Assistance with my configuration

[cpaper101]

Hello All,

I have been using my Resmed AirSense 10 AutoSet for nearly 2 months now. I was diagnosed with severe sleep apnea with an AHI of 36. 

I have been using a pressure of 8.4 - 20.0 for the past 3 days after raising it from 8.0 - 20.0, I was having some issues with CA so I turned EPR off which seemed to help it a bit. I used no EPR for about a week then turned it back on last night to 2. Thoughts on what changes I could make to assist?

I was having some aerophagia that was quite painful the whole day but seems to be getting a bit better. 

Thoughts on what if any changes I could make here I have attached the past few nights?

Thank you.

[SarcasticDave94]

Welcome to Apnea Board.

You still have some CA which are called Clear Airway on the machine and OSCAR, but are really Central Apnea. These are a bit different from Obstructive Apnea in that the airway is clear, so that's why they can be called clear airway. This is taken literally as there's no airway blockage, yet it's an apnea so it lasts 10 or more seconds. Typically, CA are not as bothersome to apneic patients, but it's a personal thing. If they disturb sleep or disrupt rest, then it's your call that these are disruptive. On your action to reduce or remove EPR, this was the right move, but it seems on these 3 snapshots of time it didn't affect CA much either way. Just remember that CA have a nasty little trait in that they are consistently inconsistent. In other words there's lots of CA then the next night there's less or none, and this variable content with no setting changes.

So after that boring classroom lesson, a few questions back to you. Are you sleeping better for the therapy? If not, what is still an issue? Lack of comfort? I do know that your AHI is barely treated if you use AHI of 5 as the threshold. Another question, do you have data from a sleep study you'd like to post as a redacted version? If not, do you know the apnea event type and count from a sleep study or titration?

Back to class briefly. CA has 3 types, treatment emergent, pre-existing/pre-dominant, and idiopathic. Treatment emergent are typical in new PAP users in that the PAP machine makes removal of CO2 too efficient and that your body isn't used to. This typically lasts 3 months or less and reducing EPR or pressure swings can avoid it until it diminishes by itself. Pre-existing are where CA showed up in equal or greater numbers on a sleep study. These need a machine called ASV to treat if the doc helps prescribe it. If not, you remain in a treatment by avoiding. It's not always successful. Last is idiopathic, this means for medically unknown cause. This too is treated by ASV or avoided on other machines.

OK end of class today. Bring your questions answered to class next time with OSCAR data and include an answer to this last question "how do you feel?" during and after therapy. Class dismissed.

[cpaper101]

Thank you. Unfortunately, I don't feel any better since starting CPAP. I think I am waking up less because sometimes I would wake up gasping for breath etc or scaring myself awake as I was trying to get to sleep when I stopped breathing. I still feel dead by lunchtime and want to have a nap.

Prior to turning EPR off I was often getting CA AHI over 5 on numerous nights which was why I ended up turning it off to see what happened. The weird thing I noticed initially when turning EPR off was that my hypopneas went higher than previous.

I have attached my sleep study here:
   
   

[Gideon]

IMHO, based on the data including your sleep study, you have idiopathic central apnea meaning an unknown cause. Turning off EPR is not affecting your CAI, some minor day to day variations is all. Your total central was 5.2 CAI (mixed + central).

Ask your doc about an ASV, ask if you can get titrated for an ASV to prove it works for you.
The big trouble you will have is that your AHI is under 5 which means the medical community considers you to be well treated. This means that you have to complain about your symptoms often and loudly (so that your doc/med team hears you. Keep a log every day so you have a record of it, evidence that your current system is not working for you. Do acknowledge that the APAP has reduced the OSA from severe levels, but it is still leaving you with symptoms.

Dave, please chime in on how to communicate with your med team.

[cpaper101]

Thank you for your response.

I am in Australia so I guess I can just tell the sleep doctor I wanted to try something else perhaps if I know what to ask for. I am not due to see them until January however, and things just got a bit more awkward because of lockdown here with COVID. I don't think we have as many issues with things as people might have in the US because we usually have to pay out of pocket for this stuff anyway rather than insurance etc.

I have NOT purchased this machine yet as I wanted to get the sleep doctors to advise before doing so, I did a trial period and the person at the CPAP shop said everything seemed fine because my AHI was under 10. She was nice but seemed to be lacking any usefulness to help with this stuff. Since the trial ended I have just continued renting the trial machine for an extra 3 months to see if I can get any better results before my January appointment.

Does this mean I likely have mixed apnea?

[SarcasticDave94]

First, yes I'd agree with bonjour on the idiopathic CA. What I see on the sleep study to indicate it is some CA and Mixed apnea but they're not high or equal/greater than OA. And to extend it, you have consistent inconsistent CA flags now that do not get affected by avoidance via EPR drops.

Do you have mixed apnea? Yes it's acceptable to call it that. Mixed means you have CA and OA. Your CA isn't pre-existing, as the CA numbers weren't there on the sleep study. Idiopathic again means unknown cause.

OK now what bonjour was wanting feedback is this, and I know it's very different in Australia than here in the US and medical systems, guidances, etc. The big thing we do here is at the point you are now, note down your apnea treatment symptoms and complaints. This can be pen and paper or Microsoft Office Word, or etc. However you want to keep some notes on the treatment is up to you as to what format it is. The goal is to identify the therapy shortcomings, CA that lingers, you can't avoid it with APAP, symptoms of not well rested due to CA, and such like. Present this to doc that you'd answer to regarding apnea therapy. You will be best served in getting a different ResMed, this is the full name ResMed AirCurve 10 ASV. If for some reason you cannot get it, I think it's acceptable to get a 9 series ResMed ASV. Basically that's it. Now when you do get an ASV, if it's 10 series, masks, filters, hoses, humidifier tub all interchange, so no new part numbers. You just need ASV instead of AutoSet.

[cpaper101]

Thank you that is very helpful. I have a phone appointment with my doctor tonight so I will ask him if it is possible for me to see the sleep doctor sooner than January, unless he is able to write the prescription for me himself (unsure if he can do that here or not).

[SarcasticDave94]

OK got it. If there's other questions, we're here. Do let us know how it goes and update when you're ready to do ASV setup. This really is easy. Mode, EPAP Min/Max and PS Min/Max. And your humidifier settings. That is really it. Best wishes you get a machine turn-around soon.

BTW if you look at my profile, that ASV is what I run right now.

[cpaper101]

I called the CPAP place now to see if they had those ASV and they do. She said I would need a prescription and then said it might be difficult to get because of something called "The Sleep Apnea Cardiovascular Endpoints (SAVE) study" and supposedly the results scared some sleep doctors in Australia from wanting to prescribe them.

I am unsure what the issue is exactly but perhaps it is a study you may have heard of before.

I will attempt to contact the sleep doctor anyway to see what can be done if anything.

[Sleeprider]

Be sure to read our wiki regarding prescriptions in Australia http://www.apneaboard.com/wiki/index.php...escription

You will find that ASV is considerably more expensive in AU than if you import a machine from the U.S. Supplier #2 is a common source for your mates to purchase an advanced bilevel like ASV, rather than pay the considerably higher costs at home. The specific machine you want is the Resmed Aircurve 10 ASV, or the older model Resmed S9 Adapt Model 36057. Both of these are auto-adjusting ASV machines, but the Adapt will be less expensive as it is discontinued. There is a Resmed S9 Adapt Model 36007 that has ASV mode without the auto-adjusting EPAP. It will work, but may need some fine-tuning.

The SAVE study only evaluated CPAP in patients with advanced cardiovascular disease. It is not the study that prevents you from getting ASV. The SERVE-HF study evaluated the use of ASV and included a cohort of individuals with advanced congestive heart failure. This study did find a risk of sudden cardiac death in patients with very low left ventricular ejection fraction (LVEF), and a guideline was established that generally prevents any CHF patient with LVEF less than 45% from being prescribed ASV. There were significant quality problems with the SERVE-HF study and lack of proper titration and supervision of the patient cohort. A new study, SERVE-HF is underway which at last report showed no adverse effect from the use of ASV in patients with CHF and LVEF<45%. Either way, I would venture to suggest you are probably not at risk unless you have some really serious heart problems.