Suddenly my Centrals got a lot more disruptive

[stevew168]

If you have mostly centrals, I agree, ASV is your best treatment. There is a reason ASV is more expensive -- it works when other apaps and bipaps do not.

[tcinoz]

If this wasn't mentioned before, I'll add this in now, Central Apnea have the nasty little habit of being consistently inconsistent. This means that their numbers will rise and fall unpredictably and without an easily identifiably cause.

If you're in the position that they're being a problem, then you're better off with treating via ASV. The CA should not bother you after a properly set ASV is involved.

Thanks, yes - a timely reminder of the very nature of Centrals - their inconsistency. If I could somehow conquer my anxiety issues, perhaps I could have consistently lower AHI scores, but in the meantime I shall discuss the possibility of an ASV machine with my sleep doctor at my next review in May. 

Thanks everyone for your input. It all helps clarify my thinking on what is a fraught topic, especially when in the thick of a run of bad nights following some positive signs. I'm prepared to do whatever it takes.

[stevew168]

You've got it, Sleepride! Sometimes some are focused on the pressure numbers, and not how they feel in the morning. ESPECIALLY with
ASV, probably the easiest bipap to sleep with, based on my experience, and others, including medical studies.

[Sleeprider]

tcinoz, the Airsense 11 has no real tools on board to manage CA events. If you don't want to go all the way to ASV, the Aircurve 10/11 Vauto has a better bilevel therapy algorithm with trigger settings that make a CA much less likely to happen. Trigger sensitivity lets us use the changeover from EPAP to IPAP (or trigger) to occur at a lower flow. Many people with CA do not completely stop breathing, they just have very low flow rates, but with higher trigger sensitivity, the IPAP pressure is triggered and this ca stimulate a spontaneous breath to occur reducing the CA rate. We use the same principle with ASV when we use a relatively low maximum PS as a stimulus of inspiration, rather forcing a mechanically assisted breath. These are pretty advanced concepts, but there are ways to cause inspiration to occur, in spite of low spontaneous effort, that do not involve brute force pressure support.

[tcinoz]

tcinoz, the Airsense 11 has no real tools on board to manage CA events. If you don't want to go all the way to ASV, the Aircurve 10/11 Vauto has a better bilevel therapy algorithm with trigger settings that make a CA much less likely to happen.  Trigger sensitivity lets us use the changeover from EPAP to IPAP (or trigger) to occur at a lower flow. Many people with CA do not completely stop breathing, they just have very low flow rates, but with higher trigger sensitivity, the IPAP pressure is triggered and this ca stimulate a spontaneous breath to occur reducing the CA rate.  We use the same principle with ASV when we use a relatively low maximum PS as a stimulus of inspiration, rather forcing a mechanically assisted breath.  These are pretty advanced concepts, but there are ways to cause inspiration to occur, in spite of low spontaneous effort, that do not involve brute force pressure support.

Thanks, Sleeprider - yes, I can see the benefits of a Vauto machine over the Airsense 11 in dealing with CAs the way you describe it. I do think I pretty much stop breathing for a spell with mine, though. I'll attach one of my old zoom shots and I'll be interested to know what you think, and whether an ASV would deal better with them than the Vauto.

The main reason I've been stalling is not so much the money aspect—although the thought of having to fork out another AUD 4k three months after paying AUD 2k for my Airsense 11 is galling, but health comes before everything else in my priorities. No, the real reason is that my sleep doctor wanted to wait and see if my CAs were no more than treatment emergent ones. I see her again next week for a review.

Apart from having a surge in CAs on a few nights recently which seemed to be stress-related, this morning one of my arousals was so intense that it sent my heart-rate (measured on my newly acquired O2 ring) leaping from 60 to 106 in one go. My heart was hurting for most of the day as a result and I've been on the point of going to the local hospital to make sure everything's OK, but eventully it's settled.

Anyway, that, plus the recent high AHI count on some nights that I referred to, in addition to recommendations from SteveW and others on this thread, have convinced me that I want to go for the best option available to me in tackling these CAs, which seems to be an ASV, by all accounts. The only doubt in my mind is from someone who worked in a Resmed shop once telling me that it's possible that if a normal CPAP doesn't do it, maybe none of the machines will work in removing CAs and that some other form of treatment may be necessary. That freaked me out a bit. But I'm prepared to try an ASV (heart condition permitting). That's if my sleep doctor is preparared to prescribe it for me. I will know by this time next week.


   

[SarcasticDave94]

While objectively your CA in this chart aren't terrible, if you feel they are an issue, then they are. This second, subjective aspect, is really key to about half your Apnea therapy, the how do you feel aspect. If myself, if you think it'll sway the ASV approval to your favor, I would lean hard on not feeling better until the CA are addressed. You can mention you're not after zero AHI, but lower than present.

That honestly would be my focus, "I don't feel as well for therapy as I would like. I feel the CA need addressed just as much as obstructive events." Something like that.

[Sleeprider]

Your CA event seem to arise out of flow limitation or obstruction. My interpretation is that you have fairly significant flow limitation that results in arousal and hyperventilation. It is the hyperventilation that sets the stage for the following hypoventilation and/or CA event. This is not really that uncommon, and is the reason I often suggest using the full EPR capability of the Resmed CPAP to mitigate flow limits, which in turn prevents the CA. Pretty weird huh?

[tcinoz]

While objectively your CA in this chart aren't terrible, if you feel they are an issue, then they are. This second, subjective aspect, is really key to about half your Apnea therapy, the how do you feel aspect. If myself, if you think it'll sway the ASV approval to your favor, I would lean hard on not feeling better until the CA are addressed. You can mention you're not after zero AHI, but lower than present.

That honestly would be my focus, "I don't feel as well for therapy as I would like. I feel the CA need addressed just as much as obstructive events." Something like that.

You've hit on the main problem I'm dealing with. Even when my AHI score is low - like last night (see below) - once I've had my main 4 or 5 hours sleep (afer which I feel I still need a few hours more) something else kicks in. That something is hard to identify, but it feels like morning hypertension combined with a sense that I need to finish my sleep in my recliner, as lying down feels somehow wrong an even dangerous at times, with my head feeling pressurised and my heart slightly constricted. Sitting up I feel more on top of things, as it were. I take meds for high BP and frusemide for a swollen ankle, and I've had an aortic valve replacement, so my cardiovascular system is below par but holding out so far. I'm wondering if it's now at the stage where it's contributing to my sleep apnea. Either way, by the time I get up I feel more groggy than I did after the first few hours' sleep, but at least I'm no longer tired, if that makes sense! I'm not sure if it's the effect of the early morning apneas and the shots of adrenalin/cortisol that my heart is absorbing or what. But it might affect whether I can have an ASV machine or not.

I see my sleep doctor next week and my cardiologist in late June for my six-monthly check-up. My sleep doctor will say she's happy with the figures. I think I might have to stumble on for another couple of months feeling crap without being entirely sure what's at the root of it. I'll certainly explore the possibility of a Vauto with my sleep doc as suggested by Sleeprider. It could prove the happy medium solution, and my heart and vascular issues will hopefully get dealt with separately by my cardiologist, who has hinted when we spoke on the phone that he might have something planned for me. Life goes on, albeit falteringly. But I'm 71, so...<shrug>

   

[Jay51]

Best Sleeping Positions After Open-Heart Surgery
Sleep comfortably and move around with confidence as you recover.

By Lisa Esposito

• Reclining. Resting in a recliner is an option. However, having to rely on a recliner continually may indicate health concerns that should be addressed, Cohen says. It could be that a patient isn't breathing well or isn't comfortable lying flat, which might be related to fluid buildup around the heart or lungs. Other patients are simply more comfortable in a recliner, which prevents them from rolling around too much or sleeping flat on their stomach. "But in all honesty, I don't think that a recliner is a great place to get a good night's sleep," he says.
  
  
• The first thing that popped into my head when reading your thread was a "heart valve".  I have very mild mitral valve prolapse.  The heart valves may function slightly better in a more upright position as opposed to lying down.  The heart's pumping action may be slightly improved also.  Take a look at a picture of the heart and valves and see how gravity affects blood flow through the different valves of the heart (and also from the left ventricle - which pumps blood to the body). My Cardiologist has taught me a lot.  I am not a Dr. though; and I am just trying to pass along some information that you might want to pass along to your Dr.s.  YMMV. 
  

[Cam12]

Hoping things are better these days but…now for something completely different (but defer to the experts here):

That the cause of your increased CAs could be due to increased PLMS (Periodic LEG (standard measures) Movements of Sleep, which can be reduced with a different pressure range but may need its own treatments. This is different than Periodic Limb Movements of Sleep which can involve body movements and/or leg movements. I have severe PLMS (PLMDisorder, AI = 44/hr, 210 movements in 120 mins the other night) and the graphs that you’ve shown look similar to mine. Here are some of the things I notice:

- the CAs are “generally” clustered with other types of apnea events.
- the CAs are “generally” correlated with a leak event.
- they are associated with what looks like a combination of “Sighing, Biots and/or Cheyne-Stokes breathing (I think I saw another graph of yours clearly showing Cheyne-Stokes respiration, which is often associated with CAs.
- it could also be that your mask is simply leaking more than you know during the night e.g.) sleeping on side often can tilt mask to one side, sleeping on back can make an otherwise nice-fitting mask too loose.

What happens apparently is that when I have a PLMS (or multiple in 1-2 seconds), they are uncomfortable but not enough to wake me. I toss a bit but never become conscious. My sympathetic (“fight or flight”) system kicks in which leads to an arousal which for me is a quick inhalation that I hold a bit (1 - 2 secs). I slowly release this which leads to a longer expiration time (see expiration time) graph, an increase in heart rate, a decrease in Sat02 (using another synced device) which leads to increased respiration rate which is peaked (W) rather than rounded (~). All these changes can lead the CPAP/therapy device to misinterpret the data as a CA (mostly) or other type of event. As far as the leaks, for me it’s either the arousal habit in which I stick a finger under my full-face mask to itch nose (which again contributes to the interpretation of a CA) or, more likely, is a way to more quickly increase SatO2.

The best way to measure these is : 

- video all or part of your sleep cycle. Don’t forget to synchronize actual time, time on CPAP machine and camera time as closely as possible. Depending on your machine, this can be frustrating. The other method is to have camera synced and recording, put CPAP on and running, then purposefully make 3 leaks every 10 seconds and this will give you and index point from which to add or subtract time from the camera or CPAP as you review the sleep period.
- to ask physician for an overnight actigraphy test (EMG electrodes on various limbs, not just legs)
- have a full PSG during which EMG electrodes are attached to all possible locations - legs, mandibles, arms, fingers (one measuring moves towards palms and one away from palm), chin, eyes, thoracic and abdominal.
- have an overnight Pulse Oximetry done to measure what happens to your pulse (goes up) and especially your Pulse Rate Variability (PRV) during PLMS. If PRV goes up along with pulse rate, your blood pressure also increases which I think is one of the main ways that your heart is damaged over time.

I’ve attached several of your screenshots which I edited to hopefully show some of the associations. Unless I’m having a “Homer” moment, one screenshot (the first?) appears to show that the events are misaligned in the Events graph and the one directly below it (?)

I’d be interested in hearing from others whether they use a different method to determine PLMS or if there are any problems with mine.

Please let me know if you have any questions