Excessive Periodic Breathing - Help....

Hello -

I'd very much appreciate some help with my Oscar data that's causing me a lot of anxiety - it's the very high amount of data flagged as CSR (periodic breathing). I've read many of the other questions and responses on this but most of ones I viewed don't seem like my situation - at least they don't seem as bad. Some background info:
- I'm 53, in shape, and exercise daily. I'm on no medication (besides lipitor) and have no known heart issues
- I've had 4 sleep studies ranging back to 2006, with the most recent in 2020 as I've always been a terrible sleeper (even in my 20s). None of these noted CSR/periodic breathing, or central apneas. They've all noted hypopneas, RERAs, and a high number of arousals/awakenings
- I was diagnosed with both sleep apnea (mostly hypopnea events) and insomnia.
- I've been using my APAP for the last 4 years. I don't feel noticeably better with it - but I've assumed that's because of a high # of unconscious arousals related to insomnia.
- I never feel refreshed in the morning
- My resting heart rate is very low at 35-40 at night (my whole life). This is genetic (I'm not a super athlete). I've seen a cardiologist and they say there's nothing wrong.
- I flip and flop a lot at night as I can never seem to get comfortable.

I've attached sreenshots of a few days ago where I thought I slept well since I didn't get up between 2-4am when I normally do - yet was fatigued and had a headache throughout the day. It shows a very high amount of periodic breathing. This is consistent with other days. The % of time in CSR has gone up over the last few years. The myair app states everything is fine (it always states this), just usually get 10-15 AHI due to central apneas. I've asked my sleep doctor about this (before I knew about oscar) and he thinks the machine is falsely reporting central apneas due to my low heart rate / respiratory rate (machine thinks I'm not breathing but I just breathe at a low rate). I'm not convinced of this and can't explain the waxing and waning of my flow rate (and it's scaring me). Any insights would be greatly appreciated. Thank You!

Welcome!

A question for you: what altitude do you live at?

You're having enough centrals that for a fair time during the night you may be seeing some O2 levels that are on the low side. As an experiment, please turn off your EPR. (If you find you really miss the EPR, try turning it down to 2 or 1.)

Your median respiration rate is 15, which is in the normal range. Your heart-rate wouldn't have anything to do with periodic breathing or CAs, at least as far as I know. So your sleep doctor's lack of interest in your CA index is hard for me to understand.

I look forward to seeing how things go with no EPR (or less EPR). Keep us posted.

Thanks for replying! I live only 30' above sea level in the Bay Area in CA. I did try turning off my EPR last night based on some of the earlier threads on this topic. It didn't bother me that it was off (it wasn't noticeable to me), but I think I was so anxious about my new findings using oscar that I didn't feel like I ever fell asleep. Nevertheless, my oscar data shows the same pattern of periodic breathing with many CAs. My sleep doctor is gone until next week so I can't get info from him now. He thought my heart rate, which is low, would drive a low respiration rate and that the machine would interpret the longer than normal time between my breaths to be central apnea (I don't know why I have a low heart rate and respiration rate that is in the normal range...). I'm not sure why my doctor didn't ask for my memory card to look deeper into the data, and I didn't know this data even existed.

Do you think it makes sense to fix my pressure to 4 cm H2O to see if the central apneas disappear? I sometimes don't wear my cpap so it's not like the risk of not wearing it in the short term to avoid OSA isn't a normal risk I've taken. The only think I can think of from my limited resarch on this is that I have complex sleep apnea where the periodic breathing and central apneas are induced by pressure. I may have been worsening my condition by wearing the cpap the last 4 years.

My first thought, like Miss E.'s was turn off the EPR.

gregbe2000 wrote: ↑

Wed Sep 18, 2024 6:21 pm

He thought my heart rate, which is low, would drive a low respiration rate and that the machine would interpret the longer than normal time between my breaths to be central apnea

Get a doctor who knows how to look at the data recorded by the machine. Good doctors don't make up theories without data.

gregbe2000 wrote: ↑

Wed Sep 18, 2024 6:21 pm

I'm not sure why my doctor didn't ask for my memory card to look deeper into the data, and I didn't know this data even existed.

You're not expected to know the data existed. But your doctor is either ignorant or negligent, and that's not the kind of doctor you want.
Get a new sleep doctor, tell them you have an SD card in your ResMed Airsense 10 Autoset inquire if they can read your data, and how they do it. Bring along your SD card and OSCAR results to the first meeting. If the doctor doesn't trust OSCAR, they should have ResMed's own software to get the info OSCAR is showing you.

gregbe2000 wrote: ↑

Wed Sep 18, 2024 6:21 pm

I sometimes don't wear my cpap so it's not like the risk of not wearing it in the short term to avoid OSA isn't a normal risk I've taken.

"Sometimes" is rather vague. Do you mean once a month, for a day, or do you mean 2-3 times a week? Do you mind posting a screenshot of the overveiw screen for the last 3 months, so we can see your usage data?

The only think I can think of from my limited research on this is that I have complex sleep apnea where the periodic breathing and central apneas are induced by pressure.

According your description, it's Treatment Emergent Central Sleep Apnea aka TESCA. https://journal.chestnet.org/article/S0 ... 2/abstract
Sometimes it goes away if CPAP therapy is used consistently

Did you ever have a titration study, where you sleep with a mask and they check the effects of different pressures and machine modes?
Insist on getting one, or, as the case may be, another one.

gregbe2000 wrote: ↑

Wed Sep 18, 2024 2:30 pm

I've asked my sleep doctor about this (before I knew about oscar) and he thinks the machine is falsely reporting central apneas due to my low heart rate / respiratory rate (machine thinks I'm not breathing but I just breathe at a low rate). I'm not convinced of this and can't explain the waxing and waning of my flow rate

It doesn't. And any doctor worth their salt should have looked at your flow data, not just at the numbers. It's the waxing and waning which is of concern.

Until you get to another doctor, if it were me, I would set the machine at a fixed pressure of 6 no EPR at all. You're having flow limitations which cause your pressure to go up. Pressure changes aren't doing your breathing stability any good.

While you are grabbing that usage graph from the Overview can you include the AHI graph right above it for the last 3 months as well.

BaHammam, A.S. Treatment-Emergent Central Sleep Apnea (Complex Sleep Apnea). Sleep Vigilance 1, 53–56 (2017). https://doi.org/10.1007/s41782-017-0015-8

Pugsy wrote: ↑

Wed Sep 18, 2024 8:16 pm

While you are grabbing that usage graph from the Overview can you include the AHI graph right above it for the last 3 months as well.

Of course!

I was actually thinking of the whole overview page, not the just the usage chart that appears on it.

ozij wrote: ↑

Wed Sep 18, 2024 8:30 pm

Pugsy wrote: ↑

Wed Sep 18, 2024 8:16 pm

While you are grabbing that usage graph from the Overview can you include the AHI graph right above it for the last 3 months as well.

Of course!

I was actually thinking of the whole overview page, not the just the usage chart that appears on it.

I wanted to make sure that we didn't get a single snippet of the usage graph.
Seems like it is feast or famine with what we are shown....either massive number of graphs and all too tiny to evaluate or little snippets without anything to go with it.

You know I have had a similar report lately.....where I get a truck load of centrals late in the night but mine never showed any green CSR flagging. Never did figure out what was going on with me and it hasn't happened again...so 3 times in last few years is all I have seen. Not enough and not consistent enough to cause me to worry. Right now I just scratch my head.

Thank you very much for replying. I do really appreciate it.

I turned off EPR for last night and will keep it off tonight. I hear you about the doctor. I'm now armed with more info. He's on vacation until next week but I'm assuming he will schedule a sleep study where I'm using my CPAP if that's what's necessary for official or actionable data. I will definitely send and bring him the oscar data.

My answer to the questions:
1) I do almost always wear my cpap. I hate it, but I wear it. It would be awesome to experience benefits of using it. I have insomnia as well and I've assumed that my inability to date to address this was behind my really poor sleep quality. I'm sure it's a big contributor but I think the cpap treatment has possibly made my insomnia and sleep quality worse.
2) I was originally diagnosed with OSA and insomnia in 2008. I had 2 sleep studies then - the first one and then the cpap titration. The first one had no central apneas. The cpap titration had central apneas in a kind of random set of pressures (e.g. at 8cm I had 13, 9cm I had 0, 10cm I had 11, etc). This was a long time ago and in reviewing my notes the doctor said it can be random like this but they'll go away over time). I couldn't tolerate the CPAP back then and I ended up getting the UPPP surgery /tonsils removed / pin in my tongue. The surgery didn't help at all with my high number of awakenings but moved me from apnea events to hypopnea events. I gave up on fixing my sleep for about 10 years and tried to address it again in 2020. Another sleep study (no central apneas) and then was finally able to tolerate the CPAP (though I am never comfortable).

Why is the waxing and waning of specific concern? Is it because this is an indicator of CSR? I was hoping the chance of this was extremely small given I have no known heart conditions. Due to my low heart rate (that I've had since I was a kid), I've recently worn a heart patch for 10 days and had an EKG done - both were normal, with exception that I'm one of the unsual ones that have a low heart rate (bradycardia). Same with my dad, same with my son.

My plan was to try 5 cm H2O with EPR turned off tonight.

Do you think I have a material amount of air leaks to address? I already wear a chinstrap because if I don't I do have high air leaks. Should I try mouth tape?

Thanks again. I've attached my usage reports.

here's the CSR one. and total leak:

Let's see what tonight's report shows.

Can you get me one other zoomed in on the flow rate image but this time do a shorter segment....like 5 minutes instead of
the approx 45 minute segment.

Start at 5:12 aprox and end at 5:17 please. I just want to see the waxing and waning in more detail.

Sure! Here you go.

BTW - I've turned off EPR because that has been a common suggestion I see in the threads. Now as I'm researching treatment-emergent central sleep apnea (the current best theory) and the ASV machine to treat it I'm confused why EPR shoudl be turned off. I think the ASV machine relieves pressure on the exhale, just like the EPR feature would do. Am I missing something?

The waxing and waning is of concern because in indicates your brain isn't creating a stable drive to inhale. And no, it's not of concern because of your brain, so don't get all upset.
The drive to inhale, in humans, appears in response to a certain level of CO2 in the blood, and EPR, by making exhaling easier, actually lets you blow off more CO2 than you do without it, so the period till your brain pushes you to inhale gets extended.
With EPR, more CO2 blown off --> a longer pause till your inhale starts --> a central apnea. And if the system is unstable ("hmmm, just a little bit of inhale? a bit more? OOPS too much? a bit less? ....and so on) you get central apneas: that is, you stop breathing even though your airway is open.
And guess what happens to the O2 (oxygen) level you body needs in the meanwhile? It drops. Just as it would drop if your airway was obstructed.

ASV therapy blows fresh oxygenized into your lungs when it realizes your airway is open, and yet you're not inhaling.
CPAP (be it fixed or Auto) simply sits there twiddling it's thumbs when your airway is open and you're not inhaling.

Have ever had you oxygen tracke when you were asleep?
Can you ask a doctor for a night or two of professional oxygen tracking?