgaras]

Having spent entirely too long staring at these graphs l, my revised thought is that the onsets look a bit too sudden compared to the tails, and that maybe it is just complex sleep apnea and my paranoia over my existing heart problems has me jumping at shadows. Hopefully some here can speak more authoritatively.

[pholynyk]

I'm not as familiar with CSR as some others here are, nevertheless I think the waxing and waning of the flow is too abrupt to be true CSR. The ResMed algorithm has a well-known propensity to mark any vaguely periodic breathing pattern as CSR. so, in my estimation, not CSR.
Again, others are more familiar with the mechanisms involved with Treatment Emergent CSA, but I will point out that one of the first things to try to reduce the CSA would be to reduce or eliminate the EPR. It's called a Comfort Feature, but some people use it to reduce hypoapneas and flow limitations (me!) and it others it leads to over-ventilation and CAs (you?). I suggest setting EPR to 1 for a week, just to see what happens to your CA count.
Of course, if you had CA during your sleep study, then these are not treatment emergent...

[SarcasticDave94]

I guess I'm a bit skeptical. This is nothing against you, but discussing the state of therapy. Your getting an ASV is not normally that easy, and is opposing the history you're stating. I think there's some piece of the medical puzzle missing. So to speak they're ready to issue you ASV as if it's candy where clear cases of pre-dominant Central Apnea like mine and I had to fight to get it.

They do not issue ASV for treatment emergent Centrals. That's where part of the discrepancy happens. So something is fishy to me.

As for CSR flags, it is possible they're false, but you do mention a congenital heart defect, so that opens the possibility that maybe the CSR is real. But I don't read the patterns well.

[desaturator]

I also have heard of the propensity of the ResMed machines to over-report CSR. While I'm aware, at the textbook level, that CSR can be found in people with heart failure, I've only ever seen it in those who are gravely ill, usually in their last days of life. I get episodes of periodic breathing in my OSCAR data but, because I know my cardiac function is sound, I wouldn't assume it was CSR, whatever ResMed says.

I would certainly trust an echocardiogram or cardiac stress MRI to tell me the overall health of my heart, more than I would a CPAP machine.

Still, that doesn't mean that we should accept this as normal breathing behaviour.

Best wishes, DS

[Malgaras]

I suggest setting EPR to 1 for a week, just to see what happens to your CA count.
Of course, if you had CA during your sleep study, then these are not treatment emergent...

So looking through the data, EPR appears to have already been off the last few days, including the one I linked. I don't actually remember turning it off but it's also possible I just forgot as it's been a couple months, or that they did it remotely. I could give it another go. I also wonder if I should just bottom put the pressure entirely for a few nights. It would be unlikely to actually treat my apnea, but it would be interesting to see if the CSA reverts back to OSA.

I guess I'm a bit skeptical. This is nothing against you, but discussing the state of therapy. Your getting an ASV is not normally that easy, and is opposing the history you're stating. I think there's some piece of the medical puzzle missing. So to speak they're ready to issue you ASV as if it's candy where clear cases of pre-dominant Central Apnea like mine and I had to fight to get it.

They do not issue ASV for treatment emergent Centrals. That's where part of the discrepancy happens. So something is fishy to me.

So I already double checked the visit reports before making my post. My pulmonologist very explicitly stated a diagnosis of TECSA. To quote from the November visit summary: 

today we discussed in detail about treatment emergent central and the fact that patient failed auto Pap and we need to do a titration study for possible qualification for getting ASV

So either my pulmonologist is deliberately lying to me for reasons I can't fathom, or that's exactly what they did. 

I will note that upon re-reading the entire report again just now, CSR is mentioned in the compliance report, but that section appears to just be the raw data dump from the machine, which we can already see is classifying this as CSR. I don't see any mention of it in the actual physicians notes, and as mentioned above he appears to explicitly contradict it with his diagnosis, unless I suppose he is equating the two and needs his license revoked. I may shoot him off a message and ask about it more directly.

My understanding is that there's no real reason that an ASV shouldn't work for TECSA, just that it's expensive and potentially somewhat overkill. I think my pulmonologist is more likely going straight to the nuclear option simply because it's easier for them than another half dozen follow ups messing with the pressure, potentially trying bi-pap, etc, than because they are not being forthcoming with a potentially serious diagnosis.

I also have heard of the propensity of the ResMed machines to over-report CSR. While I'm aware, at the textbook level, that CSR can be found in people with heart failure, I've only ever seen it in those who are gravely ill, usually in their last days of life. 

That's part of my skepticism as well. I'd like to think I'd notice some change if my heart was deteriorating significantly, but I generally feel like I always have.

I would certainly trust an echocardiogram or cardiac stress MRI to tell me the overall health of my heart, more than I would a CPAP machine.

So 100% agreed on the MRI and echo being the more reliable indicators there. My main concern is that it's been a bit. If I had them last week I probably wouldn't be here asking questions, but it's been a solid nine months. While a major deterioration would definitely be a somewhat abrupt change of course from my historic trend of "everything looks the same, come back in a year" visits, it seems at least theoretically possibly given I already have multiple known heart defects.

Another data point: I looked through the report from the in person study, and while it's more just a summary, there are about 2 hours of CSA at first before they switched the machine from CPAP to ASV, which appears to have resolved everything but a handful of RERAs. I'd like to think if the technician saw nearly two hours of CSR, they would have noted something about it in the report. I do see a note that "Lead II EKG recording revealed no significant cardiac dysrhythmias" but I'm not informed enough to know what that would or would not rule out.

[Malgaras]

Of course, if you had CA during your sleep study, then these are not treatment emergent...

Whoops, missed this the first time.

Not as of yet. The home (type 4, maybe 3? canula, chest strap, oximeter) study reported OSA (OAI:19.3, CAI:0.3). The type 1 study reported significant CSA, but that was a titration study. I was on CPAP the entire time, first with a pressure of 10 as I went to bed, with lots of centrals, then ASV which resolved anything except some RERAs. 

Long story short, no reports of CSA while not also on CPAP as it stands.

[Gideon]

Several points,
1. TECSA and CSR do present similarly with primarily 1 difference, that being duration, your are borderline with some meeting criteria and some not. http://www.apneaboard.com/wiki/index.php..._.28CSR.29 Note The apnea/hyperapnea cycle is around 45 minutes to 75 minutes.
2. Our first move is always to reduce EPR, EPR=0 in your chart.
3. ASV is where I would want you to be.

[Malgaras]

So looking through more of my data, some obervations:

1. The above was my last day, which is why I checked it first, but does also appear to be one of my worst days for CSAs, although there are certainly others.
2. The CSAs do appear to roughly correlate with an increase in pressure (and often leaks, although that may just be a function of pressure) a lot of the time, but not always. And the days where the APAP leaves the pressure pretty low all night look like my best days in general with regards to CSA. That of course leaves the chicken and egg question unanswered.
3. I often will see that mildly cyclical looking breathing as well, where it moves up and down but never actually stopping, at other points during the time.
4. Resmed is AWFUL at labeling this stuff consistency.

[quiescence at last]

maybe you could also supply an overview tab screen shot to so the variability.  would be excited to see if the lowered EPR helps you control the CA count, and maybe you could also reduce your max pressure once we see how reduced EPR works for several days.



Wishing you well and that your new machine shows up quick.

QAL