Real Central Sleep Apnea and How to Fix! Nerd out session. #centralsleepapnea — Transcript

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1. 0:00Hey Pepper people, really no fun to be
2. 0:02had in this one. So probably minimum on
3. 0:04jokes if that's what you're here for. So
4. 0:06this is a a patient I was working with
5. 0:08and they had such fascinating data that
6. 0:10I wanted to share it with you. So the
7. 0:12gist of this is uh the onset of chain
8. 0:17stokes respiration. So there was the the
9. 0:20person let me say this. There's no
10. 0:23script as you can clearly see as I
11. 0:24bumble and blabble along. Um, they live
12. 0:28at 8,000 feet, so pretty high elevation.
13. 0:31And they've lived there for years and
14. 0:32years. It's not like a new thing. And if
15. 0:35we look at their data, we can pick
16. 0:36pretty much any day and see that they
17. 0:38were using EPR on an APAP. Not the best
18. 0:41choice, but I mean, really, there's just
19. 0:43a lot of obstructive events that are
20. 0:46occurring. If, you know, you can scroll
21. 0:48through these as we will, and just kind
22. 0:50of look, you can see there's a lot of
23. 0:51obstruction occurring. and the pressure.
24. 0:54I mean, at the highest it gets to like
25. 0:5615. You can see like right there some
26. 0:58really clear obstructions occurring. Um,
27. 1:01but more or less that's it. We can let's
28. 1:03kind of scroll through some days here
29. 1:05and just get a feel for what they're
30. 1:06doing.
31. 1:08Lower pressures, some palatal prolapse
32. 1:11right there.
33. 1:13A lot of very clear obstructive hypopnas
34. 1:16throughout here. this clear decrease and
35. 1:19and the gasping for air and EPR being on
36. 1:22three still, you know, up in that
37. 1:24anywhere from 15 to kind of like 10
38. 1:26range. And you can kind of see that
39. 1:28their range is actually from 10 to 20.
40. 1:32Um, what they felt is that there was
41. 1:34something that occurred in April that
42. 1:36changed everything. And we'll we'll take
43. 1:38a look at that. Here's some rim. It
44. 1:40looks kind of crappy, but you know,
45. 1:42whatever. We have a lot of, you know,
46. 1:44leaking. leaking actually improves as he
47. 1:46goes on. He starts to tape and things
48. 1:48like that.
49. 1:50Um, oh yeah, by the way, this video is
50. 1:52sponsored by cpapsupplies.com.
51. 1:55More on them later.
52. 1:57So, we progress. You see very similar
53. 2:01look to all the data. We have these very
54. 2:03clear obstructive events. Okay. Once we
55. 2:07start getting closer to April and into
56. 2:09April, you you'll notice that there's
57. 2:11kind of a shift.
58. 2:13And this is what I mean. So, a lot of
59. 2:14obstruction here. So, probably
60. 2:16positional to be fair because it gets so
61. 2:18much worse. But then look at these kind
62. 2:22of events.
63. 2:23All of a sudden, we have this chain
64. 2:25stokes respiration pattern starting to
65. 2:28emerge after periods of awakenings. Not
66. 2:31a big deal in itself,
67. 2:33but just something to keep an eye on
68. 2:35because we haven't seen this before.
69. 2:38Okay. Then we have another segment of
70. 2:40that same chain stokes respiration
71. 2:42pattern that waxing and waning like
72. 2:44this. This is one of those things. It's
73. 2:47ironic here. A couple things. One, the
74. 2:48chain stokes respiration signal from not
75. 2:51Oscar but the machine is being reported
76. 2:52as zero. So this person's doctor has no
77. 2:55idea this is going on. And the other
78. 2:57thing, they're not being flagged as
79. 2:58anything, not even obstructive apneas.
80. 3:00So there's absolutely nothing going on.
81. 3:02Pressure is fairly low here. So we saw
82. 3:04this pattern high, we saw it low. Just
83. 3:07some things to make note of. It's also
84. 3:08not all night. If we zoom out, a pattern
85. 3:12does not happen all night long.
86. 3:15Okay, so let's go ahead and progress
87. 3:16some more. So none of it on this night,
88. 3:19no chain stirration pattern, just
89. 3:21obstructive events. So like right here,
90. 3:24we start to see, let's see, is this
91. 3:27okay, those are more obstructive events,
92. 3:28but near the end of the night, we do see
93. 3:30that same chain strokes respiration
94. 3:32pattern.
95. 3:34All right, into April. So, we're going
96. 3:36to start seeing more of a noticeable
97. 3:39change. I'm just going to kind of click
98. 3:40through these because it's not every
99. 3:42night. Okay. So, like right these
100. 3:45segments here, very clear chain st
101. 3:47respiration pattern. By the way, you can
102. 3:49tell clear chain stokes respiration
103. 3:51because these little hashtags will be
104. 3:53very close together. This is just zoomed
105. 3:55out. We have another cluster likely
106. 3:57right there. Yep. Then we have this one
107. 3:59that actually is being flagged. Very
108. 4:01clear chain stroke reseration pattern.
109. 4:03one is happening almost the entire night
110. 4:05with the exception of REM breathing. And
111. 4:08then here we can see the same pallet
112. 4:09prolapse and collapse of airway on
113. 4:12inhalation. So obstructive and central
114. 4:15style apneas. And this is probably one
115. 4:17of the first nights where it's a true
116. 4:19chain strokes respiration because it
117. 4:21goes away during REM, but during
118. 4:23non-REM, it's full of chain strokes
119. 4:25respiration
120. 4:26in these segments.
121. 4:29That's like critical to chain strokes
122. 4:31respiration. Rem looks normal. Non-REM
123. 4:33does not. And remember, we have to
124. 4:35contrast that with back in March.
125. 4:37Everything looked I mean, he's not on
126. 4:39the right pressure, that's for sure. But
127. 4:41it's also not chain strokes respiration.
128. 4:43Okay, so end of April, this is where he
129. 4:46starts thinking he's having a problem
130. 4:47where it's like in looking at this more.
131. 4:51I I think the problem was starting well
132. 4:53before he thought it was. It was just
133. 4:54not full-blown.
134. 4:57Okay, so now he starts doing some really
135. 5:00interesting things. Look at the stats.
136. 5:02What what I would actually recommend
137. 5:03someone does in this case, really see if
138. 5:05you actually have chain structure
139. 5:06respiration. Sorry, we're serious.
140. 5:08Glasses on.
141. 5:10Actually, I can't read the screen. Um,
142. 5:13what I tell someone to do is try lower
143. 5:15pressures. And he actually did that
144. 5:16without talking to me. So, he goes from
145. 5:18he changed it to fixed pressure after
146. 5:20watching some of my videos. That didn't
147. 5:21do anything. Let's go ahead and take a
148. 5:22look at that. That's June 2nd. So May
149. 5:26June 2nd, he tries putting on a fixed
150. 5:29pressure without EPR. Some things I
151. 5:32would suggest. And look, it's still
152. 5:34there. Chain Stokes respiration pattern
153. 5:36all over the place. Okay, so he did
154. 5:39that. He turned off EPR. Then he starts
155. 5:41to lower the pressure greatly. We have
156. 5:45one with fulltime EPR and one with no
157. 5:47EPR. So June 12th and 13th. We'll take a
158. 5:51look at June 12th.
159. 5:54So, this one has EPR even though it's
160. 5:56only a very low pressure. Clear chain
161. 5:59stokes respiration. We go to the 13th
162. 6:03and we still have these periods of clear
163. 6:05chain stokes respiration
164. 6:08without EPR. Now, this is really weird,
165. 6:10right? Because he was having obstructive
166. 6:12events on higher pressures and all of a
167. 6:14sudden those obstructive events are gone
168. 6:16and now we have change respiration
169. 6:17pattern. Super bizarre stuff. So, you
170. 6:20see how it's just getting seemingly it's
171. 6:23not like worse every night, but it's
172. 6:24getting worse and worse to the point
173. 6:26where the nights it does occur, it's
174. 6:28really, really bad. And then it
175. 6:30progresses to when I see him, it's like
176. 6:32everything is just really bad all the
177. 6:35time. And we're having still, like I
178. 6:37said, these mix of periods of clear
179. 6:40obstruction, these flat tops
180. 6:43mixed with these clear chains
181. 6:46respiration patterns. That one's like
182. 6:48right there. Yeah, still chain stuck to
183. 6:49respiration pattern all throughout.
184. 6:51Okay, so what's the recommendation for
185. 6:52this guy? Like what what do you what is
186. 6:55one to do? Let's see here. Yeah, so see
187. 6:58it just keeps getting worse and he's
188. 6:59like what the heck? I'm at my wit's end.
189. 7:01Can look at the overview and see how the
190. 7:04AHI just kind of spikes out of nowhere
191. 7:08as it's really all over the place. A lot
192. 7:09of these are being not captured by the
193. 7:11machine. And so it's really hard to look
194. 7:13at this view and say you can make any
195. 7:15sense of it because we've seen that so
196. 7:16many of them are not flagged on other
197. 7:18nights. So the machine's really
198. 7:20basically useless. See all these unfl
199. 7:22flagged events.
200. 7:24So what does one to do? So we already
201. 7:27did it. Decrease EPR or turn it off.
202. 7:29Decrease pressure to see if the central
203. 7:31avenas will go away. Um a lot of people
204. 7:34will say oh no you need to be on B level
205. 7:35for this. Ble is not going to help with
206. 7:37this at all. Uh chain respiration is
207. 7:39unphased by B level. So that's that's
208. 7:42going to be a big negative. Um so
209. 7:44there's some medications you can take.
210. 7:46Um I can't remember the name.
211. 7:50It's for uh like the high altitude
212. 7:52medication. The name is escaping me.
213. 7:54That's something you can try. Another
214. 7:56thing people in this situation can try
215. 7:59um are things like increasing the dead
216. 8:02space. So people have heard of EERS.
217. 8:05It stands for um enhanced expiratory
218. 8:09rebreathing space. So you add like 100
219. 8:11to 150 mill milliliters of dead space.
220. 8:15So block all the the holes on your mask
221. 8:18or you use a non-ventive mask and then
222. 8:20the exhalation port is like down here
223. 8:22somewhere. So you have all this area
224. 8:23that just kind of fills with CO2 and so
225. 8:26you're rebreathing CO2, keeping your CO2
226. 8:28levels higher and thus more stable. Um,
227. 8:31another thing which seems to not make
228. 8:32sense because it's the exact opposite of
229. 8:34what I just said is adding oxygen
230. 8:36supplementation if you're at high
231. 8:37elevation. U, but this came on all of a
232. 8:40sudden. So, I mean, realistically, what
233. 8:42probably happened and what I actually um
234. 8:45consulted him or or I said you need your
235. 8:48doctor needs to be in the loop on this
236. 8:49for sure. Um, you know, oftentimes it's
237. 8:52it's things like congestive heart
238. 8:54failure to start up. So having like an
239. 8:56echo cardiogram is helpful to see what
240. 8:58the function of your of your left
241. 8:59ventricle ejection fraction like the
242. 9:02efficiency of every beat because it's
243. 9:04probably diminished is my guess.
244. 9:06Everything else is remain the same. You
245. 9:08see the slow transition. It's it's
246. 9:10probably that. So anyway on that note
247. 9:14uh using ASV is actually another option.
248. 9:16You know ASV is excellent for chaintokes
249. 9:19respiration such as this and then for
250. 9:22periods of the rim breathing. We got
251. 9:25this REM pattern right here. And there's
252. 9:26these really clear obstructive, you
253. 9:29know, events leading up here and here.
254. 9:31There's several of them. So there is an
255. 9:33obstructive event. There's a a central
256. 9:35event. So central are helped by the ASV.
257. 9:38And so long as it's not like an upper
258. 9:40airway resistance syndrome type
259. 9:41situation, the obstructive events should
260. 9:44be taken care of adequately by the ASV.
261. 9:47So that's probably the, you know, best
262. 9:49option, but you know, it's kind of a
263. 9:51longer road. So,
264. 9:55there's a good time for a nice little
265. 9:56transition here. Hey, uh if you need a
266. 10:00ASV, you're going to need a mask. I
267. 10:02don't know if they sell ASVs here
268. 10:04anymore, but all kinds of masks. Look at
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279. 10:28guarantee. Read about them if you don't
280. 10:30know what they are. Anyway, that's
281. 10:32pretty much all I have for this one.
282. 10:34Thank you so much for watching. Please
283. 10:35like and subscribe if you want more of
284. 10:36this content.
285. 10:39Bye.
286. 10:41And time for an extra thick thanks buddy
287. 10:44to my top level supporters Doug Tombs.
288. 10:48tombs,
289. 10:48>> Jason Georgiotti, Patricia Espalong,
290. 10:51Steuart Heatherington, Alan Lou, Edward
291. 10:54Steiner, and like to say thank you also
292. 10:56to these people
293. 10:59as well as those other people up the
294. 11:02Annie, you get a shout out. Thanks for
295. 11:03watching.
296. 11:05Bye-bye. Barely even on screen, but
297. 11:08still appreciate the support.