Rise in CA events and CSR

[GrandCentral]

Hi all,

First, thanks for all you folks do around here. I have been reading through all these threads and got started with OSCAR because of this board. I am learning lots and making some progress. If there is anything you can suggest regarding the problem below I would very much appreciate it.

I was diagnosed about 1.5 years ago. I had a full overnight sleep study and they found a total AHI of 34.5 with both obstructive and central events present.

Everything was relatively fine for the first year or so, when I had an average AHI of around 3-5. Not perfect but a lot better than 34. 

Over the past few months my AHI started climbing and I have been waking up fatigued on those days. Since Dec 30 it got much worse climbing into the 20's every night. Last night I spent 19.21% of the night in Cheyne Stokes Respiration (CSR), and 9% of the past week in CSR.

Is there anything I can do with my current ResMed A10 to improve things?

Equipment: ResMed A10
Settings: 9-15cm
Mask: AirFit P10 nasal pillows

[Gideon]

Welcome to the forum.

On your CSR, Did a doctor diagnose you are are you going based on the CSR you see in these charts? ResMed calls anything Periodic in breathing CSR. It is very are that it actually is. A review of this chart makes me think this is a loop feedback situation that is occurring mostly while awake or at least not sound asleep. Post a 3-minute section of this so we can definitively see what is going on.

[GrandCentral]

Welcome to the forum.

On your CSR, Did a doctor diagnose you are are you going based on the CSR you see in these charts?  ResMed calls anything Periodic in breathing CSR. It is very are that it actually is. A review of this chart makes me think this is a loop feedback situation that is occurring mostly while awake or at least not sound asleep.  Post a 3-minute section of this so we can definitively see what is going on.

No, I don't have any diagnosis for CSR. I just noticed that it started around the same time as my AHI rise this past week. I am not particularly worried about the CSR, but the recent (past few months, and more acute over the past 9 days or so) AHI increases are more bothersome because I am also very tired waking up those days.

3-minute section attached. Thanks for having a look at it.

[Deborah K.]

Could you post a copy of your redacted sleep study? This would show us how high your CAs were. If they were high you may need a different type of pap machine.

[GrandCentral]

Could you post a copy of your redacted sleep study?  This would show us how high your CAs were.  If they were high you may need a different type of pap machine.

Sure, here you go. Let me know if you want it in a different format:

Code:

PAP Titration Study Report
 
Sleep history: The patient is a 5x year old male with obstructive sleep
apnea. A home sleep apnea test on 5/20/2022 showed a REI of 25.7 and an
oxygen saturation nadir of 84%. A polysomnogram on 6/5/2022 shwoed an
apnea-hypopneas index (AHI) of 34.5, respiratory disturbance index (RDI) of
47.2 and an oxygen saturation nadir of 72%.  The patient is not using PAP
therapy at home.  The patient endorses being a habitual side sleeper.
Past medical history: Obesity, Obstructive sleep apnea
Medications: None
Sleep procedure: PSG w/CPAP or Bilevel PAP 4 or > param PC (95811)
 
Procedure: The study was attended continuously by a sleep technologist. The
monitored parameters included: left (E1-M2) and right (E2-M1) EOG, frontal
(F3-M2 & F4-M1), central (C3-M2 & C4-M1) and occipital (O1-M2 & O2-M1) EEG,
mental and submental EMG, left and right anterior tibialis EMG, single ECG
waveform, snoring, continuous airflow via PAP interface, chest and abdominal
effort, oxygen saturation, TcpCO2, and body position via video monitoring.
 
Hypopnea definition: The peak signal excursions drop by = 30% of pre-event
baseline using nasal pressure (diagnostic study), PAP device flow (titration
study) or an alternative hypopnea sensor (diagnostic study). The duration of
the = 30% drop in signal excursion is = 10 seconds. There is a greater than
or equal to 4% oxygen desaturation from pre-event baseline.
Respiratory Effort Related Arousal (RERA) definition: 10 seconds
characterized by increasing respiratory effort or by flattening of the nasal
pressure or PAP flow waveform leading to arousal from sleep when the sequence
of breaths does not meet criteria for an apnea or hypopnea.
Respiratory Disturbance Index (RDI) definition: RDI = (#apneas + #hypopneas +
#RERAs) x 60 / TST. If AHI is 0.0, then RDI = RERA index.
 
SLEEP ARCHITECTURE:
The study started at 21:49:28 and ended at 05:41:06. Total sleep time (TST)
was 216 minutes resulting in a sleep efficiency of 57.8% (total recording
time (TRT) = 374 m). There were 56 awakenings with a total time awake after
sleep onset of 96.0 minutes. The sleep latency was 61.5 minutes and the REM
latency was 85 minutes. The patient spent 28.4% of sleep time in the supine
position. The sleep stage percentages were 29.3% stage N1, 38.6% stage N2,
22.2% stage N3 and 9.9% REM sleep. There were 187 arousals, resulting in an
arousal index of 51.8. There were 177 stage shifts.
 
POSITIVE AIRWAY PRESSURE DATA:
CPAP was initiated at 5 cmH2O. Snoring was eliminated at a CPAP setting of 7
cmH2O. There were 72 respiratory events consisting of 41 apneas [0
obstructive (0%), 0 mixed (0%), and 41 central (100%)], 7 hypopneas and 24
RERAs. The mean oxygen saturation during the study was 95%, with a minimum
oxygen saturation of 88%. The patient spent 0.1% (0.1 min) of sleep time with
an oxygen saturation below 90%. The wake supine transcutaneous pCO2 (TcpCO2)
value was ~43 mmHg.  The maximum TcpCO2 during sleep was 52 mmHg. The patient
spent 16.9% of sleep time with a TcpCO2 above 50 mmHg. Cheyne-Stokes/Periodic
Breathing was not present. Supplemental oxygen was not administered. A medium
ResMed AirFit P10 nasal pillows mask without chin strap was used. The mask
leak at the most effective pressure was within normal limits.
 
PAP SUMMARY:
By Pressure:
PAP BUR O2 TST   %Sup SupAHI REM   RAHI CAI  AHI  ArIdx Nadir AvgSaO2
05  0   0  0.0m  0%   --     0.0m  --   --   --   --    --    --
07  0   0  29.5m 0%   --     0.0m  --   18.3 20.3 16.3  88%   94%
09  0   0  53.0m 37%  15.4   11.5m 5.2  7.9  7.9  19.2  90%   95%
11  0   0  81.5m 52%  26.8   9.5m  6.3  15.5 16.9 43.4  89%   95%
13  0   0  6.0m  33%  60.0   0.0m  --   30.0 50.0 90.0  90%   95%
15  0   0  49.0m 0%   --     0.5m  0.0  1.2  3.7  60.0  94%   96%
 
 
PAP BUR O2 TST   %Sup SupRDI REM   RRDI  HI   RDI  ArIdx Nadir AvgSaO2
05  0   0  0.0m  0%   --     0.0m  --    --   --   --    --    --
07  0   0  29.5m 0%   --     0.0m  --    2.0  22.4 16.3  88%   94%
09  0   0  53.0m 37%  15.4   11.5m 5.2   0.0  7.9  19.2  90%   95%
11  0   0  81.5m 52%  45.2   9.5m  25.3  1.5  27.2 43.4  89%   95%
13  0   0  6.0m  33%  60.0   0.0m  --    20.0 60.0 90.0  90%   95%
15  0   0  49.0m 0%   --     0.5m  120.0 2.4  13.5 60.0  94%   96%
 
 
MOVEMENT DATA:
No abnormal behavior was noted. There were 0 periodic limb movements during
sleep.              
 
ECG DATA:
The average heart rate during sleep was 64 beats per minute, with a range of
57 to 88. During wake, the heart rate ranged from 58 to 86 beats per minute.
No arrhythmias were noted.
 
OTHER NOTABLE FINDINGS:
Experience to PAP therapy as stated by the patient on the morning after sleep
questionnaire:   The patient was not sure if PAP therapy benefited him.  PAP
therapy was easy to use and comfortable.
 
ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]
Primary Central Sleep Apnea [G47.31]
 
IMPRESSION:
1. At a PAP setting of 9 cmH2O, during which supine REM sleep was recorded,
the apnea-hypopnea index was improved to the mild range, but all scored
respiratory events were central apneas, the arousal index was normalized,
snoring was eliminated, and the mean oxygen saturation was 95% with a nadir
of 90%. Of note, central apneas were noted at all tested CPAP settings.
 
RECOMMENDATIONS:
Auto titrating PAP device 9-15 cmH2O with humidification, and close clinical
follow up with data download after 1 month to ensure that pressure range is
appropriate.  A medium ResMed AirFit P10 nasal pillows mask was used in this
study.
If the the central apneas index remains elevated on the download, consider a
dedicated full night bilevel PAP titration study beginning at 8/4 cmH2O, and
if central apneas persist add back up rate of 10 bpm.

[Deborah K.]

Hmm. This report does not mention the types of apnea, so it does not tell us much. Is what you posted the whole report?

[GrandCentral]

Hmm.  This report does not mention the types of apnea, so it does not tell us much.  Is what you posted the whole report?

Did you scroll all the way to the bottom? There is a chart with CAI shown. I had assumed that was Central Apnea Index, but maybe I am reading it wrong.

[Deborah K.]

Oh, I thought that was a static picture.  You had LOTS of CAs.  Others can advise you better than me, but you may need a Resmed ASV machine.

[Gideon]

Code:

[font=Courier New][b]PAP SUMMARY:
By Pressure:
PAP BUR O2 TST   %Sup SupAHI REM   RAHI CAI  AHI  ArIdx Nadir AvgSaO2
05  0   0  0.0m  0%   --     0.0m  --   --   --   --    --    --
07  0   0  29.5m 0%   --     0.0m  --   18.3 20.3 16.3  88%   94%
09  0   0  53.0m 37%  15.4   11.5m 5.2  7.9  7.9  19.2  90%   95%
11  0   0  81.5m 52%  26.8   9.5m  6.3  15.5 16.9 43.4  89%   95%
13  0   0  6.0m  33%  60.0   0.0m  --   30.0 50.0 90.0  90%   95%
15  0   0  49.0m 0%   --     0.5m  0.0  1.2  3.7  60.0  94%   96%[/b][/font]

RECOMMENDATIONS:
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]Auto titrating PAP device 9-15 cmH2O with humidification, and close clinical[/font][/size][/color]
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]follow up with data download after 1 month to ensure that pressure range is[/font][/size][/color]
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]appropriate.  A medium ResMed AirFit P10 nasal pillows mask was used in this[/font][/size][/color]
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]study.[/font][/size][/color]
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]If the the central apneas index remains elevated on the download, consider a[/font][/size][/color]
[color=#000000][size=small][font=Monaco, Consolas, Courier, monospace]dedicated full night bilevel PAP titration study beginning at 8/4 cmH2O, and[/font][/size][/color]
if central apneas persist add back up rate of 10 bpm.

Nearly always 'they' will try a CPAP first.  IMHO this has failed for you.
For you, I'd like you to trial a ResMed VAuto.  What it has that your CPAP has is a setting called Trigger.  This will reduce the effort to start a breath.  It has worked for many on this forum.

The next option is a ResMed ASV. This machine is specifically designed to treat Central and Complex Central Apnea, such as yours.  With this machine there is a considerable amount of large and quick pressure changes. It functions by maintaining  your breathing volume on the same breath on which a issue exists. With it you will have an AHI that approaches zero.  IMHO the VAuto will be more comfortable if it works.

The third option is basically what 'they' suggested.  A BiLevel with a Backup Rate.  This applies a defined large pressure increase after you haven't initiated a breath in your normal amount of time.

Your thoughts?

[SarcasticDave94]

In agreement with Gideon, as Deborah K mentioned you may need ASV. Here is a case that it may be best to do proper Central Apnea machine progression into the VAuto next. If I was able to glean the data repost from Gideon, CA and OA were about 50-50 but not quite. Sound correct?

BTW here's the diagnosis lines...

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]
Primary Central Sleep Apnea [G47.31]

The VAuto may be easier to get, using the trigger setting to reduce potential CA. And yes it might be more comfortable. I've had the ASV and I was ok with it until my Emphysema COPD interference with breath timing ruined the ASV Auto timing for me.