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6 weeks in on bipap, still centrals, still sleepy
#1
6 weeks in on bipap, still centrals, still sleepy
I am starting a new thread as the last one seemed to go dormant after my last post.
I started on bilevel 6 weeks ago with initial settings of EPAP 4, PS 4, Max IPAP 25, which triggered a slew of central apneas. Lowering the pressure support to 3 didn't help much, but lowering the Max IPAP to 9 did, or at least it seemed to -- most nights the average CA index is less than 5, and a couple of nights it was less than 1. But it has spiked back up again the last couple of nights, as have the OAs, which were way down most nights.

Also the overall average seems misleading to me, as both the OAs and CAs come in pretty dense clusters. More worrisome is that I am waking up repeatedly and often not able to go back to sleep for long periods, and I am still sleepy during the day.

If I look at the Oscar graphs over several nights it seems clear that the CAs come in response to pressure spikes, which come due to OAs and flow limitations. Even a small spike seems to set off CAs. I tried lowering the max IPAP to 8.2 with the idea that I could decrease the spike range, but that doesn't seem to have helped, and may be why the OAs are up. It does seem that many of the apneas cluster around transitional wake-sleep periods, and I thought that they reflected "junk breathing" during those periods. Now though I am wondering if I have the cause-effect pattern backwards, and the CAs are actually causing arousals. Either way, I need help.

These are graphs from the past two nights, both of which were subjectively awful, plus the overview of all nights so far:
[attachment=12073]
[attachment=12074]
[attachment=12076]
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#2
RE: 6 weeks in on bipap, still centrals, still sleepy
Hi.  I'm no expert by any stretch of it.  Others with more knowledge will offer their thoughts, so be patient.

Your marginal information says your bottom pressure is only 4.0.  That has a 99% chance of being too low since about that many PAP users complain when theirs is set that low.  It should be at least 5.0, and maybe even 5.5 ot 6.0 before things settle out for you.
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#3
RE: 6 weeks in on bipap, still centrals, still sleepy
(05-20-2019, 07:12 PM)mesenteria Wrote: Hi.  I'm no expert by any stretch of it.  Others with more knowledge will offer their thoughts, so be patient.

Your marginal information says your bottom pressure is only 4.0.  That has a 99% chance of being too low since about that many PAP users complain when theirs is set that low.  It should be at least 5.0, and maybe even 5.5 ot 6.0 before things settle out for you.

You forgot to apply the PS of 3

OP has an initial inhale of 7 and exhale of 4.  The pressure issue is with inhale, not exhale.
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#4
RE: 6 weeks in on bipap, still centrals, still sleepy
Aaagh!!  Thanks for correcting me, bonjour.  I didn't go on to read the info in the lower column which would have revealed my assumptive error to me.

So, my apologies to the OP.

Looking at your second chart, you go fairly substantial periods with seemingly good control, but then you get a cluster of events. Often those are indicative of positional problems with the head and chin-tuck. Often, this is what happens if we turn onto our backs, where most of us experience most of our problems with obstructive apnea. Yet, these obstructive events do not comprise the bulk of your apneas. Instead, as you know, it's centrals. Perhaps bonjour or another savvy member will suggest something about tightening up the EPR.
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#5
RE: 6 weeks in on bipap, still centrals, still sleepy
I'm thinking you might be on the wrong therapy, or you'll have to reduce the EPR to maybe one or even turn it off. Again, the 'others' will chime in with some confirmation or their own interpretation eventually. Please stand by.
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#6
RE: 6 weeks in on bipap, still centrals, still sleepy
Your machine, the VAuto, does not treat centrals. With your machine they are treated by avoidance. Since centrals may be caused by either higher pressures, how high varies by individual, and/or pressure changes from either the algorithm chasing obstructive events or pressure support.

Set your PS to 1 and reevaluate.
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#7
RE: 6 weeks in on bipap, still centrals, still sleepy
Let me add that you have already negated the advantages of the VAuto and the VAuto is acting as an APAP/AutoSet and the proper machine for you would be an ASV which is designed to treat centrals.
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#8
RE: 6 weeks in on bipap, still centrals, still sleepy
(05-21-2019, 05:50 AM)bonjour Wrote: Let me add that you have already negated the advantages of the VAuto and the VAuto is acting as an APAP/AutoSet and the proper machine for you would be an ASV which is designed to treat centrals.

So I must have been out of it as I missed your last two posts, Bonjour--also I was traveling. But I have also been so sleepy and tired that I am not functioning on even two cylinders.

The problem with setting the PS to 1 is that the main reason I moved to bilevel is because I can't take exhaling against the pressure, also that on APAP I had severe aerophagia, which I don't with this machine. So setting the PS down would negate the whole point. I'm not sure what you mean that I've negated the advantages of the VAUTO. As far as the ASV, I am wondering how I could qualify as the central index is running just under 5 -- but they come in big clusters where the index goes up to 10 or more.

In any case, I am feeling worse and worse, very fragmented sleep  and what looks like lots of arousals, or at least very erratic breathing. I tried raising the pressure a bit to see if that would help, maybe a bad move -- though it doesn't seem like it actually went that high most of the time. This is from last night -- index is less than 5, but the pattern just looks ugly.
[attachment=13350]
[attachment=13351]

These are stats for the last month -- looks a lot better than how I feel:
[attachment=13352]

So what do I do now? I am thinking of asking my doctor for another sleep study, with the bilevel this time, to see what happens -- and maybe ask what we would have to do to try the ASV?
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#9
RE: 6 weeks in on bipap, still centrals, still sleepy
ASV can be self-titrated, but I don't know if insurance would accept that as proof of efficacy. You have a medical need for ASV as shown your your intolerance to CPAP and BiPAP. I think we have previously linked the "Justifying Advanced PAP" wiki. Read it again.
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#10
RE: 6 weeks in on bipap, still centrals, still sleepy
So to update. I reached out to my doctor and she is fine with trying the ASV (Let's hear it for Kaiser) -- just wants to do an echocardiogram first to make sure my heart is fine.
So I will likely be needing some help with the ASV once I get it.
Thanks for all your help!
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