I am wondering if "difficult to treat hypopneas" could be a form of Complex Sleep Apnea Syndrome (CompSAS). In CompSAS, the patient is diagnosed with Obstructive type sleep apnea. But, when treated with CPAP, patients begin to experience Central apneas, that do not fully resolve with various pressures. These patients often do not do well on CPAP treatment. It is beleived that patients are mostly male, and the condition is described based upon how it presents in males (= central apneas).  

I am female, and am wondering if the condition would exhibit in some people, especially females, as hypopneas when treated with CPAP. I think that most labs do not differentiate between central and obstructive when measuring hypopneas.

Any feedback would be appreciated, because I am going to try to persuade a sleep doc/lab into testing/treating me for this.

Edited April 4, 2008
I made a special note of females in the original post only because I have seen posts from at least  4 forum members, all women, who have described having mostly hypopneas, and not seeing much improvement with treatment.



Last edited by Guest MJ on Fri Apr 04, 2008 4:12 pm; edited 1 time in total

You are well aware of my situation MJ. My 1st study showed 2 centrals if I'm remembering correctly. I failed CPAP... or, it failed me.  I was put on Vpap which is a totally different technology.

Because of potential oxygen issues, I've been checking out many things and keep coming back to centrals in regards to those who need or may need supplemental oxygen. (some things I've posted on the boards today)

Even though the sleep studies say one thing,I'm becoming more and more convinced that *my problem* is that of centrals being called difficult hypopneas.

I've said nothing that help you other than thinking I'm in the same situation as you are. I'm not sure how I'm going to get my answers.


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Hi MJ,

I have all hypopneas and also UARS, along with a stray apnea here and there, my AHI is ~53 and RDI ~85.  The occasional obstructive apnea responds to a low pressure (7 or 8) while the hypopneas run to 12, and often up to 14 (the current max on my auto), and a few are still unresolved at that pressure.

My REMStar M Series Auto scores obstructive events and something called "non-responsive" apneas/hypopneas.  A non-responsive event is logged when the apnea or hypopnea does not respond to pressure.  Since the machine cannot actually measure a central event, this scoring represents the machine's best guess.  

FWIW I have never seen a non-responsive event for scored for me.  The unresolved hypopneas left at pressure 14, are all scored as obstructive.  I presume this is because the machine *is* able to measure the hallmarks of an obstructive event...

Blessings,
--pseudonym

Hi Pseudonym and PuhJommies,

I don’t think treated or untreated reliably means central versus obstructive. There needs to be some measurement of physical effort/movement to determine if the cause is physical or not ( not = central ). I think PAP devices reliably measure air flow but not physical movements.

During my titration study, I had –0- obstructive apneas, 1 central apnea, 73 hypopneas, and 175 spontaneous arousals.

I always believed all hypopneas were obstructive, until I learned that there are central hypopneas, and read a researcher's comment that most labs do not differentiate between central and obstructive hypopneas during a sleep study. In the context, the researcher considered that to be a problem.

If possible, would you be willing to ask your sleep labs whether or not they differentiated between central/obstructive hypopneas during your sleep study, or if they just automatically counted them all as being obstructive?

Guest MJ

If possible, would you be willing to ask your sleep labs whether or not they differentiated between central/obstructive hypopneas during your sleep study, or if they just automatically counted them all as being obstructive?

Sure, I'll do this.


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Now you guys are getting me concerned.  I had a total AHI of 100.6 BUT my central apnea index was 16.2

My doc has never addressed this so I really didn't give it much thought but now I wonder if I should be concerned.

The last titration suggested that I go to 14 on my cpap but I am unable to tolerate that pressure.  The study did show that 11 was my second best pressure so I changed my machine after a week of trying 14 VERY unsuccessfully now I can sleep better.  I still don't feel DONE sleeping I make myself get up but wish I could have that feeling of being rested some of the time.  

What is done to treat centrals and should I be concerned???


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~ElleMarie~ One day at a time, ARE YOU KIDDING ME! Sometimes it's just a minute at a time.



AHI 100 -Diagnosis June 2007-

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Complex Sleep Apnea
Almost all of the info about Complex that I could find is in research studies coming from Mayo Clinic & Harvard/Beth Israel. It’s my impression that most sleep labs, even the university ones, do not yet diagnose it. One treatment for Central/Complex is the new ASV-PAP.

I put info and links in a thread in the interesting links section:
Complex Sleep Apnea (CompSA) Info and Links
http://www.apneasupport.org/about13558.html

Difficult to Treat AHI, including Hypopneas
This is my own question, and there is no research study to support this. Again, Complex is so new that I think most labs don't diagnose it. Even if they did, they might be expecting to see mostly males with central apneas. I am questioning whether or not there could be form of Complex in people, especially women, with not fully treated AHI inculding hypopneas, or maybe even difficult to treat UARS.



Last edited by Guest MJ on Mon Feb 18, 2008 2:50 am; edited 4 times in total

Quote:

One treatment for it is the new ASV-PAP.

I will start a daily recording of the readouts starting tomorrow. I started out well with the VPAP but it's not so great at this point. I've also been told that after the VPAP, the only level up left is an actual respirator, which does the breathing for you.

I've also hooked up the oximeter to the VPAP and will start recording this tonight as well.

Monday is a holiday so I don't know if my Dr will be in the office or doing hospital rounds or what, but I'm going to call her and ask about being put on oxygen now no matter what the oximeter says.... of course, that might be an insurance issue if the oximeter doesn't show enough cause for the expense of the portable oxygen converter.

One thing at a time... first make the call.


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Guest MJ wrote:

I don’t think treated or untreated reliably means central versus obstructive. There needs to be some measurement of physical effort/movement to determine if the cause is physical or not ( not = central ). I think PAP devices reliably measure air flow but not physical movements.

I agree it is only a CPAP machine's "best guess" that it is not obstructive, as it is based solely on what the machine *can* detect.

Guest MJ wrote:

If possible, would you be willing to ask your sleep labs whether or not they differentiated between central/obstructive hypopneas during your sleep study, or if they just automatically counted them all as being obstructive?

My sleep study detailed reports show all events (apnea and hypopnea) classed into columns labeled central or obstructive.  For apneas there is also a "mixed" column.  All hypopnea events are listed in the obstructive column.

That does not mean the lab could differentiate between central and obstructive hypopneas, however, it may only mean that the software allows a column for both.  My lab was Stanford.  I could call to ask but based on my past experiences, it is doubtful I'd get an answer.  The medical care is very good there but their administration needs a bit of work IMO.

Blessings,
--pseudonym

Hi Pseudonym,

I don’t know if Stanford looks for or diagnoses ComplexSAS. All the research that I have seen is relatively new (starting 2005 and 2006), and comes from Mayo Clinic and Harvard/Beth Israel. I took the following sentences from a couple of articles about Complex:

( “Trained to identify typical obstructive and central sleep apnea phenotypes of sleep disordered breathing (SDB), many sleep lab clinicians and technicians remain unfamiliar with complex sleep apnea syndrome (complex SAS). Complex SAS is often encountered in the clinical sleep laboratory. [… ]Their prevalence ranges from 15%  to as high as 48%  in clinical practice, based on study population characteristics. The difficulty in recognition may be directly related to the standard practice in sleep labs of not scoring mixed apneas and hypopneas and limitations of viewing the polysomnography (PSG) in 30 second epochs and the scoring guidelines governing it.

Central apneas and severe periodic breathing including Cheyne-Stokes respiration are readily recognizable. More subtle forms of periodic breathing are much more difficult to characterize, and in clinical practice 'central hypopneas' are not scored.

Qualitative scoring of this type of disease is limited by imprecision of terms such as 'mixed apnea,' and accurate scoring of central hypopneas is impractical in routine clinical practice. “ )

I’ve never seen even one scored central hypopnea on anyone's sleep study report, including my three. I sent emails to the two labs that tested me to see if they did differentiate between central/obstructive hypopneas, or if they automatically put them in the obstructive column. I will post the findings when I get them.

I am not getting my hopes up. Even if I have this condition, it will be difficult to persuade doc/lab/insurance to treat me.

Regards,
Guest MJ

I have found three main published articles about Complex: Mayo, Australian, and Harvard/Beth Israel.

The Harvard/Beth Israel article refers to advanced diagnostic methods of EEG and ECG (Electrocardiogram) analysis that are currently not used in sleep labs. They mention central hypopneas several times, and comment that in clinical practice 'central hypopneas' are not scored.

The Mayo and the Australian studies looked at patients coming into sleep labs. Both studies defined apneas as being central/obstructive, but not hypopneas. The Australian study was a retrospective study, and notes that was a limitation of the study. This is a quote: "We based the definition of CSA-CPAP on the presence and frequency of central apneas rather than central hypopneas, to minimize the risk of overreporting cases of complex sleep apnea".

Since there apparently are no studies that looked at central hypopneas, how can they conclude that it would lead to overreporting of cases?

Guest MJ

Maybe this study will be useful to you ~  http://www.chestjournal.org/cgi/content/full/128/4/3013


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My first study showed 2 obstructive 9 mixed 607 central 14 hypopnea RERA 3
Second study showed 0 obstructive 0 mixed 466 central 41 hypopnea RERA 11

So while the hypopnea are not listed as either obstructive or central I am guessing they are central due to the low number of obstructive and the high number of central. guess i could be wrong.  

My sleep Dr still diagnosed me as having extremely severe obstructive sleep apnea.  I am going for a third study (as I just had my deviated septum fixed and was told that if the CPAP does not fix the problem right off they will switch me to the VPAP for teh remainder of the study.  

So do I have Central or Complex Sleep Apnea Syndrome, heck if I know, but I do know I need some sleep.


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Started 22 Nov 07
AHI 129, O2 level 70%, 2 obstructive SA, 9 mixed apnea, 14 hypopneas, 607 central apnea
Currently using a ResMed VPAP Adapt SV, set at 10EEP and PS of 5 to PS of 10

You-all obviously know more about this topic than I do but doesn't anybody wonder how you could have a central hypopnea?  

Central apneas are defined as not breathing because the brain doesn't send a signal to breath.  However, hypopneas are breaths by definition albeit shallow ones.  How can one not receive a signal to breath and still breathe even if shallowly?

Good going, Frances, right to the heart of the matter!


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Resmed VPAP Auto. Humidaire 3i, Simplicity & Micro masks, ResScan 3.4, S8 ResLink, Embla oximeter.