What is the Significance of Periodic Breathing?

JohnBFisher wrote:I am also not a doctor, but it is my understanding that periodic breathing does not have to include a central apnea. Though it generally does include central apneas in the case of advanced heart problems, it does not need to include it.

That was my understanding and why I used the term periodic breathing. I did specify that I do not have the central apneas in mine normally.

JohnBFisher wrote:Though I do not think it is serious (since it is periodic and does not seem to cause any problems), you should certainly ask your doctor about the waxing and waning when you next have the chance. Why? Periodic breathing can be an indication of cardiovascular issues. Not the "can". Some people have periodic breathing with central apneas and have not cardiac issues. Some people have central apneas without the periodic breathing and no cardiac issues.

I actually asked my pulmonologist. I guess he is not familiar with charts produced by machines at home. I think he is only used to looking at graphs produced in the ICU. In any event, he told me to ask my sleep doctor. My sleep doctor has relegated me to the NP in his office, and his NP knows nothing. The last time I saw her, she could not answer the simplist question about why my Rx was written the way it was, in spite of the report saying that a different Rx produced better results.

JohnBFisher wrote:All that being said, I would not worry overly much. This could just be a normal pattern for you. If you have no other indication of issues, it's probably nothing to worry about.

Well, I'm not really worried at this point. I'm not sure what symptoms would cause me to remember to come back to this issue, so I was just asking if anyone had an idea if this is harmless or something that really needs to be investigated? I'm thinking it's harmless.

brain_cloud wrote:Hi LoQ, I have tons of B through the night also, extremely similar to yours except generally with somewhat longer peak-to-peak interval, more like 1.5-2.0 minutes, whereas yours looks just slightly less than a minute, although maybe that varies. Anyway, you are not alone.

Thanks, BC. That is reassuring.

LoQ wrote:

DreamDiver wrote:And their idealized example of Complex Sleep Apnea:
[image]

I am confused by this. What benefits would the person with CSR get from improving their flow to that chart that someone like me, who does not have the apneas between the cycles, NOT get? All that shows is that the oscillation of breathing leveled out.....nothing happened to the apneas! What does that do for them that it wouldn't do for me?

These images were offered merely as a reference for what you probably don't have: an extreme form of periodic breathing: Cheynes Stokes Respiration. I apologize for not being clear.

LoQ wrote:

DreamDiver wrote:From my own experience, I've found the oscillatory breathing from Graph B sometimes manifests because of what I consume. For instance, alcohol (2 drinks, in my case) may cause this in me.

Interesting. I don't drink, some something else causes mine.

I generally don't drink either - maybe once a month for social occasions, so we're in the same boat on this one.

LoQ wrote:

DreamDiver wrote:One thing I do notice that's different between you and me is that my flow limitations tend to be dead flat at the bottom of the graph, whereas yours are more or less motile. I'm not exactly sure what that means for you or me. I'm curious - do you smoke or have you been at any time in your life a long-term smoker?

I do not smoke, and I have never smoked, not even a single cigarette just to see what it is like.

It's excellent that you've never tried smoking. I did. I gave up after a couple weeks, because it made me puke. I was curious because I was wondering whether the difference in our flow limitations might be due to difference in life habits. Except we both don't really drink or smoke, nor have we either of us made them habitual. Fascinating.

LoQ wrote:What do you mean by "dead flat at the bottom"?

Here's last night toward the end of the night:

I've just gone back and looked randomly at a few recent previous evenings. Apparently the slight periodic breathing in the upper graph is normal for me too. The blue line for flow limitation is generally flat against the bottom of the graph all night long except for the occasional example pointed out. To me, this implies that flow limitation may not always have a bearing on whether we experience periodic breathing.

LoQ wrote:

DreamDiver wrote:Same here - if you're on Auto, you may want to increase your pressure or at the very least increase the upper limits of your max pressure to help with flow limitation.

I wish I could. My poor little machine is working its heart out, but the engineers decided, for whatever reason, that people don't need more then 20 cm.

Now that I know your pressure, I can certainly sympathize with your situation. Sadly, the flow generator within the machine is known to be capable of sustaining higher pressures, even though it's been set not to go above 20. Since we can see from the new ResScan software that the S9 is coming out with a VPAP version soon, if it hasn't already, why not see if you can get your doc to write you a script for an S9 VPAP? It will probably go as high as 25cm H20. EDIT: They're also making a new S9 VPAP Adapt, apparently. That might help both of us with regards to the periodic breathing.

Sorry I’m slow getting back, I’m in Australia.

First, your case is very different to mine as you can see by my pressures.

Normally I leave my pressure on 7 – 20, but occasionally when the pressure goes above 10 it causes enough leaks to wake me as the mask is adjusted for lower pressures.

The other night I limited my pressure to 10 to see what would happen, and while I didn’t have any apneas while the pressure was limited to 10, I could see changes in my flow limitation and flow curves.

Normally as you can see my flow limitation curve sits on the baseline, and any increase in the flow limitation causes the machine to increase pressure.
When my pressure was limited to a maximum of 10, the flow limitation increased (kicked up), and my flow rate was steady at a lower flow.

My interpretation is that the machine did correctly interpret a restriction in my breathing, and would have liked to increase the pressure further but was restricted to 10.

When looking at your curves I thought they looked a bit simular to mine when the pressure was limited.

Your case though is very different as your pressure is on the design limit of the machine, and you obviously have more complex issues that me.

The below are my thoughts only.
To me there are two main issues with sleep apnea that normally but not always go together, the first is day time tiredness and night snoring, and the second is reductions in blood SPO2. I had no issues with the first, but reductions inSPO2 where causing all sorts of rather odd medical issues that no could identify as no one suspected I had sleep apnea as I didn’t have any issues with daytime tiredness. (All are now solved)
In your case I think it would be very interesting to check your SPO2.

To everyone please, I would love to see some critical comments.

I thought that maybe some of you would be interested in how EncorePro 2.2.14.0 presents Periodic Breathing episodes. This is from a PR SystemOne BPAP Auto. The CA are clear airway events, OA are obstructive events, H are hypopnea events, RE are respiratory effort events. I forget what the black dots are.

greg-g wrote: ... To me there are two main issues with sleep apnea that normally but not always go together, the first is day time tiredness and night snoring, and the second is reductions in blood SPO2. I had no issues with the first, but reductions inSPO2 where causing all sorts of rather odd medical issues that no could identify as no one suspected I had sleep apnea as I didn’t have any issues with daytime tiredness. (All are now solved)
In your case I think it would be very interesting to check your SPO2.

To everyone please, I would love to see some critical comments.

[image]

LoQ definitely could try a VPAP, since he's already at 20cm for his lower pressure. That might handle his higher pressure needs during higher flow limitations. It seems almost criminal that he was given a machine not capable of handling the extra pressure he needs.

Slinky wrote:I thought that maybe some of you would be interested in how EncorePro 2.2.14.0 presents Periodic Breathing episodes. This is from a PR SystemOne BPAP Auto. The CA are clear airway events, OA are obstructive events, H are hypopnea events, RE are respiratory effort events. I forget what the black dots are.

[image]

Thanks for the image, Slinky. It appears that you too have a bit of periodic breathing. Maybe it's not that uncommon?

LoQ wrote:... I'm not sure what symptoms would cause me to remember to come back to this issue, so I was just asking if anyone had an idea if this is harmless or something that really needs to be investigated? I'm thinking it's harmless. ...

I also suspect it is (at this point) harmless. Periodic Breathing is often associated with cardiovascular problems (typically congestive heart failure). In that case, you might want to see more information about Cheyne-Stokes Respiration (CSR) at http://en.wikipedia.org/wiki/Cheyne-Stokes_respirations .

In your shoes, if you have issues that would contribute to heart disease (weight, high blood pressure, diabetes, etc), during your next physical you might want to chat with your internist about the risk of heart disease. But I doubt you need to be overly concerned. Afterall, sometimes people just do periodic breathing. Then doctors give it a fancy name (ideopathic), which just means "I dunno!".

Hope that helps clarify this.

Actually, the % of the night I spend in PB is usually 0.0% and almost always under 2.0% but as I read thru this thread I remembered having a "bad" PB graph from a nap I took one time. I just thought others might be interested in how EP2 reports PB so dug thru my files to find it.

But, you know, DreamDiver, I was having some A fib episodes out of the blue for some reason and was put on coumadin, a rate control and then an anti-rhythmic medication and haven't had an episode in .... a month? Or almost a month. One of the meds was causing a problem and I'm tapering off of it w/no problems ... knock, Knock, KNOCK ... so far. I don't remember the date of this screen now, darn it, I've already forgotten, BUT it was sometime during the above period.

The lightbulb just came on inside my head. I finally understand what you all have been trying to tell me. Thank you, DD and g-g, for posting those charts. Suddenly I see what I have been failing to understand.

In the past I have heard or used the word "flat," concerning flow limitation, to mean that each breath was "flat" on the top on the flow graph. That's why I was confused over whether you all were talking about the flow graph or the flow limitation graph. Now I see what you mean by flat. You actually have achieved flow limitations that don't "kick up." All this time, I've been looking at my flow limitation charts, and I thought they were fairly normal. I did not understand until I saw your charts that the graph might actually register zero limitation under some conditions, because mine, if they do so, are only there for a moment. Wow. I guess my night is really just one long hypopnea.

So thanks. I'm no longer thinking at all about the PB, because it looks to me like my FL is perhaps a more important issue.

DreamDiver wrote:I apologize for not being clear.

You were not unclear at all. I misread it. I'm still working on deepening my understanding of these topics.

DreamDiver wrote:Since we can see from the new ResScan software that the S9 is coming out with a VPAP version soon, if it hasn't already, why not see if you can get your doc to write you a script for an S9 VPAP? It will probably go as high as 25cm H20. EDIT: They're also making a new S9 VPAP Adapt, apparently. That might help both of us with regards to the periodic breathing.

Yeah, I'm thinking about how that might work. I wondering if when those machines come out I should call around and ask various DME's if they have one of them that I could do a trial on and then get my doctor to write a script for a trial on it. I do not know how that would fly with insurance, if I decided a newer machine worked better for me. Would they be willing to pay for a new machine like that after just a trial? I don't know.

greg-g wrote:To me there are two main issues with sleep apnea that normally but not always go together, the first is day time tiredness and night snoring, and the second is reductions in blood SPO2. I had no issues with the first, but reductions inSPO2 where causing all sorts of rather odd medical issues that no could identify as no one suspected I had sleep apnea as I didn’t have any issues with daytime tiredness. (All are now solved)
In your case I think it would be very interesting to check your SPO2.

Thanks for your thoughts. I'm glad to see you have resolved your problems. I would be curious to know if you needed a doctor's help to find and treat your OSA. It sort of sounds like you did it on your own, which I think is terrific. Hats off to those that figure it out for themselves.

Slinky wrote:I thought that maybe some of you would be interested in how EncorePro 2.2.14.0 presents Periodic Breathing episodes.

That was really interesting. They make it a lot easier to find PB. I wonder why they report it at all? That sort of reinforces the idea that PB isn't completely normal.

DreamDiver wrote:LoQ definitely could try a VPAP, since he's already at 20cm for his lower pressure. That might handle his higher pressure needs during higher flow limitations. It seems almost criminal that he was given a machine not capable of handling the extra pressure he needs.

Actually, I developed some central architecture on bilevel, and I don't think my doctor concerns himself with flow limitations, just with clearing the events. I think he thought that CPAP was adequate. He may not approve of auto, I dunno, but it works better for me than straight CPAP at any pressure.

JohnBFisher wrote:In your shoes, if you have issues that would contribute to heart disease (weight, high blood pressure, diabetes, etc), during your next physical you might want to chat with your internist about the risk of heart disease. But I doubt you need to be overly concerned.

I'm not concerned now about the PB. Now I'm a tiny bit concerned about the flow limitation. I did not understand before now that my FL was not really normal. I will be interested to see, when the new S9's come out, if they have one that will be better for me.

I notice on nights when I have a very low AHI (under 1) that my percentage of periodic breathing is higher say around 2 to 2.5%. When my AHI is between 1 and 2 the periodic breathing is always under 2% and usually closer to 0%. Any relation between the two?

DadscreepyCPAPmask wrote:I notice on nights when I have a very low AHI (under 1) that my percentage of periodic breathing is higher say around 2 to 2.5%. When my AHI is between 1 and 2 the periodic breathing is always under 2% and usually closer to 0%. Any relation between the two?

It appears there is some connnection in your case. What that connection might be, I have no clue. But both sets of number (0-2% and 2-2.5%) are really low.

on those "periodic breathing" graphs the main waves (not the oscillations) are at a minute apart which correlates with a heart rate. So John Fisher might have a point with the possible connection to the cardiac issues. From the literature we know that Periodic Breathing occurs in a number of different disease conditions and involves the heart, lungs, brain's center of control of respiration, and the total body's quantities of stored gases.

DreamDiver wrote: Except we both don't really drink or smoke, nor have we either of us made them habitual.

If you two don't smoke or drink, what vices DO you have?!

Like my husband, their only vice is their perfection.

My breathing sometimes oscillates like that too. - and that's my oxygenation has some oscullations to it. A nice stable flow line is accompanied by a nice stable oxygenation line in my case.

About the flow limitation graphs:

• Note than when ResScan moved from 3.10 (or was that 3.11?) to the next version, they change the way flow limitations were depicted: The older version had the line drooping down when there were flow limitation, the newer version has them going up.
  ResMed machines are very agressive in responding to what they deem to be flow limitations - instatntly pushing the pressure up