ASV data help, please

[tonycog]

Hello
I would appreciate any input regarding a trend in my data lately. To sum up, I use the BiPAP Auto SV to treat Cheyne-Stokes breathing. I am 100% compliant. For several months I have noticed that on many nights (1 or 2 nights per week) I will have a cluster of events during the first hour of sleep. When this happens, the IPAP pressure kicks way up. You can see it on this chart, which looks pretty typical of a night when this happens. Typically, I only get a cluster like this during the first 60 or so minutes of sleep, just like on this chart. The rest of the night looks fairly smooth. On the night of this chart, I was not lying awake for long; I fell asleep within 5 to 10 minutes, which is typical for me.

My doctor suggested I bump my EPAP pressure to combat these. I'm at an EPAP of 11 right now, up from 10. I get more considerably more leaks at 12, so have kept it at 11 for now. He does not accept the Periodic Breathing indications on this data, saying that a true sleep study is the only reliable indicator of these. He is only trying to combat any obstructive events with the pressure increase.

I would welcome any thoughts, suggestions or other observations.

Thanks,
Tony

[avi123]

[tonycog]

I tried Photobucket earlier today. For some reason, this image shows up with a green background on Photobucket. It's the exact same image that I uploaded at my Cox site. I don't know why the Cox site image won't show up for you. I'll try again later today when I have more time to play with it. For now, I'll post it again from Photobucket in green. (I can't explain the green - it was white when it left my computer.)



Thanks,
Tony

[JohnBFisher]

... For some reason, this image shows up with a green background on Photobucket. ...

Cool special effects. Let's see if I can take a stab at the information.

The first graph shows your pressure throughout the night. You minimum IPAP is 11 with your maximum set to 20. It typically won't go that high unless it must address an insufficient volume on your last breath.

You will note that several times throughout the night the machine assisted your breathing by increasing the pressure. Soon after falling asleep is a normal time (during the transition from wakefulness to sleep). So, the algorithm appears to be adjusting the pressure as needed.

The second graph shows a breakdown of your breathing issues. The model you have only notes Periodic Breathing (a waxing and waning of your breathing), Apneas (obstructive and central), as well as Hypopneas. Your AHI was 6. That's not bad, considering most of that was due to Hypopneas. While not perfect, it certainly indicates you are on the right track.

The third graph shows the average peak flow (how much are you move per minute).

http://en.wikipedia.org/wiki/Lung_volumes

The fourth graph shows your average tidal volume. This is the volume inspired or expired per breath. Your average is a little high for average. However, unless your doctor is worried about it, I would not worry.

The fifth graph is your breaths per minute. You fit within the average breaths per minute for most folks (between 12 and 20).

The sixth graph shows patient triggered breathing. 99.2 percent of the time you were breathing as anticipated. This is excellent.

The seventh graph shows the leak rate (including what is anticipated for the mask). Since this is a pretty flat line, it does not appear you have any leak problems.

Of course, this is must my thoughts as a layman. You might want to bring a sample night data when you next talk with your doctor. Or if you see some problematic trends, provide an example of that. I find it always helps to have concrete data when you discuss sleep issues with your doctor. But on the whole, it appears your therapy is working.

Hope that helps.

[tonycog]

Thanks for your reply, John. On the whole, I agree. My doctor does also. It's those clusters in the first hour that have me curious about why they happen. It's not every night. I have wondered whether or not they happen more frequently on nights when I'm unusually tired, but I haven't attempted to track that.

Thanks,
Tony

[JohnBFisher]

... It's those clusters in the first hour that have me curious about why they happen. It's not every night. I have wondered whether or not they happen more frequently on nights when I'm unusually tired, but I haven't attempted to track that. ...

Greetings Tony! I don't remember if you have any underlying neurological issues. I do. I have "flares" when my symptoms get worse. This is not a "flare" like someone with MS will see. In those cases when a flare desists the body tends to be back to normal (with a slight downgrade in performance). Instead, i go from bad to awful and it settles back to bad. These "flares" tend to be due to increased stress (physical, mental or emotional). They also predict my future "normal". Sigh! And I do know that when my symptoms flare (for whatever reason), then my sleep will also be bad. Sometimes astoundingly bad.

So, yes. if you overdo it, it is possible your apnea is worse during the transition from wakefulness to sleep. Most everyone has some. Most people don't have severe enough issues they need an ASV unit. But hopefully your ASV unit will help you improve those "bad" nights.

Hope that helps.

[avi123]

... It's those clusters in the first hour that have me curious about why they happen. It's not every night. I have wondered whether or not they happen more frequently on nights when I'm unusually tired, but I haven't attempted to track that. ...

So, yes. if you overdo it, it is possible your apnea is worse during the transition from wakefulness to sleep. Most everyone has some. Most people don't have severe enough issues they need an ASV unit. But hopefully your ASV unit will help you improve those "bad" nights.

Hope that helps.

I think that I get clusters of central apneas when I get awaken or fall asleep.

[Paper_Nanny]

It's those clusters in the first hour that have me curious about why they happen. It's not every night. I have wondered whether or not they happen more frequently on nights when I'm unusually tired, but I haven't attempted to track that.

As other said, having those clusters of events in the transition from waking to sleeping or vice versa is a fairly typical event. I think it would be interesting to track what variables effect when you do have those clusters.

I have MS and fybromyalgia. There are all sorts of things that can make a difference in the level of symptoms I experience, and I would imagine that would hold true of my sleep related symptoms. I am still trying to get a handle on that one, though.

Some of the variables that make a the biggest difference for me in general are: emotional stress, being overly tired, being too hot or too cold, dehydration, and any acute physical problems like infections or allergies.

I'd be curious if the ones that make a difference for you are similar or not.

Deborah

[Paper_Nanny]

This is not a "flare" like someone with MS will see. In those cases when a flare desists the body tends to be back to normal (with a slight downgrade in performance).

Somewhat OT, possibly, but I had to say what is more correct about what happens in flares associated with multiple sclerosis. There are two separate types of events that people refer to as "flares" in ms. One is a true exacerbation and the other is a pseudo exacerbation.

In a true exacerbation or true flare, there is an increase in disease activity. The immune system attacks the myelin in the central nervous system. This results in firther damage which may or may or may not cause an increase in symptoms. It depends on the location of the damage. If symptoms do occur from the attack, they may be new symptoms or may be a worsening of old symptoms. They can range from mild to severe.

When the immune system stops the attack and the inflammation subsides, the new symptoms may resolve completely or not at all.

Some examples, from people I know. One friend of mine had a flare up involving her optic nerve. She ended up almost completely blind in the left eye and had very distorted vision in the right. After the flare had subsided, vision in her left eye returned, but is somewhat blurred. Vision in her right eye has returned to normal. Another friend of mine had a flare in which his legs became so weak he was unable to stand. That was over five years ago and he has not regained strength in his legs. I have had flares in which my legs became extremely numb. After the flare resolved, the numbness went away.

A pseudo exacerbation, or pseudo flare, there is no new disease activity. There is no additional damage to the myelin. In a pseudo flare, there is an increase in previously existing symptoms. This happens because the brain is unhappy for some reason. Maybe the body is tired or sick, maybe overheated, maybe hungry or dehydrated. I regularly have pseudo flares related to my muscle spasticity. When I have a bladder infection, for example, my muscle spasticity gets much worse. When the infection clears up, the spasticity returns to its usual level.

Sorry for such a long post that is somewhat off topic. If it is horribly inappropriate, I will gladly remove it. I just felt the need to provide the correct information about ms exacerbations.

Deborah

edit to modify subject line

[tonycog]

Thanks for all of your input. As for me, I don't have any neurological issues, as far as I know. Two years ago I saw a neurologist when we first discovered the Cheyne-Stokes. We wanted to see if we could figure out why I have this. The parade of doctors has ruled out congestive heart failure, brain tumor and other known neurological issues. It was atrial fibrillation that led me to a sleep study. The AFib (I've written about it here in the past) was/is unexplained. The same is true for Cheyne-Stokes breathing. It is also unexplained. "Idiopathic" is one of my new vocabulary words.

I think I'm going to not worry much about these event-clusters unless someone here points me toward something that seems worth chasing.

Thanks again,
Tony

[avi123]

Tony, I was going to ask you if you have also considered this treatment:

•Added dead space or inhaled carbon dioxide: Added dead space by attaching a plastic cylinder of variable volume (400-800 mL) to a tightly fitting mask can act as a source of increased carbon dioxide concentration in the inspired air and can increase the carbon dioxide reserves above the apneic threshold. Such a treatment in an experimental setting has been shown to be effective against both primary central sleep apnea and CSB-CSA. The increase in PaCO2 is miniscule (approximately 1.5-2 mm Hg) but can be effective in stabilizing the breathing pattern. Similar results have been obtained by adding supplemental carbon dioxide (5%), but safety and accuracy of carbon dioxide delivery devices remains a concern. Another potential problem of added dead space or inhaled carbon dioxide is worsening of obstructive sleep apnea by the increased mechanical load. Hypercarbia stimulates sympathetic discharge with potential deleterious effects on the heart.



Deborah, have you ever considered this device which was developed to help MS patients to walk:

http://www.ats.org/site/News2?page=NewsArticle&id=5689

See video: https://www.youtube.com/TechnionSociety ... SUVQLVDywc

[rested gal]

I think I'm going to not worry much about these event-clusters unless someone here points me toward something that seems worth chasing.

Given how well your night goes after that first hour, I think you're right to not be very concerned about them.

[JohnBFisher]

... Somewhat OT, possibly, but I had to say what is more correct about what happens in flares associated with multiple sclerosis. ...

Thanks for the full correction. I do not mind the additional detail. Though I am aware of MS (from a couple friends, who struggle with it), I did not clearly articulate the issues. You did. And I fully believe that as we learn the struggles others face, we learn to accept our own situation and be grateful. Thanks for taking the moment to educate us.

[tonycog]

Tony, I was going to ask you if you have also considered this treatment:

•Added dead space or inhaled carbon dioxide: Added dead space by attaching a plastic cylinder of variable volume (400-800 mL) to a tightly fitting mask can act as a source of increased carbon dioxide concentration in the inspired air and can increase the carbon dioxide reserves above the apneic threshold. Such a treatment in an experimental setting has been shown to be effective against both primary central sleep apnea and CSB-CSA. The increase in PaCO2 is miniscule (approximately 1.5-2 mm Hg) but can be effective in stabilizing the breathing pattern. Similar results have been obtained by adding supplemental carbon dioxide (5%), but safety and accuracy of carbon dioxide delivery devices remains a concern. Another potential problem of added dead space or inhaled carbon dioxide is worsening of obstructive sleep apnea by the increased mechanical load. Hypercarbia stimulates sympathetic discharge with potential deleterious effects on the heart.

avi:

Thanks for the info. I've read a little bit about CO2 and Cheyne-Stokes, but it's been awhile. I would need to talk with my sleep doc about a treatment like that before I tried it. I'll see him later this year. I'm going to make a note to ask him about it, if for no other reason than I'm a little curious about it.

Thanks again,
Tony