Need more info on Cheyne-Stokes

[RadarRalfs]

Hello,
 
I am a 66-year old male diagnosed with atrial fibrillation (afib) in October 2020.  Evidently afib and sleep apnea are correlated so a home sleep study was subsequently performed which indicated severe sleep apnea.  CPAP therapy was recommended which I began in late November, 2020.
 
My initial three-week experience with CPAP therapy was unpleasant.  There were numerous difficult nights with mouth breathing, leaks, and increasing CA events.  I became worried about “treatment-emergent central sleep apnea”.  There was also a sales pitch to purchase the equipment for an inflated price.  I ended up discontinuing therapy and returning the gear just before Christmas.
 
After about three months unsuccessfully experimenting with various options to reduce the obstructive apneas, I finally accepted the need for CPAP and purchased a “Resmed AirSense 10 Autoset” machine and F&P Vitera Full Face Mask from Amazon Canada for about 40% of what I had been quoted before.  I have been using this equipment since March 18, 2021 with 100% compliance.
 
With the wealth of guidance on this forum I have been successful in adjusting to the machine.  Adjusting the machine to me is still a work in progress although the current settings seem acceptable.  The obstructive apneas have been virtually eliminated.  The CA events are still present though and seem to wax and wane.  I wondered how much they were affecting my oxygen levels so purchased a Wellue O2Ring and the resulting oximetry has reassured me that things are okay.  My only serious concerns involve two episodes of what the Resmed data indicates as Cheyne-Stokes Respirations (CSR).
 
In the 17 days I have been using this machine, the data has twice (Mar 21 and Apr 4) indicated a period of CSR (Mar 21 and Apr 4).  Both occurred late in the sleep cycle after getting up to urinate and then returning to bed and then being awake for 10-15 minutes reading before drifting back to sleep.
 
CSR was indicated in the original sleep study also but the respirologist provided the following comment:
 
“0:30 hours of Cheyne-Stokes respirations was identified on in-home sleep testing. However, on my review of the raw data I do not believe diagnostic criteria for central sleep apnea with Cheyne-Stokes respirations was met.”
 
CSR is an alarming disorder to read about but, as far as I know, I do not suffer from any of the underlying conditions which cause it.  I have several questions:
 
1)      Is this really Cheyne-Stokes Respiration?
2)      Is it worth worrying about?
3)      If it is worth worrying about then what is the recommended course of action – ASV perhaps?
4)      Are the CA events of concern?
 
I have attached OSCAR screen shots which are hopefully adequate to provide additional insight.  Thanks in advance for any help.

[Gideon]

Welcome to the forum

1)      Is this really Cheyne-Stokes Respiration?
2)      Is it worth worrying about?
3)      If it is worth worrying about then what is the recommended course of action – ASV perhaps?
4)      Are the CA events of concern?

1. No, it is not long enough or consistent enough to be CSR.  ResMed calls ALL periodic breathing, that is what this is, CSR.
2. Worry?  No.  Watch? Yes.  Watching means a simple glance to see if it is getting worse.  Note that CA is "consistently inconsistent".  That means CA frequently bounces all over the place.
3. Be aware that increasing may, actually likely will increase your CA events.  The treatment for this is Time, 2-3 months to allow your body to get used to breathing with the PAP machine.  This is actually treatment-emergent central apnea.  Again nothing to worry about, but it is worth watching.
4. Since you have mentioned them, and mentioned them a lot, (that's ok, we are here for that), they are a concern, but they are nothing to worry about.

Going forward. I would like you to carry, knowingly carry, a few CA events because with these events your body will adjust better and faster.
Treatment-Emergent Central Apnea offers because your PAP matching is doing a good job, actually a little too good.  This is a simplified explanation. The main driver that causes us to take a breath is CO2 in the blood, not low oxygen as many think, low oxygen tends to make us breathe faster.  The body senses the CO2 and 'says' I need to get rid of it, so it breathes a little harder driving the CO2 levels down smoothly (see how smooth your breathing is during your periodic breathing, how it tends to wax and wan) until the CO2 level is below your 'apneic' threshold at which point you stop breathing as evidenced by the CA event.  Now that you have stopped breathing and are no longer expelling CO2 from your system thus causing CO2 levels in your blood to increases and when the CO2 levels are above your apneic threshold you resume breathing with stronger and stronger breaths which result in renewing the cycle again, and again.

I would like you to increase your EPR from 1 to 2 (full-time) to do two things
1. to better control your flow limits, they are a bit higher than I like to see.  This should also help to lower your hypopnea count.
2. to confirm that in fact you do have Treatment-Emergent Central Apnea.  I do expect the CA events to increase somewhat.  Note that CA events are consistently inconsistent. If it is too much we will lower EPR back to 1.



Please not critically if your current settings (with EPR=1) or new settings (with EPR=2) feel better.

[SarcasticDave94]

Agreed with all this. Welcome to the forum.

[multicast]

You're far away from this:

   

So don't worry.

[Gideon]

That. Is CSR and I'm asking you to see your primary doc, your cardiologist, your pulmonologist, and your sleep doctor today, same day appointment so they can run a battery of tests to determine cause. I want to know how often it occurs and how long it occurs for. I'm asking you specifically if you have any known cardiac or respiratory conditions. And then I'm reminding you that your doc is going to want to know the answers to the questions I asked above and I'm going to ask you to go I. Today even if it is to the ER. We will also cover the basics of reducing central Apnea.

That is how you know to be concerned with CSR, again you don't.

[AndrewSlong]

I am interested in these questions and realized that it is still too early for me.

[RadarRalfs]

Thanks very much Gideon.

Interesting about CSR just being one form of "periodic breathing".  It happened again this morning - same circumstances after getting up and then going back bed for that last hour.  I wonder if others have this happen also.

Good to know that CA or Central events are not always bad.  I found it alarming to think that I was not breathing due to a miscommunication between my brain and the rest of my respiratory bits and pieces.  I am reassured to hear that these are likely an expected response to treatment and should resolve after 2-3 months.

With regard to your recommendation to increase the EPR from 1 to 2.  I spent the first 13 days with it set to 2 and then reduced it to 1 for 2 days, and then tried turning it off entirely (which lasted only for about 2 hours as I found it very uncomfortable). I had read various comments cautioning about using EPR in some situations involving Central Apnea.  Here is one example (won't let me post the link):

"The extra breathing work done by EPR can be enough to hyperventilate you, sending your CO2 level too low which, in turn, causes central events."

Apart from the 2 hour experiment with no EPR, it has been 4 days now with EPR set to 1.  I can't say I have noticed much difference in appearance of the Flow Limit Chart or in the way I feel.  I wonder if the flow limits could be related to congestion.  There are periods in the night when one or both nostrils become somewhat congested and then clear.  I think I am always a bit congested and use a corticosteroid nasal spray (Avamys) prior to heading off to bed.  Anyway, I will set the EPR back to 2 and learn more about flow limits and report back.

Again, this forum and the OSCAR software are very much appreciated!

Regards,
(waiting to no longer being a "New Member" so I can compose a signature!)

---

Thanks also for all the other replies.

[Gideon]

There is a school of thought that is to only use EPR during the Ramp because you do not get central apnea there and it is thus "safe". I don't agree with this. It is about not using EPR because it might, just might, increase central apneas.

Central Apneas do not show during ramp because the ramp is typically below therapeutic pressures and the device doesn't report them.

The philosophy here is to try EPR and if, that is if you have central apneas induced because of the application of EPR you then back off and ensure that the CA is managed as well as it can be. You do not assume that it is always going to be there.

We have a trick, I mean technique that can be used to slightly increase your CO2 concentration called EERS, Enhanced Expiratory Rebreathing Space http://www.apneaboard.com/wiki/index.php...ace_(EERS) where we have you rebreathe a small amount of your exhaled CO2 thus raising your CO2 levels that very small amount needed. The type of central apnea that you are having looks like it is CO2 induced so this could apply to you. I'm not there yet.