Central sleep apnea and the ASV machine.

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Central sleep apnea and the ASV machine.

Postby jsewell » Sun Mar 31, 2013 7:42 pm

Hi , i am new to all this. After my sleep study my doc prescribed a cpap even though he saw central apneas as well. I went back to see him after 2 weeks when my AHI numbers had stayed high, usually above 20. He looked at the data and went back to my sleep study and said i need an ASV machine. Has anyone with a similar situation had a problem with the insurance company not paying for the ASV?
If i use the cpap it takes care of all my obstructive apneas, but it is causing more centrals. Does anyone know if i should still be using the cpap?
Did anyone ever investigate to find out the cause of the central apneas.
Thanks for any answers
Judy
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Re: Central sleep apnea and the ASV machine.

Postby Xney » Mon Apr 01, 2013 3:30 am

If you have both centrals and obstructives without any CPAP, then you have what's called "mixed sleep apnea".

If you have obstructives and when you get CPAP treatment to remove them, centrals emerge, then you have what's called "complex sleep apnea".

Both require a different type of machine to treat - the ASV - so you're on the right track. Insurance should pay for it once it's determined that you have mixed or complex sleep apnea, but it's always good to double and triple check.

CPAP alone will not treat either mixed or complex sleep apnea fully.
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Re: Central sleep apnea and the ASV machine.

Postby blueh2o » Mon Apr 01, 2013 12:30 pm

You can correct me if I'm wrong (with appropriate citation) but I believe mixed sleep apnea is when one who has a central apnea "arouses" to take a breath and then has an obstructive apnea (sounds brutal). Complex sleep apnea is when you have both central and obstructive apnea but not during one event. I don't believe the term distinguishes between pressure induced central apneas or otherwise.
Also, it is Dr. Guilleminault's opinion, at least in my case, that APAP is the appropriate treatment for complex sleep apnea NOT ASV.
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Re: Central sleep apnea and the ASV machine.

Postby Xney » Mon Apr 01, 2013 2:10 pm

I've never read that, anywhere, but I'm no doctor. :)

I don't see how APAP would treat any form/presentation of central apnea - the ASVs are what have the technology to treat it. Prior to the ASVs, you had the BiPAP S type machines, but they didn't work for everybody.
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Re: Central sleep apnea and the ASV machine.

Postby 49er » Mon Apr 01, 2013 2:13 pm

Blueh20,

Didn't you say in a previous post that Dr. G's theory is eventually the centrals disappear in the case of complex apnea but it takes 6 months?

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Re: Central sleep apnea and the ASV machine.

Postby snuzyQ » Mon Apr 01, 2013 2:52 pm

Mixed sleep apnea and complex sleep apnea are different types of central sleep apnea. Central Sleep Apnea is a form of sleep disordered breathing (SDB) caused by the temporary abnsence of a signal from the brains' respiratory center. Without this signal, there is no effort to breathe.

Mixed sleep apnea is fairly common and consists of both central and obstructive components.

Complex sleep apnea is diagnosed only after treatment on CPAP or bilevel devices reveals it. Complex sleep apnea consists of all or predominantly obstructive apneas which convert to all or predominently central apneas when treated with a CPAP or bilevel device. Since complex apnea results from the use of a CPAP (or auto CPAP) or bilevel device, one could not reasonably expect an auto CPAP or bilevel device to adequately treat it. The clinical consequences of treating complex aleep apnea with CPAP or bilevel are residual symptoms (fatigue, sleepiness, depressed mood) and intolerance to therapy.

For complex sleep apnea patients, treatment with CPAP (auto or not) or bilevel therapy will leave them with a somewhat elevated AHI and a disorder that is not completely resolved. If I were a patient with complex sleep apnea, I would not want to risk trying an unproven, unsubstantiated 6 months of APAP therapy to try to resolve it. If any doctor suggested this route to me, I think I would be very careful to inquire after his/her sources before giving this a go.

Awareness of central sleep apnea is relatively new (2006) and knowledge about it continues to expand. Best wishes to all who have this condition.
Last edited by snuzyQ on Tue Apr 02, 2013 12:20 pm, edited 1 time in total.
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Re: Central sleep apnea and the ASV machine.

Postby blueh2o » Mon Apr 01, 2013 6:07 pm

I was diagnosed with Complex Sleep Apnea, been there done that. Stating that Complex Sleep Apnea only appears after treatment with CPAP is just plain false (SnuzyQ do your homework please). I had central apneas as part of my SDB before I ever saw a CPAP machine. In fact, it was my own realization of having a central apnea that made me see a sleep doctor in the first place. It's true that central apneas emerge in some people after CPAP use in what's termed "pressure-induced central apneas". Both PIC and non-PIC apneas in healthy people evolve in response to CO2 levels in the bloodstream NOT because your brain "forgets" to breathe.
The APAP concept being that if you resolve the obstructive component of your apnea the central component will follow. How it was explained to me is; as a SDB patient falls asleep the airway begins to collapse. As the airway collapses, the patient responds with more effort to breathe. This increased effort to breathe creates less CO2 levels in the blood. Higher CO2 levels in the blood are required to maintain sleep. To counter the lower CO2 blood level, the brain sends a signal to not breathe thereby increasing the CO2 level in the blood in an effort to maintain sleep.
Without going in to my entire history, based on Guilleminault's recommendation of switching from an ASV to APAP, my central apneas were eventually resolved (2-3 months). I know that many in the sleep medicine industry continue to push ASV for this condition but look up Guilleminault's qualifications and see if you can top his.
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Re: Central sleep apnea and the ASV machine.

Postby blueh2o » Mon Apr 01, 2013 6:14 pm

Having said all that, I can only comment on what my experience is. It may be true that ASV can work for others with Complex Sleep Apnea. I am not a doctor either.
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Re: Central sleep apnea and the ASV machine.

Postby Bons » Mon Apr 01, 2013 6:35 pm

Call your insurance company and ask what the requirements are to qualify for a titration of Apap/bipap/ASV. Most plans call for a trial period, and after "failing" cpap, you can have the second titration study.

I went from cpap to bipap to ASV in a three month period, since my AHI increased (mostly due to increased centrals) with the first two machines.
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Re: Central sleep apnea and the ASV machine.

Postby snuzyQ » Tue Apr 02, 2013 12:56 pm

There is a wonderful dissertation on this subject. Wikipedia has recently updated their "sleep apnea" definition. It contains an escellent review of central sleep apnea and complex sleep apnea...how they are defined as well as the C02 effects on the respiratory system with respect to obstructive and central sleep apnea. It is excellent. I highly recommend a thorough read.

As patients, it is clear that we know a little...but not much, really...only enough to get us into trouble. I am very thankful for the specialists who devote their lives to this field of study and am deeply respectful of their expertise. It is also clear that they don't know everything either. There is just too much to know and too many pieces yet missing.

What we do know is sure fascinating stuff, though. Awesome.
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Re: Central sleep apnea and the ASV machine.

Postby Daniel » Tue Apr 02, 2013 1:49 pm

I was diagnosed with Complex Sleep Apnea, been there done that. Stating that Complex Sleep Apnea only appears after treatment with CPAP is just plain false (SnuzyQ do your homework please).


No. SnuzyQ is correct and has done her homework. You couldn't possibly be diagnosed with Complex Apnoea without having undergone a titration study.
Complex Apnoea was discovered by the Mayo Clinic (approx 2006), and their web site quotes the following:

Patients with complex sleep apnea at first appear to have obstructive sleep apnea and stop breathing 20 to 30 times per hour each night. But unlike typical obstructive sleep apnea patients, their breathing problem is not completely alleviated by a CPAP (continuous airway pressure) machine, which functions like a pneumatic splint to open a patient's airway. Instead, once the CPAP is applied to complex sleep apnea patients, the obstruction seems to dissipate, but still they do not breathe properly. Symptoms of central sleep apnea then appear and fragmented sleep results, due to frequent pauses in breathing.

The ResMed site quotes the following:
What is complex sleep apnea?
Complex sleep apnea (CompSA) is a form of sleep apnea in which central apneas persist or emerge during attempts to treat obstructive events with a continuous positive airway pressure (CPAP) or bilevel device.
Complex sleep apnea (CompSA, also called “treatment-emergent central sleep apnea”) is the emergence or increase of central apneas and hypopneas during the initiation of continuous positive airway pressure therapy (or bilevel positive airway pressure without a backup respiratory rate) for obstructive sleep apnea (OSA).


There are numerous other similar definitions, from various sources, available on the web.

On the other hand, Wikipedia published the following.....which is completely incorrect:
There are three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (i.e. a combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively. In CSA, breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to airflow despite respiratory effort, and snoring is common.

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Re: Central sleep apnea and the ASV machine.

Postby Todzo » Tue Apr 02, 2013 8:59 pm

jsewell wrote:Hi , i am new to all this. After my sleep study my doc prescribed a cpap even though he saw central apneas as well. I went back to see him after 2 weeks when my AHI numbers had stayed high, usually above 20. He looked at the data and went back to my sleep study and said i need an ASV machine. Has anyone with a similar situation had a problem with the insurance company not paying for the ASV?
If i use the cpap it takes care of all my obstructive apneas, but it is causing more centrals. Does anyone know if i should still be using the cpap?
Did anyone ever investigate to find out the cause of the central apneas.
Thanks for any answers
Judy


Hi Judy!

Central apnea comes in two basic flavors, hypercapnic and hypocapnic.

In hypercapnic central apnea the brain really does “forget to breath” so the carbon dioxide (capnic) levels rise above normal (hyper).

In hypocapnic central apnea the breathing control systems cause the person to over breath which washes out the carbon dioxide (capnic) levels so they become lower than normal (hypo).

CPAP emergent central apnea is also known as Complex Sleep Apnea (I assume that OSA is being treated by xPAP) and tends to occur due to the constant pressure of the CPAP reducing the effort it takes to breath a greater volume of air. This tends to move things toward hypocapnic. The person being upset by the greater volume of air may well be part of this.

If I were you I would make it a point to spend some quality time using the machine during the day for at least the next month. Perhaps an hour a day.

Part of it should be in bed, relaxing, and concentrating on breathing very quietly and gently with the machine. You are at rest and your body needs little air to keep up with your needs. Part of the time in bed should be spent moving to all of the positions you are likely to use during the night. This is a good time to check mask fit, hose management, etc …

Part of it should be doing somewhat distracting things such as reading books, watching non-violent TV, listening to quiet peaceful music. Both the in bed and partially distracted times get you familiar with the machine and help to develop breathing reflexes while breathing with the pressure of the xPAP machine.

The more you are familiar with the machine the less what it does will bother you.

I have found a way to treat my Post Traumatic Stress (PTS) emergent hypocapnic central apneas by using enhanced expiratory rebreathing space (EERS)[1]. It uses a few simple parts added to your hose. Please work with your doctor to see if this may be a much more practical solution for you.

They are working hard on making new kinds of CPAP machines. The future may hold much better solutions (e.g. Dynamic CO2 therapy[2]).

From my own experience I would say that anything you can do to reduce the stress in your life is likely to help with your xPAP therapy.

May you quickly find the best solution!

Todzo

[1]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[2]: Dynamic CO2 therapy in periodic breathing: a modeling study to determine optimal timing and dosage regimes
Yoseph Mebrate, Keith Willson, Charlotte H. Manisty, Resham Baruah, Jamil Mayet, Alun D. Hughes, Kim H. Parker and Darrel P. Francis
J Appl Physiol 107:696-706, 2009. First published 23 July 2009; doi: 10.1152/japplphysiol.90308.2008
Link: http://www.ncbi.nlm.nih.gov/pubmed/19628721
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Re: Central sleep apnea and the ASV machine.

Postby blueh2o » Thu Apr 04, 2013 11:50 am

What is complex sleep apnea?
Complex sleep apnea (CompSA) is a form of sleep apnea in which central apneas persist


Daniel,
To my point, what you quoted above, with emphasis added to "persist" demonstrates that central apneas do occur without CPAP therapy. Again, I can only comment on my experience and my personal conversations with Dr. Guilleminault to disagree that CPAP therapy is necessary to have central apneas. How would you explain the central apneas on my initial PSG without CPAP? Maybe we're just arguing about semantics and the definition of Complex Sleep Apnea?
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Re: Central sleep apnea and the ASV machine.

Postby Daniel » Thu Apr 04, 2013 5:11 pm

blueh2o wrote:
What is complex sleep apnea?
Complex sleep apnea (CompSA) is a form of sleep apnea in which central apneas persist


Daniel,
To my point, what you quoted above, with emphasis added to "persist" demonstrates that central apneas do occur without CPAP therapy. Again, I can only comment on my experience and my personal conversations with Dr. Guilleminault to disagree that CPAP therapy is necessary to have central apneas. How would you explain the central apneas on my initial PSG without CPAP? Maybe we're just arguing about semantics and the definition of Complex Sleep Apnea?


My actual quote is as follows, not your shortened version..which is misleading

What is complex sleep apnea?
Complex sleep apnea (CompSA) is a form of sleep apnea in which central apneas persist or emerge during attempts to treat obstructive events with a continuous positive airway pressure (CPAP) or bilevel device.
Complex sleep apnea (CompSA, also called “treatment-emergent central sleep apnea”) is the emergence or increase of central apneas and hypopneas during the initiation of continuous positive airway pressure therapy (or bilevel positive airway pressure without a backup respiratory rate) for obstructive sleep apnea (OSA).


taking into account the full quote, your statement
To my point, what you quoted above, with emphasis added to "persist" demonstrates that central apneas do occur without CPAP therapy


doesn't make sense, within the context of Complex Apnoea, which you stated you had been diagnosed with.

Cpap therapy is NOT necessary to have Central Apnoeas is true, but within the context of Complex Apnoea and the full definitions of exactly what it is....a diagnosis of Complex Apnoea requires the application of CPAP or Bilevel Therapy.

Remember, this is what you stated:
I was diagnosed with Complex Sleep Apnea, been there done that. Stating that Complex Sleep Apnea only appears after treatment with CPAP is just plain false (SnuzyQ do your homework please).


I brought it to your attention that you were incorrect, and quoted the relative definitions. There really is no argument here, and SuzyQ was completely correct in her post.

Daniel.
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Re: Central sleep apnea and the ASV machine.

Postby blueh2o » Fri Apr 05, 2013 11:48 am

Daniel,
For my and other's education, what is the diagnosis when you have obstructive apnea and central apnea absent of CPAP therapy?
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