Replies to This Discussion

Permalink Reply by RockRpsgt on September 23, 2009 at 12:49am

Are you on an ASv now?

Vicki E Jones said:

Hi, Rock. I don't know about the person who started the thread, but I've had 5 sleep studies done.
The first showed obstructive and central, but there were no PAP machines out for the central
apnea. Worse, the doctor ignored the results and didn't order CPAP. He did order an oral
appliance to bring the lower jaw forward, but it could only be brought forward a little due to
long-standing TMJ (jaw joints limit the moving it forward to a very small amount).

The second two studies, a year later, showed the obstructive and central, and I was put on CPAP.
The second study that year was the overnight CPAP titration.

Unfortunately, that doctor didn't follow up, and I was on the CPAP 4 years, until my old Fisher & Paykel
machine started to break down. I was loaned a CPAP machine by my DME (durable medical equipment)
provider, an overnight study was done, and showed I needed a machine for Central Sleep Apnea i.e.
the oral appliance + CPAP corrected the obstructive, and only the obstructive.

The VPAP titration was done late June, but it took until the end of July to get rent-to-buy approved
by our insurance. I had asked the doctor to do the titration on Respironics, because I knew enough
by then to know I may not be able to wear something on my face that is compatible with the
ResMed VPAP.

I tried the VPAP 6.5 weeks, then gave up, and called my doctor in desperation to switch me to the
Respironics. That can be done if the DME consults tech support at Respironics as to how to convert
over to the equivalent settings on the Respironics. The two machines work two different ways, but
accomplish the same thing.

Vicki in Illinois

*************

Rock Hinkle said:

Obrtuctive apneas can disguise themselves as central apneas. have you had a titration study done? Are you on PAP?

• ▶ Reply

Permalink Reply by Leslie Scott on September 23, 2009 at 1:10am

Hi Sandra. Here in Colorado we deal with altitude as well, so I do tend to see a lot more central apneas than we do in lower states. When I am doing my introduction with my patients, I mention both kinds of apneas and I explain both kinds to them.
Central apneas are caused by your central nervous system. It could be that you have had obstructive apnea for so long that your brain assumes there will be an obstruction, It could be that you have had a head injury or have an underlying neurological disorder or I have seen it with underlying lung disorders. We also see it with age. Basically the difference between the 2, with a central apnea, your oxygen drops and then you stop breathing, with an obstructive, you stop breathing then your oxygen drops. The only way to tell the difference between the 2 is with a polysomnogram.

When you first start on cpap, your body can also kind of go into 'shock', not knowing how to react when all of a sudden you are breathing like you should rather than with apneas like you have been. We have found that some times if we give patients oxygen inline for about a month, it can get them through the initial 'shock' of breathing normal and after about a month, we can take the oxygen out (we do a nocturnal pulse ox before discontinuing completely). Granted, I think the reason we see it more here is because we are at 6K feet here.

There is a whole lot more to this stuff, but that is some of the basics. Hope it helps some. But by the way... the treatment for central apneas is oxygen rather than cpap. Cpap can actually cause more central apneas. I always tell patients that even a 10% weight loss can inprove OSA and if symptoms start coming back, it's time to come back for a retitration. There is a fine line between enough pressure to treat OSA and causing central apneas.

• ▶ Reply

Permalink Reply by RockRpsgt on September 23, 2009 at 1:39am

Do you have any problems with your patients developing a psychological addiction to the o2?

Leslie Scott said:

Hi Sandra. Here in Colorado we deal with altitude as well, so I do tend to see a lot more central apneas than we do in lower states. When I am doing my introduction with my patients, I mention both kinds of apneas and I explain both kinds to them.
Central apneas are caused by your central nervous system. It could be that you have had obstructive apnea for so long that your brain assumes there will be an obstruction, It could be that you have had a head injury or have an underlying neurological disorder or I have seen it with underlying lung disorders. We also see it with age. Basically the difference between the 2, with a central apnea, your oxygen drops and then you stop breathing, with an obstructive, you stop breathing then your oxygen drops. The only way to tell the difference between the 2 is with a polysomnogram.

When you first start on cpap, your body can also kind of go into 'shock', not knowing how to react when all of a sudden you are breathing like you should rather than with apneas like you have been. We have found that some times if we give patients oxygen inline for about a month, it can get them through the initial 'shock' of breathing normal and after about a month, we can take the oxygen out (we do a nocturnal pulse ox before discontinuing completely). Granted, I think the reason we see it more here is because we are at 6K feet here.

There is a whole lot more to this stuff, but that is some of the basics. Hope it helps some. But by the way... the treatment for central apneas is oxygen rather than cpap. Cpap can actually cause more central apneas. I always tell patients that even a 10% weight loss can inprove OSA and if symptoms start coming back, it's time to come back for a retitration. There is a fine line between enough pressure to treat OSA and causing central apneas.

• ▶ Reply

Permalink Reply by Vicki E Jones on September 23, 2009 at 10:53am

Rock -
Yes, I am on a SV machine - the Respironics Auto BiPap SV. There are only two SV machines out so far -
the ResMed VPAP Adapt SV, and the Respironics Auto BiPap SV. I could not deal with the ResMed's
limitations on what masks it would accept (since I have facial contour/fitting problems and am limited in
what will give me a seal), so have finally been switched by my doctor to the Respironics.

I like it very much. Respironics even planned for a household power failure: There is a DC Power Kit
you can get (Respironics brand) that has 1. A cable that plugs in the back of the SV machine, and the
other end has red and black cable connectors to hook up to a marine battery (fully charged, of course,
that you buy at AutoZone or another auto supply), and 2. A cable with little black box for use with
a special battery pack (more expensive than the marine battery), and another backup method.

I bought this "kit." All I needed was 1., but you have to buy it complete. It cost me $125 on sale,
from www.bestcpapprice.com, and they included free shipping, no tax. The other websites that have
it charge a lot more, and my DME (durable medical equipment) supplier wanted $205. for it. Yikes!

I bought it because we get occasional power outages here, and a few have been 12 or 14 hour outages
over the years. Suburb of Chicago, but our side of block on east (our grid) has electric wires above ground,
lots of squirrels (that can short it out temporarily), and plenty of thunderstorms.

Backup system for regular CPAP or for ResMed VPAP Adapt SV or other BiPap: power inverter and a marine battery.
The power inverter must handle the max wattage for the machine, and the marine battery must be big enough to provide enough hours of usage during a power outage. Just recharge it, or have it recharged, the next day. You can keep a cheap trickle charger, also called a float charger, hooked up to the marine battery when not in use to keep it charged.

The float charger is low wattage, I think. Turn heat/humidity to zero when using a backup, since heat/humidity raise the wattage required by quite a bit. Both ResMed and Respironics tech support told me to turn heat/humidity to zero if using the backup system during a power outage.

If you do a backup system for the ResMed Adapt SV machine, and there is any chance you will use heat/humidity, the power inverter must be a more expensive pure since inverter instead of the much-lower-cost modified sine inverter. I don't recall my physics classes (taken in college decades ago), but it relates to physics.

The SV machines have an alarm that sounds if you lose power. You can also buy a cheap alarm online that you just plug in a socket, and it will sound it your household power goes out.

Vicki in Illinois

********

Rock Hinkle said:

Are you on an ASv now?

Vicki E Jones said:

Hi, Rock. I don't know about the person who started the thread, but I've had 5 sleep studies done.
The first showed obstructive and central, but there were no PAP machines out for the central
apnea. Worse, the doctor ignored the results and didn't order CPAP. He did order an oral
appliance to bring the lower jaw forward, but it could only be brought forward a little due to
long-standing TMJ (jaw joints limit the moving it forward to a very small amount).

The second two studies, a year later, showed the obstructive and central, and I was put on CPAP.
The second study that year was the overnight CPAP titration.

Unfortunately, that doctor didn't follow up, and I was on the CPAP 4 years, until my old Fisher & Paykel
machine started to break down. I was loaned a CPAP machine by my DME (durable medical equipment)
provider, an overnight study was done, and showed I needed a machine for Central Sleep Apnea i.e.
the oral appliance + CPAP corrected the obstructive, and only the obstructive.

The VPAP titration was done late June, but it took until the end of July to get rent-to-buy approved
by our insurance. I had asked the doctor to do the titration on Respironics, because I knew enough
by then to know I may not be able to wear something on my face that is compatible with the
ResMed VPAP.

I tried the VPAP 6.5 weeks, then gave up, and called my doctor in desperation to switch me to the
Respironics. That can be done if the DME consults tech support at Respironics as to how to convert
over to the equivalent settings on the Respironics. The two machines work two different ways, but
accomplish the same thing.

Vicki in Illinois

*************

Rock Hinkle said:

Obrtuctive apneas can disguise themselves as central apneas. have you had a titration study done? Are you on PAP?

• ▶ Reply

Permalink Reply by Vicki E Jones on September 23, 2009 at 10:57am

We aren't all overweight. I have both obstructive and central sleep apneas and I am over 5'7" (at age 62, yet) and weigh 142 lbs.

Vicki in Illniois

**********

Leslie Scott said:

Hi Sandra. Here in Colorado we deal with altitude as well, so I do tend to see a lot more central apneas than we do in lower states. When I am doing my introduction with my patients, I mention both kinds of apneas and I explain both kinds to them.
Central apneas are caused by your central nervous system. It could be that you have had obstructive apnea for so long that your brain assumes there will be an obstruction, It could be that you have had a head injury or have an underlying neurological disorder or I have seen it with underlying lung disorders. We also see it with age. Basically the difference between the 2, with a central apnea, your oxygen drops and then you stop breathing, with an obstructive, you stop breathing then your oxygen drops. The only way to tell the difference between the 2 is with a polysomnogram.

When you first start on cpap, your body can also kind of go into 'shock', not knowing how to react when all of a sudden you are breathing like you should rather than with apneas like you have been. We have found that some times if we give patients oxygen inline for about a month, it can get them through the initial 'shock' of breathing normal and after about a month, we can take the oxygen out (we do a nocturnal pulse ox before discontinuing completely). Granted, I think the reason we see it more here is because we are at 6K feet here.

There is a whole lot more to this stuff, but that is some of the basics. Hope it helps some. But by the way... the treatment for central apneas is oxygen rather than cpap. Cpap can actually cause more central apneas. I always tell patients that even a 10% weight loss can inprove OSA and if symptoms start coming back, it's time to come back for a retitration. There is a fine line between enough pressure to treat OSA and causing central apneas.

• ▶ Reply

Permalink Reply by Vicki E Jones on September 23, 2009 at 11:01am

I hate to ask this, but if CPAP causes Central sleep apnea and the correct treatment is oxygen and not CPAP, then why were the ResMed VPAP Adapt SV machine and the Respironics Auto BiPap SV machines developed, and why are titrations being done with them and machines rented, sold, and in use/prescribed/recommended by top institutions?

Also, if a person needs CPAP for OSA and oxygen for CSA (Central Sleep Apnea), but one requires oxygen and the other requires CPAP, what is the person who has mixed or complex apneas (has both, like me) supposed to do???

The SV are automated servo-ventilator BiPap machines, I think, and are for Central, but correct Obstructive, and can run in either SV BiPap or SV mode.

????I am confused. ???

Vicki in Ilinois

Rock Hinkle said:

Do you have any problems with your patients developing a psychological addiction to the o2?

Leslie Scott said:

Hi Sandra. Here in Colorado we deal with altitude as well, so I do tend to see a lot more central apneas than we do in lower states. When I am doing my introduction with my patients, I mention both kinds of apneas and I explain both kinds to them.
Central apneas are caused by your central nervous system. It could be that you have had obstructive apnea for so long that your brain assumes there will be an obstruction, It could be that you have had a head injury or have an underlying neurological disorder or I have seen it with underlying lung disorders. We also see it with age. Basically the difference between the 2, with a central apnea, your oxygen drops and then you stop breathing, with an obstructive, you stop breathing then your oxygen drops. The only way to tell the difference between the 2 is with a polysomnogram.

When you first start on cpap, your body can also kind of go into 'shock', not knowing how to react when all of a sudden you are breathing like you should rather than with apneas like you have been. We have found that some times if we give patients oxygen inline for about a month, it can get them through the initial 'shock' of breathing normal and after about a month, we can take the oxygen out (we do a nocturnal pulse ox before discontinuing completely). Granted, I think the reason we see it more here is because we are at 6K feet here.

There is a whole lot more to this stuff, but that is some of the basics. Hope it helps some. But by the way... the treatment for central apneas is oxygen rather than cpap. Cpap can actually cause more central apneas. I always tell patients that even a 10% weight loss can inprove OSA and if symptoms start coming back, it's time to come back for a retitration. There is a fine line between enough pressure to treat OSA and causing central apneas.

• ▶ Reply

Permalink Reply by RD on September 25, 2009 at 5:49pm

Hi Sandra,
From what I understand, central apneas occur when we don't breath at all. As explained to me by my sleep specialist, with OSA and hypopneas the chest and stomach show movement as if to try and breath normally. With the central apneas the signal to breath from the brain doesn't happen and the chest and stomach don't move to facilitate the breathe. From some of the articles I've read on it, some think that it's our survival mechanism that finally triggers the need for air when the CO2 concentration gets too high in our lungs.
In my study, I had 154 episodes with 1osa and the rest split somewhat evenly between hypopneas and central apneas. So, I do understand what your thinking. I was asked if I had any concussions or other head trauma that I could recall. I have no serious illnesses to worry about. More than likely NEITHER DO YOU! Some neuro connection just isn't being made all the time. While centrals are the result of a neuro disconnect somewhere in the brain, no one from the articles can pinpoint a single cause for these events. In my world, the treatment of choice for both my centrals and hypopneas is use of the CPAP machine. The VA tends to view this the same way basically. In fact, some of the better articles and research notes I've read online come from the VA.
Having said that, go to www.va.gov and search under sleep apnea and read for yourself some of the articles before going to other sites. The VA has a big interest in this and will get bigger as more war veterans who have experienced some type of head trauma get cycled through the system. Some are even getting disability ratings for SA that was is considered duty related. Check again with your VA rep or DAV advocate.

• ▶ Reply

Permalink Reply by RockRpsgt on September 25, 2009 at 6:25pm

I have never been told that o2 was the treatment for CSA. I however am very new to the field of sleep. At my lab we are very stingy with o2 as we see alot of patients whom are psychologically addicted to it. Working in Indiana I have not had the opportunity to see the effects of altitude on apnea. CPAP is the first line of defense for any SBD. CPAP does not work for everyone though. Especially for those with CSA or complex apnea. From what I have been taught a central apnea has to have an underlying cause. As the causes may vary so too must the treatments. thus the need for Bipap and ASVs.

• ▶ Reply

Permalink Reply by Vicki E Jones on September 25, 2009 at 7:04pm

I agree, Rock. I was taught CSA means there is a delay in the signal to start the next breath, meaning at the end of the exhale, or an interruption to that signal.

With the auto BiPap SV machines, the ResMed VPAP Adapt SV and the Respironics Auto BiPap SV, the machine senses when the exhale pressure is dropping, i.e., when you should be coming to the end of the exhale, and ramps up the incoming pressure ("inspiratory pressure") to get you to inhale i.e. to start the next breath.

Unless the oxygen pressure increases substantially when it senses the exhale pressure is tapering off, I can't see where oxygen would really stop the CSA.

In my case, an overnight CPAP titration with oral appliance (to bring the lower jaw forward, since the receding chin/retrognathic jaw/tongue flopping back in throat causes the OSA) does correct the OSA, but I still have 21 CSA events an hour.

When the overnight VPAP titration was done with the ResMed machine, it corrected my OSA (with oral appliance in place) AND corrected the CSA 100%. This is at the pressure range (low and high settings) and EEP (pressure added for machine to flush out your carbon dioxide from the mask when you exhale) setting arrived at to have these good effects, during the study.

When I later changed to the Respironics SV machine, as mentioned in my previous posts, there was a way to convert the ResMed Data to the Respironics machine's settings. The two machines operate by two different methods, but accomplish the same thing. Both are specifically for CSA.

I would be surprised if oxygen alone could give me those results. My understanding is that you need an oxygen bleed if you require pressures above a certain amount.

Vicki in Illinois

***************

Rock Hinkle said:

I have never been told that o2 was the treatment for CSA. I however am very new to the field of sleep. At my lab we are very stingy with o2 as we see alot of patients whom are psychologically addicted to it. Working in Indiana I have not had the opportunity to see the effects of altitude on apnea. CPAP is the first line of defense for any SBD. CPAP does not work for everyone though. Especially for those with CSA or complex apnea. From what I have been taught a central apnea has to have an underlying cause. As the causes may vary so too must the treatments. thus the need for Bipap and ASVs.

• ▶ Reply

Permalink Reply by RockRpsgt on September 25, 2009 at 7:42pm

you seem to know way more about ASV than I do. that is usually the case with ASV/AVAP patients. Leslie is a tech in Colorado. I have read very little of altitude causing CSA. I can see how it could happen though. It is my understanding that CSA is caused by a lack of signal from the brain to breathe. The most obvious reason for this would be high 02 levels in the lungs which would cause a delay to the hypercapnic drive.

• ▶ Reply

Permalink Reply by RockRpsgt on September 25, 2009 at 7:44pm

What part of Chicago are you from? My wife is from the Antioch/Lake Villa area. I love it up there. if it were not so expensive I would move. I like the lakes.

• ▶ Reply

Permalink Reply by RockRpsgt on September 25, 2009 at 7:51pm

We are all right.

http://www.ncbi.nlm.nih.gov/pubmed/18363194?ordinalpos=4&itool=...

Central sleep apnea (CSA) is characterized by a lack of drive to inspire for at least 10 sec. In the CSA-syndrome accompanying arousals and desaturations of the arterial blood cause sleep disturbances and sympathetic nerve activations which lead to excessive daytime sleepiness and increase the risk for cardiovascular morbidity. There are six manifestations of CSA: a rare primary or idiopathic form, often in hypocapnic patients with an increased hypercapnic ventilatory drive; Cheyne-Stokes respiration, characterised by periodic CSA and a crescendo/decrescendo breathing pattern, often in patients with severe cardiac or neurological diseases; high altitude-induced periodic breathing (above 4000 m), CSA due to medical or neurological conditions; CSA due to drug or substance use; and primary sleep apnea of infancy. Besides the consequent treatment of the underlying medical conditions therapeutic options include the use of drugs, e. g. acetacolamide or OXYGEN, as well as non-invasive ventilation, e. g. continuous positive airway pressure (CPAP) or adaptive servo-ventilation.

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