Variable Breathing/CSR?

[tresero]

I still can't figure out why I have so much variable breathing and periodic breathing. I switched to a small nose piece from medium (I may have forgotten which one I used before and just used the medium). It is more comfortable for me, but I'm still dead tired all the time, and I've been using CPAP for over 2 years. I'm worried that it is CSR, but my cardiologist says I have no heart failure. 

I tried the chinstrap I was sent, and ripped it off after about 10 minutes. Completely claustrophobic and made me feel out of breath.

Here are 3 different screenshots. Last night, last Sunday, and about a year ago. My AHI seems to really ramp up after 3 am or so, and mostly CA.  They did offer another titration test, but I'm wondering if that will be worthwhile.

   
   
   

[coutherino]

Hi. Sorry to hear you've been struggling. That is almost certainly mistagged Cheyne-Stokes respiration. Periodic breathing doesn't look like what's being tagged in the 3rd screenshot you sent, where it's just random 1-2 minute sections. It is often back, to back, to back, over the course of the entire night. I'm not very familiar with Phillips' algorithm or the criteria used for tagging periodic breathing, but no algorithms are infallible, and events constantly get mistagged on every machine. That being said, it is utter chaos in the second screenshot you posted (Oct 27th) from around 3:45 to 5:45. So if you could zoom into one of those areas and take a few more screenshots that are 3–4 minutes long where events are being most heavily tagged, I'd be able to tell what is actually going on. Like I said I doubt it's actually Cheyne-Stokes respiration, but I don't want to say for sure until I can see what your individual breaths look like.

Also, if you're trying to stop leak with a nasal or nasal pillow mask, chinstraps are going to do nothing. Air will still be able to escape your mouth. The entire reason mouth leak happens is because your tongue relaxes while you sleep and that allows the air to shoot out through your mouth. Either you have to find a way to keep your tongue in position (which is impossible, you're asleep) or you have to seal your lips. All a chin strap does is hold your jaw in place. That means tape if you truly want to solve it.

[tresero]

Thanks for the reply, hopefully this screenshot helps.

   
   

[coutherino]

I see. Thanks for sending those. Seems I might've been wrong. Those do look pretty central-ish. How often do you see that type of breathing in your data, like what's in the first image? Where it looks like it's slowly waxing and waning. Transient centrals are nothing to worry about, especially during REM where they're quite common. Same for that waxing and waning pattern, which can also be found during REM. Breathing can get quite wonky. So I'm mainly concerned about how often you're seeing breathing like that, and if the pattern ever becomes more exaggerated. Seeing a bit more data from different nights where you feel you're having periodic breathing would help.

I have a few recommendations, but I'm gonna wait to give them until I can see a bit more data. I don't want to say anything without knowing for sure. All I'll say is that if that truly is periodic breathing not related to REM, it's not necessarily something to worry about. Central apnea can absolutely be CPAP induced, especially given a certain setting you have turned on. Turning it off may fix it.

[tresero]

I get them every night since about August, but only after about 3:30. 

Here are 3 other nights. One night was not as bad just so you can see it.


   
   
   

[tresero]

I'm guessing that you mean changing the pressure to 15 from 18? That's when this seems to have changed.

Dealing with the VA, it's difficult. They get really mad if I change anything.

[tresero]

I decided it may help to give a sample from about a month before they changed my max pressure to 18
   

[G. Szabo]

Your flex setting change is causing the problem and not the pressure. Becuse you have this periodic issues at low pressures too. I would tune down the flex to zero (Off)

[tresero]

Just changed it. My VA therapist will be mad, but I'll try it.

Thanks!

[coutherino]

Well, looks like someone already told you. I wanted to see some more zoomed in data, but you might as well try it. Yea, turn A-Flex off. As opposed to obstructive apneas, centrals occur when your body is not even trying to breathe (or barely trying). CPAP can induce this in some people because it has a natural ventilatory effect, meaning it causes us to expel more CO2 at any given moment than if we weren't on CPAP. It is the buildup of CO2 in our bodies that triggers the drive to breathe, and if you expel enough of it the drive goes away for a bit. This ventilatory effect is increased even more if you have a difference between your inspiratory pressure (the pressure you inhale with) and your expiratory pressure (the pressure you exhale against). Which is exactly what A-Flex does, and why it can cause centrals in some people. 

Also, too much pressure in and of itself can absolutely induce centrals in some people. I'm genuinely not sure why the VA changed your max pressure to 18. APAP never even comes close to raising your pressure to that. In all the graphs you've sent, it's only even set you above 15 a few times. It probably is too high, but just try turning off A-Flex for now and see if it does anything.