Replies to This Discussion

Permalink Reply by Rock Conner RRT on May 4, 2009 at 2:22pm

No, CPAP is for restoring ventilation due to sleep apnea, usually obstructive. Unless you have other indications of hypoxia, don't worry about your SpO2.

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Permalink Reply by PD Laire on May 4, 2009 at 2:34pm

But isn't ventilation, which i guess means clearing the obstruction so that air can pass through, all aimed at the ultimate result of getting oxygen into the system on a cellular level?

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Permalink Reply by Judy on May 4, 2009 at 3:30pm

When the obstruction is cleared and kept cleared, the air can pass thru, and the 02 is getting into the system on a cellular level. No events, no lowered 02 levels - unless you happen to have an underlying causes for hypoxia such as COPD, asthma, emphysema, etc.

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Permalink Reply by Mike on May 4, 2009 at 4:43pm

i see the issue breaking down this way: there are apnea and hypopnea events that may not be severe enough to cause oxygen desaturation, but still cause arousals and disrupt sleep quality, which brings its own physiological consequences; then there are apneas and hypopneas that last long enough or are significant enough to lower the transfer of oxygen on the cellular level, which is very dangerous for your health. i would think that if your sleep studies shows oxygen desats, it would be a good idea to get an oximeter to track them with your cpap and see whether your cpap is bringing them up or not. if not, then maybe that's something you should talk to your doctor about along with what can be done to improve the situation (e.g., upping the pressure).

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Permalink Reply by Dave Hargett on May 4, 2009 at 5:01pm

There are people with diagnosed sleep apnea whose oxygen levels don't drop all that severely, but the constant interruption of their sleep causes daytime sleepiness, possibly daytime hypertension, and the ebb and flow of heart rate and blood pressure during the night, which can cause physical damage over time to the heart.

The oxygen levels tend to drop because of the obstructive events. The CPAP provides air as an air splint to keep open the airway tissue that otherwise collapses. When those airways stay open, you simply breathe normally and get the oxygen/air you need and prevent the constant interruption of those apnea events. In this case the oxygen desats don't occur.

In my own case, I was diagnosed with an AHI of 82 events per hour (mostly hypopneas) and a lowest level of oxygen at 52%, although I spent more than 2/3 of my night below 80% oxygen.

With my CPAP I get about 1 event per hour and my oxygen stays in the low-to-mid 90's, which is very acceptable.

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Permalink Reply by RL on February 26, 2010 at 3:32pm

I am not sure the best place to ask my oxygen related questions, but this thread seems as good as any. I will try to make sense here, though I am feeling exceptionally fog brained and tired today. I have several questions around the use of oxygen with my CPAP therapy, which I have tried to express to my medical team, all of whom have no extensive replies, and are taking a "wait and see" approach. Meanwhile, I continue to feel well below par at least 50% of the time, and while 100% compliant with my therapy of 2 months, I am wondering what I can do to improve my situation. This is affecting my day to day functionality far more than I find acceptable.

I have been using straight CPAP at pressure 7 with O2 bleed at 3 lpm. My diagnosis are ICD-9 327.23 moderate to severe OSA, and ICD-9-327.21 "Complex SA with central apnea in response to CPAP, although present on the baseline". The central apnea has been deemed "idiopathic" as no underlying cause has been discovered.

My first PSG report includes the following notes: "AHI was 32 events per hour. This included 51 obstructive hypopneas, 2 mixed apneas and 29 central apneas. There was no positional component. Respiratory events were worse in REM sleep (REM AHI = 45). Oxygen saturations were typically in the high 80% range, with cyclic desaturations to 82%. The lowest oxygen saturation was 76%. "

My second PSG report includes the following notes: "Supplemental oxygen was initiated alone on the baseline, partially improving the AHI to 22 events per hour, with 90 minutes of non-REM sleep. The patient continued to have central apnea-predominant events. The mean saturation was above 91%. Thereafter, CPAP was titrated from 5-11 cmH2O with supplemental oxygen. The patient appeared to do best on CPAP of 7 cmH2O with supplemental oxygen at 4 lpm, normalizing the AHI to 4 events per hour, including 33 minutes of non-REM sleep and 1 minute of REM sleep. Both on higher and lower pressures, the patient continued to have central apnea index greater than 30 events per hour. Whether this serves as a definitive setting or represents a moment in time is uncertain."

Questions:
1. Would it be reasonable to expect that with successful xPAP therapy, that my oxygen levels would be normalized, potentially eliminating my need for supplemental oxygen? I understand that this might require ASV PAP treatment if the central apneas don't resolve with CPAP or Auto PAP therapy.

2. How is the level of oxygen supplementation determined? My titration study indicates they used 4 lpm. My Rx is for 3 lpm. I am wondering if 2 or even 1 lpm. would suffice, if CPAP therapy is mostly successful. It seems that if there is no underlying health condition preventing normal oxygen intake and utilization while awake, that normal O2 saturations are quickly restored when awake and breathing normally. Thus, if CPAP therapy is working well, then O2 levels should also be in the normal range while sleeping and using CPAP. The supplemental oxygen would only serve to maintain full saturations, thereby lessening desaturations that might occur during central apneic events. Does this make sense? I don't think I should eliminate use of oxygen supplementation until and if the central apneas are mostly eliminated, but a lower setting might lower the energy costs of the oxygen concentrator.

3. Regarding the oxygen concentrator: I just got an exchange of my unit from my DME to a new unit that has a 25% lower energy consumption as well as being a little quieter. The original unit was rated at 390 watts at 3 lpm usasge compared to 280 watts for the new unit. The DME tech originally mentioned that some clients had stated their using a concentrator made an increase to their electric bill of about $20 per month, so any savings here is appreciated. I am also wondering if using a lower lpm setting, say 2 or 1 would have a significant effect on energy consumption by the concentrator. Of course changing this setting would have to be with consultation with my doctor.

Any feedback on any of these questions, or my Dx status would be appreciated.

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Permalink Reply by Judy on February 26, 2010 at 4:39pm

Two options to ease your mind: 1] request your family doctor or sleep doctor order an overnight oximetry whislt you are using your CPAP and 02 supplementation or 2] buy your own recording oximeter in which case the two most popular in the apnea support forums for the price are the SPO 7500 and the Contec CMS 50D+ (it has to be the D Plus). They both come w/their own software.

It sounds like, to satisfy your insurance, your sleep doctor is starting you out on CPAP, expecting the data will prove you have "failed" CPAP therapy and therefore qualify for insurance purchase of a device such as the Resmed Adapt SV Enhanced (if the Resmed Adapt SV is scripted INSIST that it be the Enchanced version). Resmed developed this device SPECIFICALLY for Cheyne-Stokes and central apnea therapy. I believe Respironics has also come out now w/a device to address Cheyne-Stokes and CSA.

Is there ANY reason to suspect that you might also have daytime shortness of breath or desaturations? Smoker? Ex-smoker? Asthma? COPD?, etc., etc. Any medications that might be causing the desaturations and/or centrals? Rock Hinkle was compiling a list of medications that could affect or cause sleep disordered breathing.

Be the way, I envy you your new concentrator!!! I was first provided w/an old DeVilbiss 5L concentrator. Noisy and far from energy efficient. It recently died. I had hoped for a nice new one. One like the loaner I had while out of town, quiet, oh so quiet. No such luck. I now have a InvaCare Platinum DeLuxe 5L concentrator. Platinum?? A yecky beige! DeLuxe?? By who's standarads? It is more quiet than the old DeVilbiss - but it sure isn't QUIET like that loaner when I was out of town. I WISH I had paid attention to brand and model of that baby. *sigh*

And, yeah, I've had the old time emphysema and COPD sufferers tell me that a concentrator could add as much as $30 to $40 to your monthly electric bill!!!! Thank goodness for newer, more energy-efficient models, eh?

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Permalink Reply by Sleeping Ugly on February 26, 2010 at 9:26pm

I see this is an old post by PD Laire, but I hope he is still receiving notifications about this, as I'd be interested in clarifying this.

PD Laire, are you asking this: If one's oxygen saturations are fine (such as would be the case in UARS), is it imperative that one use CPAP? If so, have you found out the answer to this? Is it correct that there are cardiovascular (and other) health risks to sleep disordered breathing, but that these are a function of hypoxemia? In UARS, for example, there are many arousals, which can lead to excessive sleepiness and problems in daytime functioning, but in someone who is intolerate to CPAP, daytime functioning may plummet further as a function of CPAP use. In that case, is it necessary for the person to use CPAP?

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Permalink Reply by Sleeping Ugly on February 26, 2010 at 10:41pm

Is one night's data from an oximeter enough to indicate if someone is desaturating, even if they aren't desaturating significantly?

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Permalink Reply by RL on February 27, 2010 at 2:05am

Thank you jnk & Judy,
It is also my point that "idiopathic" is just a fancy term for "we don't know". I can appreciate that, but I hope to help them figure it out, if not make it go away! I have considered that there is the potential that my undiagnosed OSA has led to the CSA, which may be a result of reversible or irreversible brain cell loss. I have never smoked cigarettes, and avoided being around them as much as possible, as I am very sensitive to the smoke and even the ashes. I have never taken any opioids, benzodiazepines, or psyche meds. My worst is the frequency that I take OTC ibuprofen; sometimes every day, one or two, but less lately, and antihistamine (loratidine - no drowsiness), and occasionally a half dose of pseudoephedrine for sinus congestion (which I limit due to mood effects), no alcohol either, it makes me sick, no fun at all.

I am waiting to see if the central apneas go away or reduce, so maybe it is just to soon to tell. Three days now, just started on my rental unit PR REMstar Auto CPAP range 5-12 pressure. This was ordered by my pulmo so we could get some efficacy data. (PCP & myself did not know enough to order this first time around) I will take the card to the RT/DME after 2 weeks for first print out. Seems I have a "picky" pulmo, per the RT (Ha!) - he demands that the DME give them a color print out of the efficacy data, so they take it to a local copy store, and hand deliver the color printout to the pulmo office! Now I'm wondering if they take their card reader to the copy store (no that can't work without the software), or maybe it is put on a flash drive to transport for the color print out. I think I will have to be demanding to get my own copy of this. I guess it is not possible for the DME to get their own color printer, or the Pulmo office to get their own software and reader (what do I know!?!) We're not actually trying to save money here!
So I am writing down the little bit of data from the LED screen, 3 day AHI average = 6, 90% pressure average = 7.8. periodic breathing 0%. Is periodic breathing the centrals? I look forward to the full report. I agree that perhaps further testing is called for, perhaps in the heart/pulmonary area. As I was diagnosed with migraines in 2008, and that has a neurological basis, there may be some clue there also. No thyroid issues per test, no heart arrhythmias per EKG and sleep study report. Getting another overnight oximeter test (finger clip type) would be a good way to check the O2 desats or lack of. I will ask the pulmo about that. I guess I've joined Judy's "impatient patients club". It was a little "telling" when I asked my RT if the Auto PAP would monitor for mask leaks, and she said "no, it can't do that". So I found the setting for mask leaks on the LED screen after I went home, and made sure it was turned on. But --- she did get me the improved oxygen concentrator they just got in, right away. BTW - this is an Invacare IRC5P and I think it may be a new model. I will consider getting my own recording oximeter as budget allows, but for now, I think I could get the doc to order the test with DME equipment. Thanks for the model suggestions. I do sometimes have daytime shortness of breath but not consistent or severe, no Dx for asthma, and I hope the pulmo will look at this potential, and I probably need to ask him directly about that, but I think I did mention a question on that at 1st appointment, he did not bite that one yet.

So I think I am on the path of try/fail one CPAP, insurance o.k.'s next level, and on and on. I'm am not so sure the insurance is actually going to say no, but maybe the docs are also trained to think this way. I don't know why, when rental/trial is an option, that they won't just try an xPAP or ASV that can be reset with which ever limitations are desired, and just change settings as needed. If I try to think about it from the pracitioner's perspective, I can see how it might make sense, but from my perspective, dragging this out is a big disadvantage, especially when the PSG sleep doc mentioned in his report that I "may need to return to the sleep lab for ASV to manage both the obstructive and central component". The said statement still confuses me when I read it so let me just quote it in full:
"Overnight oximetry is suggestive on these settings that the patient either has clinical tolerance issues (NOT!) or an abnormal overnight oximetry is evidenced by either the presence of a saw tooth appearance or deep desaturations, then I would recommend a return to the sleep lab for ASV to manage both the obstructive and central component."
So does this mean that there is the presence of a saw tooth appearance and/or deep desaturations? and does he then recommend ...ASV? Well, I didn't see the charts so maybe I'll have to push for that too. Maybe vagueness is an advantage in allowing for different therapy options? And maybe I need to be more patient with myself, and my sleep debt.

I would still like to know what the criteria is for determining the O2 level for Rx, at least as it relates to the apnea & CPAP therapy if anyone can point me in the direction of such an explanation I could read. Can you actually get too much O2 at the 1-5 lpm dispense rate? Maybe I'll google that question.

I will keep searching for a more efficient oxygen concentrator; I want the Prius of concentrators! If I come up with something, I'll let you know.

Sorry, I don't know what Sleep Ugly is talking about so I'll leave that alone.

j n k said:

RL,
As a patient, I'm not sure I believe in "idiopathic" central apnea. To me, that is a fancy way of saying "we don't know why they are happening, so we'll just say there is no reason." Sometimes centrals occur in reaction to PAP therapy but then slowly go away over time as the body gets used to PAP. If the centrals continue, even months later, then it is time to see what else is going on, in my opinion, even if ASV deals with the symptoms.
Treatment for Complex SA may sometimes involve trying simple CPAP, CPAP with O2, bilevel, bilevel with O2, ASV, or medication, or combinations of machine and medication. My position, personally, as a patient, is that APAP or autobilevel are not so much indicated.

But a thorough examination of the neurological and cardiovascular systems, perhaps by more than one doctor, would be in order, in my opinion, if you are continuing to have a lot of centrals, regardless of what else is done, to see if any cause can be found. Other than that, trying some of the treatments above are mostly about finding something that keeps you numbers within reason and that keeps you feeling as good as you can feel.

Your numbers (spO2 and events) and how you feel during the day should be monitored by you as you and your team figure out whether O2 is doing you any good and if so at what amount. Watching it all over time and keeping good records is the key, until a cause is found.

Hope it goes well.

jeff

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Permalink Reply by 99 on February 27, 2010 at 9:11am

here in britain

those on oxygen concentrators have a discount with the electric used

you can make enquireies do they do a discount on your electric bill as it is a medical nessesity

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Permalink Reply by RL on February 27, 2010 at 11:04am

Thanks for your perspective here jnk, and I do agree with you about giving it some time to see if the centrals resolve and working with the therapy protocol as is. I was wondering if they would set the APAP to steady pressure, but they didn't, so I don't know if that was intentional or not. I am happy I have a "picky" pulmo too, but I've only met him once so far. I would be very happy to wind up needing only the basic CPAP with no oxygen, for simplicity and long term costs as well. I just wonder what qualifies as "few centrals" vs significant number, and as the centrals were a strong presence without CPAP on the second PSG, and somewhat problematic on most settings of CPAP, I guess I don't know what to make of that. Some things I've read about this type of condition are not very comforting, and I guess I am just trying to find a way to identify and work with therapy to maximize my results, and keep my hopes up that this is something I can manage and improve with the right effort. My doctors have not said much to me about the details of the diagnosis, and so my own research is mainly what I am going on; trying to not feel overwhelmed and discouraged by this condition that is mostly unknown and definitely not understood by virtually all people I know.

I work with two family members with significant chronic disabilities (epilepsy, diabetes, arthritis) as a caregiver, but having my own medical situation to manage is new for me. At least there is some acknowledgement and patience learned and shared from this other experience.

On the other hand, the comments I have found from those who needed the ASVs have all been very positive, with patients not finding relief of symptoms until using the ASV over other types of xPAPs. I know many people go through years of not having a complete or correct diagnosis and this is often personally frustrating and discouraging. Thank you very much for your thoughts and encouragement. It all helps me to think out what is racing through my head and consider what is reasonable and what is not so reasonable.

Interestingly, my Auto pressure does seem to be staying very close to the originally prescribed pressure, and so mostly has not caused difficulty for me in adapting to it so far.

j n k said:

If the centrals during a sleep study were from 'clinical intolerance' of PAP therapy (in other words, pressurized air itself seemed to trigger centrals), then it makes sense to let you use CPAP for a while to see if the centrals go away on their own. And if they do mostly go away, then staying on CPAP would make sense, since a few centrals now and then are no big deal. That is important for you as a patient to understand, if that actually is the case, because that helps you see that you were given CPAP not merely to set you up to fail it but likely to see if it actually solves the problems over time. My understanding is that this approach is more up-to-date than putting every patient who presents with an increase of centrals during titration immediately on ASV without seeing first if the patient eventually does OK on CPAP or bilevel.

Some docs might jump straight to ASV. But I agree with not doing that. See if CPAP helps first. If it does, after a few weeks of letting the body get used to it so that it doesn't have as many centrals, then GREAT! And not just financially but all the way around. The more modern approach to Complex SA is to see if it resolves WITHOUT ASV on CPAP or bilevel. And trying O2 is something to try, too. It is more than a checklist for qualifying you for another machine. It is an attempt to keep you from having to go on a machine that is less pleasant for many patients than CPAP.

It also makes sense to me to use an auto to get data and to do a mini-titration. But my personal preference would be NOT to use the auto mode for treatment. The body is more likely to get used to PAP therapy and resolve its own centrals, in my opinion, on straight CPAP mode than if the pressures are jumping around in auto mode. But that is nitpicking on my part, and I'm sure the doc knows more about it than I do, especially if, as the RT put it, the doc is picky. That is a good thing, I think.

I am not a medical professional, so be sure to take my take with a grain of salt. My opinions are based only on what I've read in studies, in reference works, and from patients in the apnea forums.

jeff

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