Replies to This Discussion

Permalink Reply by Butch Hernandez on March 25, 2009 at 6:21pm

I wouldn't say that. I've maaaybe seen one titration where the of presented with CSA initially and came out fine using CPAP. I really feel like that was an anomele(sp?) or a touch of complex sleep apnea before we even knew what it was. I have seen bilevel work at times in this scenario as well.
Footnote: I did catch the 0 AHI at the pressure of 8. Not sure exactly why they kept going unless they had a running AHI count >5 or if snores/unscorable respiratory disturbance was seen at that pressure. In my experience, snoring can be tenacious and is usually the last thing to go!

Mike said:

can Central Sleep Apnea or Complex Sleep Apnea be effectively treated with straight CPAP?

Butch Hernandez said:

It looks like he was titrated pretty agressively. Given the posted report, I think OSA is an accurate diagnosis. If anything, his CSA events were predominant at lower pressures suggesting Complex Sleep Apnea..however, the centrals did not persist as pressures were increased. His AHI at 14cmH2O, was almost 0 and that's well within acceptable parameters for an effective titration. For those reasons, I'd say OSA is the correct diagnosis. At face value, it does seem like CSA would be more likely, but the clinical data doesn't support that diagnosis.
On a side note, the tech that ran the study did a great job treating. Most of us rely on training and instinct. After all, titrating is more of an art than a science ;)

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Permalink Reply by RockRpsgt on March 25, 2009 at 11:50pm

I agree that this is an aggressive titration. But why was he not stopped at 10cmwp when the events stopped? His spo2 never went under 90%. For 26 minutes he did not have 1 event. With Spo2 in the normal range I would not raise for snoring. up to 10 he had 2 reras. After leveling out he was raised and went on to have 14 reras and 2 apneas. I would think that these might have been caused by the raise in pressure, rather than setting a precident for it. I am allowing for more events during S3 and REM. That however does not explain to me why he was raised past 10. Please Butch, you probably have way more experience than me at this. Help me see what I am not seeing in this report. I also agree once you have the science of it down titrating is very much an art.

Mike said:

can Central Sleep Apnea or Complex Sleep Apnea be effectively treated with straight CPAP?

Butch Hernandez said:

It looks like he was titrated pretty agressively. Given the posted report, I think OSA is an accurate diagnosis. If anything, his CSA events were predominant at lower pressures suggesting Complex Sleep Apnea..however, the centrals did not persist as pressures were increased. His AHI at 14cmH2O, was almost 0 and that's well within acceptable parameters for an effective titration. For those reasons, I'd say OSA is the correct diagnosis. At face value, it does seem like CSA would be more likely, but the clinical data doesn't support that diagnosis.
On a side note, the tech that ran the study did a great job treating. Most of us rely on training and instinct. After all, titrating is more of an art than a science ;)

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Permalink Reply by Butch Hernandez on March 26, 2009 at 1:12am

Well, judging by the hypnogram and the pressure table, the tech increased for mixed apnea. I'm not in the habit of bumping cwp for mixed apnea, but thats the only reason i see for going beyond 10...that and very little REM. And who really knows why ya know. The techs' lab could have a p&p/protocol for bumping at any sign of occlusion.
Had I been doing it, I think I would have been a lil more patient as the events started to wane.

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Permalink Reply by RockRpsgt on March 26, 2009 at 2:00am

I agree. I would have been a little more patient also. You are right we do not know the labs protocols. Thanks for the insight. I could talk about this stuff for days.

Butch Hernandez said:

Well, judging by the hypnogram and the pressure table, the tech increased for mixed apnea. I'm not in the habit of bumping cwp for mixed apnea, but thats the only reason i see for going beyond 10...that and very little REM. And who really knows why ya know. The techs' lab could have a p&p/protocol for bumping at any sign of occlusion.
Had I been doing it, I think I would have been a lil more patient as the events started to wane.

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Permalink Reply by James Bacher on March 29, 2009 at 12:10am

He should have the diagnosis of sleep disordered breathing, with mixed apnea, and yes an adaptive ventilator would provide better results.

Obstructive sleep apnea is the lack of breathing caused by obstruction of the airway. Central sleep apnea is the lack of breathing caused by the brains failure to direct the autonomic nervous system to stimulate that function.

Continuous positive airway pressure (CPAP), Bi-Level positive airway pressure (BiPAP), and Auto-titration positive airway pressure (APAP) machines work well for obstructive apnea and hypopnea. However they do not treat central apnea. A patient may derive a degree of symptomatic benefit in the process of treating the obstructive events. Central apnea is only effectively treated in an outpatient setting with non-invasive ventilation. Resmed addresses central sleep apnea therapy with their VPAP Adapt SV™ it is an adaptive servo-ventilator designed specifically to treat central sleep apnea (CSA) in all its forms, including complex and mixed sleep apnea.

According to the titration info posted he had 5 central apnea (CA) @ pressure of 4, 5 CA @ 6, and 7 CA @ 8 with 2 obstructive events, all in the first half hour. He then had 2 more CA @ 11 pressure in the second hour, and all while sleeping on his back. When the pressure was increased to 13 he rolled onto his right side and had 8 resp arousals. Next he rolled onto his back again when the pressure went to 14 and finished the study with only 2 more resp arousals.

On the report posted March 26 he is probably getting the actual benefit of a pressure around 11 due to the leaking mask, and the leaking must wreak havoc on his sleep itself. I would dump the mask. I tried a full face mask many years ago to solve the mouth breathing issue but had the leak problem too. I trashed the full face and eventually settled on the mirage activa, a chin strap and self discipline. I am using a Respironics BiPAP® Synchrony® Ventilatory Support System. It is one of the older models of the VPAP autoset variable noninvasive ventilators. I eventually trained myself to not mouth breath but still use a chin strap. I am treating OSA, CSA, and Cheyne-Stokes Respiration. When I was thirty pounds heavier I was using an in/out pressure of 18/14, but now I am set at 14/10. The machine essentially adjust it's pressure to keep me in that range so sometimes it outputs more other times less.

I am surprised at the O2 sat of 91 when awake with 96.7 when sleeping. What is behind that? Perhaps there is a correlation between it and the number of resp arousals without apnea events.

Good luck with the treatment. There is a lot to consider.

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Permalink Reply by Mike on March 29, 2009 at 1:10am

James, this is a very thoughtful analysis. I'll make sure to bring it to the attention of Dave, my friend. there's also some discussion here about the data he pulled off his ResMed S8ii

James Bacher said:

He should have the diagnosis of sleep disordered breathing, with mixed apnea, and yes an adaptive ventilator would provide better results.

Obstructive sleep apnea is the lack of breathing caused by obstruction of the airway. Central sleep apnea is the lack of breathing caused by the brains failure to direct the autonomic nervous system to stimulate that function.

Continuous positive airway pressure (CPAP), Bi-Level positive airway pressure (BiPAP), and Auto-titration positive airway pressure (APAP) machines work well for obstructive apnea and hypopnea. However they do not treat central apnea. A patient may derive a degree of symptomatic benefit in the process of treating the obstructive events. Central apnea is only effectively treated in an outpatient setting with non-invasive ventilation. Resmed addresses central sleep apnea therapy with their VPAP Adapt SV™ it is an adaptive servo-ventilator designed specifically to treat central sleep apnea (CSA) in all its forms, including complex and mixed sleep apnea.

According to the titration info posted he had 5 central apnea (CA) @ pressure of 4, 5 CA @ 6, and 7 CA @ 8 with 2 obstructive events, all in the first half hour. He then had 2 more CA @ 11 pressure in the second hour, and all while sleeping on his back. When the pressure was increased to 13 he rolled onto his right side and had 8 resp arousals. Next he rolled onto his back again when the pressure went to 14 and finished the study with only 2 more resp arousals.

On the report posted March 26 he is probably getting the actual benefit of a pressure around 11 due to the leaking mask, and the leaking must wreak havoc on his sleep itself. I would dump the mask. I tried a full face mask many years ago to solve the mouth breathing issue but had the leak problem too. I trashed the full face and eventually settled on the mirage activa, a chin strap and self discipline. I am using a Respironics BiPAP® Synchrony® Ventilatory Support System. It is one of the older models of the VPAP autoset variable noninvasive ventilators. I eventually trained myself to not mouth breath but still use a chin strap. I am treating OSA, CSA, and Cheyne-Stokes Respiration. When I was thirty pounds heavier I was using an in/out pressure of 18/14, but now I am set at 14/10. The machine essentially adjust it's pressure to keep me in that range so sometimes it outputs more other times less.

I am surprised at the O2 sat of 91 when awake with 96.7 when sleeping. What is behind that? Perhaps there is a correlation between it and the number of resp arousals without apnea events.

Good luck with the treatment. There is a lot to consider.

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Permalink Reply by Mike on March 29, 2009 at 1:53pm

actually, Dave has been using xpap longer than I have -- a few years. he's way beyond the 'get to know you' stage of xpap use. which is why he's at his wit's end at this point -- he's been using a therapy for several years that hasn't quite worked. but before we write off him using any sort of machine, i find it odd that no medical professional has talked to him about the central apneas, or using an ASV.

j n k said:

If the patient gets a data-capable machine, the patient and doc will be able to see how many apneas are occurring and will know if too many apneas of any kind remain. After a few weeks on PAP, then questions could be raised about the effectiveness of the type of machine used. Other than that, centrals that occur as the body gets used to PAP are generally no big deal, as I understand it.
I am not a sleep professional, though.
jeff

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Permalink Reply by Mike on March 29, 2009 at 7:03pm

j n k, not sure about the desats while awake, but here's a link to some of his data in his own bed (off his ResMed machine) with the straight cpap pressure of 14 that he's used to: http://www.sleepguide.com/forum/topics/resmed-data-report

j n k said:

Sorry about that. I misunderstood completely. My question would be, then: What is his AI in his own bed with straight pressure that he is used to every night?

Those aren't all that many centrals, really, if there aren't any bad desaturations. It there a health reason, or medical reason, for the low saturation while awake?

Personally, I'd want to see what my data did for a few weeks on a rented bilevel, or an autobilevel with a limited range, before I got talked into an ASV. But, hey, that's just me. I'm a fussy patient. :-)
Mike said:

actually, Dave has been using xpap longer than I have -- a few years. he's way beyond the 'get to know you' stage of xpap use. which is why he's at his wit's end at this point -- he's been using a therapy for several years that hasn't quite worked. but before we write off him using any sort of machine, i find it odd that no medical professional has talked to him about the central apneas, or using an ASV.

j n k said:

If the patient gets a data-capable machine, the patient and doc will be able to see how many apneas are occurring and will know if too many apneas of any kind remain. After a few weeks on PAP, then questions could be raised about the effectiveness of the type of machine used. Other than that, centrals that occur as the body gets used to PAP are generally no big deal, as I understand it.
I am not a sleep professional, though.
jeff

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Permalink Reply by RockRpsgt on March 29, 2009 at 8:32pm

Why should he have been diagnosed with mixed apnea? Mixed apnea is when you have obstructive and central apneas(or vice versa) on top of each other. They are represented on the report by the MA initials, which was 0.

James Bacher said:

He should have the diagnosis of sleep disordered breathing, with mixed apnea, and yes an adaptive ventilator would provide better results.

Obstructive sleep apnea is the lack of breathing caused by obstruction of the airway. Central sleep apnea is the lack of breathing caused by the brains failure to direct the autonomic nervous system to stimulate that function.

Continuous positive airway pressure (CPAP), Bi-Level positive airway pressure (BiPAP), and Auto-titration positive airway pressure (APAP) machines work well for obstructive apnea and hypopnea. However they do not treat central apnea. A patient may derive a degree of symptomatic benefit in the process of treating the obstructive events. Central apnea is only effectively treated in an outpatient setting with non-invasive ventilation. Resmed addresses central sleep apnea therapy with their VPAP Adapt SV™ it is an adaptive servo-ventilator designed specifically to treat central sleep apnea (CSA) in all its forms, including complex and mixed sleep apnea.

According to the titration info posted he had 5 central apnea (CA) @ pressure of 4, 5 CA @ 6, and 7 CA @ 8 with 2 obstructive events, all in the first half hour. He then had 2 more CA @ 11 pressure in the second hour, and all while sleeping on his back. When the pressure was increased to 13 he rolled onto his right side and had 8 resp arousals. Next he rolled onto his back again when the pressure went to 14 and finished the study with only 2 more resp arousals.

On the report posted March 26 he is probably getting the actual benefit of a pressure around 11 due to the leaking mask, and the leaking must wreak havoc on his sleep itself. I would dump the mask. I tried a full face mask many years ago to solve the mouth breathing issue but had the leak problem too. I trashed the full face and eventually settled on the mirage activa, a chin strap and self discipline. I am using a Respironics BiPAP® Synchrony® Ventilatory Support System. It is one of the older models of the VPAP autoset variable noninvasive ventilators. I eventually trained myself to not mouth breath but still use a chin strap. I am treating OSA, CSA, and Cheyne-Stokes Respiration. When I was thirty pounds heavier I was using an in/out pressure of 18/14, but now I am set at 14/10. The machine essentially adjust it's pressure to keep me in that range so sometimes it outputs more other times less.

I am surprised at the O2 sat of 91 when awake with 96.7 when sleeping. What is behind that? Perhaps there is a correlation between it and the number of resp arousals without apnea events.

Good luck with the treatment. There is a lot to consider.

• ▶ Reply

Permalink Reply by RockRpsgt on March 29, 2009 at 8:50pm

I have been doing alot of research on the mechanics of central apneas since the beginning of this post. As humans we breath to rid our lungs of co2. Meaning that when the co2 is high in our lungs the brain sends the signal to work. so in turn if the o2 is higher in our lungs(which is not always a bad thing) the message is not always needed, which in turn causes a central. In this circumstance there usually won't be a desat on the o2. when titrating I have been taught to only raise for centrals if they have a dramatic desat(No harm no foul). We are also taught to give a pt a few minutes to get to sleep, because of the odd effects on the respiratory system, before we start counting events. almost everyone has events as they fall asleep.

Don't forget that as a few other people have said centrals can also be caused by an underlyng medical condition. Anything from heart,lung problems to some sort of brain or psychological problem. In my research I have not found a 100% way to treat CSA. Sometimes they just happen.

j n k said:

Wow. Confusing.

I would tend to discount the centrals in the titration because they were near sleep onset. But the apneas showing up in ResScan would make me want to take a methodical approach to see if there was anything I could do about them. If it were me, I would be tempted to sleep for a week with my pressure at 8, sleep for a week with my pressure at 10, sleep for a week with my pressure at 12, and sleep for a week with my pressure at 14, and then compare results to see what pressure helped my AI, ignoring AHI. I would probably use the ramp or settle feature to keep the machine from counting the onset centrals, too.

My personal view of centrals is that, although they can sometimes be a symptom of larger issues (depending on medical history), they are only worth addressing directly if they are doing something damaging such as making O2 go low. Some people just have a lot of centrals if they wake up a lot at night and then cycle back into sleep stages. Centals aren't like obstructive apneas, which put the body into a panic from the struggle against throat blockage. It seems to me that if the body decides once in a while that it is happy with the state of its blood gasses and it wants to skip a breath or two now and then during sleep, there isn't always a reason to get in there and try to change its mind. :-)

My views, though, are very simplistic, since I am not a medical professional. I am simply under the impression from what I've read on other boards that central apneas aren't necessarily something to be all that worried about. If the accredited sleep doc is aware of them and doesn't see the need to treat them, I would tend to trust his judgment on that. Though I would still see what the best results I could get were by trying different pressures for myself. But that's just me.

I certainly wouldn't think of asking for an ASV over a handful of non-desat centrals near sleep onset.

Just my take.

Mike said:

j n k, not sure about the desats while awake, but here's a link to some of his data in his own bed (off his ResMed machine) with the straight cpap pressure of 14 that he's used to: http://www.sleepguide.com/forum/topics/resmed-data-report

j n k said:

Sorry about that. I misunderstood completely. My question would be, then: What is his AI in his own bed with straight pressure that he is used to every night?

Those aren't all that many centrals, really, if there aren't any bad desaturations. It there a health reason, or medical reason, for the low saturation while awake?

Personally, I'd want to see what my data did for a few weeks on a rented bilevel, or an autobilevel with a limited range, before I got talked into an ASV. But, hey, that's just me. I'm a fussy patient. :-)
Mike said:

actually, Dave has been using xpap longer than I have -- a few years. he's way beyond the 'get to know you' stage of xpap use. which is why he's at his wit's end at this point -- he's been using a therapy for several years that hasn't quite worked. but before we write off him using any sort of machine, i find it odd that no medical professional has talked to him about the central apneas, or using an ASV.

j n k said:

If the patient gets a data-capable machine, the patient and doc will be able to see how many apneas are occurring and will know if too many apneas of any kind remain. After a few weeks on PAP, then questions could be raised about the effectiveness of the type of machine used. Other than that, centrals that occur as the body gets used to PAP are generally no big deal, as I understand it.
I am not a sleep professional, though.
jeff

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Permalink Reply by Mike on March 29, 2009 at 11:04pm

not to get off topic, but if centrals without desaturation of O2 aren't a problem, shouldn't the same be true of obstructive events without O2 desaturation?

j n k said:

A nice explanation in harmony with Rock Hinkle's mention of CO2 in the bloodstream: http://www.apneos.com/csa.html

'The brain continuously monitors the body's status and continuously decides the proper rate and depth of breathing to command. In particular, the brain continuously monitors how much carbon dioxide is contained in the bloodstream.

'Breathing is normally controlled by a simple cycle of events:

'1. When the level of carbon dioxide gets too high, the brain sends a "breathe now" command to the breathing muscles.

'2. The act of breathing lowers the level of carbon dioxide in the blood.

'3. There is no stimulus to breathe until the level of carbon dioxide rises again to the "too high" level.

'4. Since the body continuously produces carbon dioxide, the "too high" level is reached again in a few seconds. The cycle starts again at step 1. '

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Permalink Reply by Judy on March 30, 2009 at 12:09am

I'm just a patient. I'd put my pressure back to 10 for a week w/a fully data capable CPAP which Dave has. But then, what the heck do I know?.

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