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CA - Treatment Emergent or Positional arousal
RE: CA - Treatment Emergent or Positional arousal
Hi @betterforthis,
I can understand how you feel with the issues wearing a mask.
I have similar issues after changing my mask from Nasal(Mirage FX) to  nasal Pillows.
I've been using Mirage FX for almost 7 years I did not have cluster centrals with that. My sleep was fine with Mirage Fx but used to get aches above eyes and sleep was not fully refreshing on dialy basis.
Recently to get more comfort (to get rid of Mirage FX straps etc.) changed my mask to Nasal pillows  Brevida  and Airfit N30i and I started getting cluster of central events when compared to the Nasal Mask(Mirage FX). Though wearing these pillow masks is very comfortable and does not cause pain above eyes.

From the experts comments and literature, it seems it has to do something with the Oxygen/CO2 w.r.t inhale/exhale or positional.

Here are the below things I've been changing.
1.Changed EPR setting to 2 as 3 yielded more cluster of centrals. Reducing the EPR is working  as centrals are less comparatively.
2.Changed the pillow from thick to thin to avoid bend near the throat for easy breathing(positional). I think this also helps.
3.I should try the constant pressure setting and see how it works.

while using the Brevida I've noticed that after few days of consistent use,  the cluster of centrals  got better even though there were around 1-5 one each day.

I am not sure if this has to do something to do with the way of Brain adapting to breathing in new way of inhale/exhale O2/Co2  or something like that.
Couple of  differences between Mirage FX and the nasal pillows is these Nasal pillows that I tried  have more vent capacity and direct Jet of air flowing blows into the nose.
Not sure if this is the cause and effect for centrals.

Lots of centrals daily  is actually causing some chest discomfort to me.

Each one of us is different, but for me it seems Mirage FX does not give many centrals although it gives me some other issues.

I am trying to adopt to one of the nasal pillow masks and see if they get better with time w.r.t  centrals.
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RE: CA - Treatment Emergent or Positional arousal
Tx for  that MS, I appreciate your input, I am following Geers advice re the settings at this stage, i was chasing ,y tail over the last month changing everything too often.

Update for fixed 7/7 epr 1   Night 1

Disaster....got up for toilet, stopped machine  and noted within the first 1.5hrs 23 CA events, my incentive just took a nose dive and didn't bother replacing the mask for the remainder of the night

see attached


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RE: CA - Treatment Emergent or Positional arousal
I had a feeling EPR would make things worse, the odd night you tried it before was on the higher end of your results as well.

Lets try 9/9 no EPR to see if higher pressure has any effect.
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RE: CA - Treatment Emergent or Positional arousal
Tx Geer,

there was no response by the time I went to bed so I persevered with 7/7 epr 1 again and surprisingly better results last night just 
AHI 1.4  6 x Ca and I believe only 2 of these had no preceding breath pattern disruption.

flow limits higher today, a couple of spike groupings no major leaks?  don't feel too bad this morning

just looking at that chart from yesterday, doesn't it look like a positional issue? it went for an hour smoothly then clustered for the remaining 30 mins

want me to change tonight still Geer?


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RE: CA - Treatment Emergent or Positional arousal
You can stay with EPR 1 again since last night went decent.

It doesn't look like an obvious positional issue to me as positional is obstruction based and most of the examples you have posted have looked central or at least mostly central. Trying basic positional apnea treatments like using a single thinner pillow to make sure airway stays fairly straight/open is worthwhile but I probably wouldn't bother with things like a cervical collar.

The thing with central apnea is that it is notoriously inconsistent.
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RE: CA - Treatment Emergent or Positional arousal

I think you are making progress.

Only a few other things I can see.

On your chart of Jan 25th your were on APAP 7.4 - 14 (EPR = 0)
Interesting how all your CA occurred when you had low Flow Limitations. In your periods of high FLs you had no CA.
Same comment for the 4th Feb, even though on fixed pressures. Your FLs fluctuate despite being on fixed pressures, this suggests there is another factor at play: pillow, neck position, congestion, medication, maybe others.

Maybe if we eliminate Flow Limitations too quickly things get a bit confused with respect to Loop Gain and it's better to try and bring FL down gradually. Often I felt better in the morning on nights when I still had moderately high FL and some OA.

Note on the 25th Jan how the machine tried to keep your Med EPAP around 7.8. The usual recommendation from our experienced members here is to set the Min to something just below the Med Pressure.
(For me I find I am increasing my lowest starting pressure to be a whole lot closer to my Median Pressures.
This results in less fluctuation of FL, as well as lowering the FL, and less disturbed sleep, but that's an observation applicable to me).

For me, with the nasal pillows Increased EPR (or pressure support) makes less difference to the FL than raising my lowest starting pressure. I note Geer1's recent suggestion of starting with higher pressures. That may mean you won't need as much or even any EPR.

Earlier on you said:
"Well that's 5 nights on this setting and as you will see from previous entries and todays attachments we appear to be on another upward trend 

Day 1  .90          3 ca
Day 2  1.90        14 ca
Day 3  1.30        4 ca                                  2 x valerian sleep tab
Day 4  4.62        15 ca and 1 CSR hmm        2 x stronger sleep tabs   (3.5hrs  very crappy sleep)
Day 5  4.09        23 ca                                1 melatonin tab'

It's tough to resist doing whatever it takes to get some sleep, but it's good to try and keep sleep hygiene constant too.
I stopped using sleep aids (benzo's) to "get me through the night" about 6 months ago. I just found they knocked me out but also suppressed my respiratory drive in some way, landing up with higher FL, pushing up my minimum pressures, and faster Resp rates. Since stopping them things are more consistent. Paradoxically the Melatonin that the Sleep Doc advised did nothing to improve my sleep latency or quality. Quite the opposite but I was only on 3mg.

Let's see how you go over the next few weeks.
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RE: CA - Treatment Emergent or Positional arousal
Tx for looking SA,

I considered the non use of sleeping aid last night and went to bed without them, I think I may have cheated though does rum and coke count  Dont-know  not a bad sleep, however ahi count went back up 3.96 with 26 CA events.

@ Geer do we make the pressure change you suggested earlier?  9/9 no epr?

se attached charts and included respire/tidal charts during a selected cluster of ca



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RE: CA - Treatment Emergent or Positional arousal
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RE: CA - Treatment Emergent or Positional arousal
Quick update

fixed setting 9/9 was a shocker removed due to very restless, back to 6/6 epr 1 and epr 2

flow limits dropped right off and this was prob the most comfortable level i have had over past 2 months, ahi were increasing over 5 per hour mainly ca still, they dropped right off to .61 2 days ago and out of the blue last night saw 100 events 95 CA LOL i have no clue to this and why there were 90 min gaps with no ca   - positional?  even had some csr happening good stuff  !!!

even with this apparent 100 events and 30 mis in apnea didn't sleep too bad and don't feel too bad now?

see attached


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RE: CA - Treatment Emergent or Positional arousal
It's just central apnea and a bad night.

Not much you can do but wait and see if it goes away with time. Higher EPR is probably more comfortable but will make central apnea more likely so you might have to increase very slowly.

If centrals don't improve after a few months you may need to revisit doctor and ask about ASV (machine capable of treating central apnea).
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