[Diagnosis] Very high amounts of periodic breathing / CSR ?

[gregbe2000]

Hi -

I'm new to Oscar data and would very much appreciate some help with some data that's causing me a lot of anxiety - it's the very high amount of data flagged as CSR (periodic breathing).  Some background info:

• I'm 53, in shape, and exercise daily.  I'm on no medication (besides lipitor) and have no known heart issues
  
• I've had 4 sleep studies ranging back to 2006, with the most recent in 2020 as I've always been a terrible sleeper (even in my 20s).  None of these noted CSR/periodic breathing, or central apneas.  They've all noted hypopneas, RERAs, and a high number of arousals/awakenings
  
• I was diagosed with both sleep apnea (mostly hypopnea events) and insomnia.
  
• I've been using my APAP for the last 4 years.  I don't feel noticeably better with it - but I've assumed that's because of a high # of unconscious arousals related to insomnia
  
• I never feel refreshed in the morning
  
• My resting heart rate is very low at 35-40 at night (my whole life).  This is genetic (I'm not a super athlete).  I've seen a cardiologist and they say there's nothing wrong.
  
• I flip and flop a lot at night as I can never seem to get comfortable
  

I've attached sreenshots of a few days ago where I thought I slept well since I didn't get up between 2-4 when I normally do - yet was fatigued and had a headache throughout the day.  It shows a very high amount of periodic breathing.  This is consistent with other days.  The % of time in CSR has gone up over time.  The myair app states everything is fine (it always states this), just usually get 10-15 AHI due to central apneas.  I've asked my sleep doctor about this (before I knew about oscar) and he thinks the machine is falsely reporting central apneas due to me low heart rate / respiratory rate (machine thinks I'm not breathing but I just breathe at a low rate).  I'm not convinced of this and now the oscar data is scaring me. Any insights would be greatly appreciated.  Thank You!

   
   

[Jay51]

Your situation is kind of unique IMO.  You have a low resting heart rate (Cardiologist says nothing wrong here).  

Your close up OSCAR does look like the crescendo-decrescendo pattern of real CSR.  Sleep Dr. says they are falsely flagged though.  

Here is some more reading from our wiki on CSR.  *Pay particular attention to the section that give some alternate causes of CSR other than heart failure ("Associated Conditions").  Do any of these apply to you?  

Cheyne-Stokes respiration

[gregbe2000]

Thanks for the reply. No, I don't have any of those conditions and I don't live at a high altitude. This issue wasn't flagged in my sleep study 4 years ago. My sleep doctor assumed the central apneas were due to my low heart rate - but he hasn't seen the oscar data and he hasn't seen the periodic breathing data. I can't see how a low heart rate would result in this type of respiration. I have an email into him but I coudn't make an appointment until late December.

I do find it very hard to stay asleep - I'm not sure if this could be the cause of periodic breathing or the other way around.

[gregbe2000]

Since I didn't have central apneas in my sleep study 4 years ago and not it appears I have a lot of them while wearing the cpap. Does it make sense to fix the pressure really low at 4 and see if I'm getting central apneas then?

[Jay51]

Great question you pose.  Hopefully, when you show these OSCAR's to your Dr., they can interpret them correctly. 

Most adults feel, "air starved" with a pressure of 4 (too low).  Your pressures don't get that high.  Usually, EPR and pressure support (PS) can contribute more to CA's than anything.  But, higher pressures may cause CA's like you are thinking.  You can try it if you want to.  Or even just slightly decrease your pressure min and max by 0.2    And then another 0.2 etc.  And see how that goes.  

It is a balancing act with CA's vs. OA's, etc.  Pressure must be high enough to stop OA's, but not too high as to cause CA's.

[Jay51]

You may even want to experiment and try a fixed cpap set up rather than an APAP with adjusting pressures.   Your median pressure are around 4 and 6.  Pretty low.  You only get up to 9 maximum very briefly.   

Another experiment may be using 7 as a fixed cpap for a couple of nights and see if that lowers your CA's.

[gregbe2000]

Thanks. My sleep doctor is on vacation now but hopefully I can exchange some messages with him next week. I don't know if he'll look at my Oscar data or instead schedule a sleep study while sleeping with my CPAP - which I think is necessary and might be the only data they can officially use. In the meantime, I feel I need to do something to investigate on my own. I do plan on setting to a lower pressure tonight.

[Phaleronic]

Hi gregbe2000, good suggestions so far, I would also add that you should turn EPR off tonight. Set the machine to static pressure (cpap mode) too at 7cm, give it a shot for about 30 minutes tonight before bed please. Also, that looks like valid CSR respiration waveforms-you likely will need an ASV machine to treat this successfully.

[gregbe2000]

Hi gregbe2000, good suggestions so far, I would also add that you should turn EPR off tonight.  Set the machine to static pressure (cpap mode) too at 7cm, give it a shot for about 30 minutes tonight before bed please.  Also, that looks like valid CSR respiration waveforms-you likely will need an ASV machine to treat this successfully.

Thanks.  I've set it to a static pressure of 5.4cm and turned EPR off.  I hope it works.  I've been reading about CSR and see that it can be caused by CPAP treatment.  I've come to the same conclusion about the ASV machine...wow, all this with some data I didn't know existed 2 days ago.  I hope the decreased pressure makes this go away or it will be even more complicated to figure out.

[Crimson Nape]

A word about your pressure. Most adults will have a suffocating feeling if the pressure is below 7cm. This can lead to causing CAs, because you have the need to try and overcome the lack of air feeling and hyperventilate. Looking at your chart, I would set a range of 7 to 9 cm. This is a narrow pressure band, but enough to see if this may help. You can try this with or without EPR. Your flow limits indicate that some EPR (1) could be to your advantage, but that's for another day.
- Red