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[CPAP] New and need some help lowering AHI
#21
Just to emphasize, CHF should not really be a discussion here. Complex apnea is a fairly routine complication of CPAP, especially in individuals that expressed mixed or central apnea in their sleep study. CHF is usually manifested as a specific form of periodic breathing called Cheyne Stokes Respiration, and the OP has not shown ANY tendency towards periodic breathing of any kind. Let's just get that off the table.

Both Rich and I suggested limiting maximum pressure to 12 cm. Central apnea can be made worse by pressure that is too high, so we want to limit that possibility. Also, some people have central apnea when using a significant pressure difference between IPAP and EPAP (inhale/exhale pressure support). Eliminating the high pressure and pressure support as potential causes of your CA helps to simplify whether you need to consider a more advanced therapy like ASV or not.
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#22
(11-30-2016, 10:52 AM)caseyfontneau Wrote: So I read everything you put down there and just see the words chronic heart failure Huh phrases like that tend to scare me. Sad

Anyways so it sounds like it need to make max pressure 12 and possibly minimum pressure 7 and get another appointment with my doctor about reviewing my data and the possibility for a detailed titration to narrow down my issue and at the presence of central apneas I need to peruse an ASV, but then also hope to not die from chronic heart failure in the time being? Sad

Central Apnea is often associated with Chronic heart Failure. It does not cause it. If Chronic Heart Failure is the cause of Central Apnea treating it (Central Apnea) can be detrimental. On the other hand treating Chronic Heart Failure can reduce Central Apnea. That being said, you only need to rule out CHF AND a low ejection fraction if you are going to go on an ASV machine. You may also want to talk with your cardiologist if you think you might be at risk for CHF. My initial assumption is that you are NOT at risk for CHF, but I have to let you know of the risk. You can still do some diagnostic work on your own. One problem that you are going to face is a lack of knowledge regarding Central Apnea among Docs and Techs. If you like me have Central Apnea without CHF and a low ejection fraction you very well could be a candidate for an ASV machine. The problem is that you generally have to fail at using conventional CPAP and Bi-PAP in order to qualify (insurance wise) for an ASV machine. Generally you don't get a detailed Polysonogram to diagnose Central Apnea. You can do a much better job yourself using Sleepyhead and various pressure settings. Do some research on what the waveforms for Central Apnea and Central Hypopnea look like. Highlight and blow up a 5 minute section of your flow waveform at a point with several CA events. This will give you an idea of what you are looking for. Then you can try tightening the pressure range first than cut out the EPR and then start lowering the pressure. This would be for your own diagnostic purposes.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

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#23
Okay gotchya. It's all great information and I appreciate everyone's input. I'm just impatient haha. I've learned so much in the last 24 hours though. Joining this forum is the best decision I've made.
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#24
(11-30-2016, 11:02 AM)caseyfontneau Wrote: Also More for curiosity, but what is the logic behind turning off EPR and thinking it will help with the centrals? I guess I don't understand centrals well enough to know what's causing them to begin with.
Throwing in my two cents.

While a few people do seem to have CAs that are triggered by using EPR, many people do not find the EPR setting relevant to the number of CAs they experience and some people find that they have fewer CAs with EPR = 3. And in fact, some insurance companies will first require a patient diagnosed with complex sleep apnea to try out a plain bilevel machine before authorizing moving to an ASV machine. The reason behind their rule? Some complex sleep apnea patients have no problems with machine induced CAs while on bilevel with an appropriately chosen PS even though they do have problems with machine induced CAs on CPAP/APAP.

Here's the thing: The CA clusters are triggered by a CO2 overshoot/undershoot cycle, and it doesn't much matter if the start of the cycle is an overshoot or an undershoot. Too much EPR may trigger "blowing off too much CO2" which can trigger the overshoot/undershoot cycle to develop. But not enough EPR may trigger "blowing off too little CO2" which can trigger a CO2 undershoot/overshoot cycle with the exact same problem of lots of CAs at the nadir of the cycle.

My advice is this:

1) If turning off EPR makes you more uncomfortable (and less likely to use the machine all night long), then you're better off keeping EPR on. You might try decreasing EPR if it's currently set to 3. But you might also try increasing EPR to 3 if it's set to 1 or 2.

2) If turning off EPR does not lead to more discomfort and it reduces the CAs, that's great---you've identified part or all of the problem.

3) If turning off EPR leads to MORE CAs, then turn EPR back on and consider increasing EPR to its max setting. If using EPR = 3 leads to fewer CAs than using EPR = Off or EPR = 1, then that's great, you've identified part or all of the problem. And in fact if the number of CAs is still to high, but is less at EPR = 3 than it is when EPR = 1 or EPR = OFF, then that may indicate that a simple bilevel with a PS = 4 or 5 might do the trick for you without the need of going all the way to an ASV machine.


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#25
RobySue,

That makes a lot of sense. Thanks for the input!
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#26
It is most likely that my Central Apnea is caused by a defective cero-neural feedback mechanism. I had Central Apnea/Hypopnea before being treated with xPAP. I most likely have a defective Carotid Body feedback defect. The CO2 washout that CPAP produces in me causes my Central Hypopneas to turn into Central Apneas and CSR. I don't have any significant Obstructive Apnea symptoms. My ASV machine produces an average AHI of close to 0.0 with many nights at 0.0 but it is working like crazy all night.. Idiopathic Central Apnea by itself is quite rare. Most cases of Central Apnea are side effects of Apnea treatment with xPAP machines.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
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#27
That's great information. I've made some adjustments to my machine and am optimistic for tonight. It was EPR 1 , RampTime off, EPR always on. Aside from the max and min pressure (which are now 7-12) I changed EPR to 2, EPR Ramp only, Ramp Auto, starting pressure 5. (I'm thinking this will help me get to sleep easier).

The two questions I have now are as follows:

1. Does facial hair really make a big difference with mask seal?
2. I sleep with a 7" foam bed wedge under my pillow to help with acid reflux. Is there a possibility that this incline could cause additional issue?

Thanks again, y'all are amazing!
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#28
1. Mask leaks are a problem for those with facial hair. At least it is not a snorkel mask. 2. I think the incline can be helpful in reducing any Obstructive events.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur


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#29
UPDATE: (All graphs via imgur below so you don't need to backtrack)

Two nights ago I had set my APAP settings as Max Pressure 12, Min 7, Start 5, Auto Ramp, EPR (RampOnly) and ended up with a AHI of 4.49 including 35 CA events. There were a few leaks showing on the sleepyhead charts.

I readjusted my mask and shaved my facial hair to help with leaks and also adjusted max pressure to 10.8 keeping everything else the same, but ended up with an AHI of 10.52 including 110 CAs, but very little leaking.

So leaking looks to be solved (what you see will be the few times I had an itch and lifted the mask), but clearly something else is going on.

My original settings (seen in other charts) were pressure 5-20 EPR 1 always. When I looked at the chart from 2 days ago I thought pressure of 12 was too much, but it may be that not having EPR on after ramp caused a problem?

Looking for some tips, but I feel like setting EPR 2 Always and pressure 7-12 will help, but am open to suggestions. SleepyHead shows 10.52 as "Horrible, please consult your doctor." So I'm a little leery. Soonest I can see my doc is the 16th, but don't want to continue with the 110 CA nights as I feel terrible when I wake up.

Nov 10-23 is Philips DreamWear mask
Nov 24-27 didn't use machine due to cold and congestion
Nov 28-Dec1 (and current) is Philips AmaraView mask

Imgur links to all charts including past two nights are here

(first day of therapy Nov 10)
Nov 10 - http://imgur.com/zjeRpmN
Nov 11 - http://imgur.com/zpRFoki
Nov 12 - http://imgur.com/Bp8FSDU
Nov 13 - http://imgur.com/qdzz52J
Nov 14 - http://imgur.com/CDAilTh
Nov 15 - http://imgur.com/fbGC3jl
Nov 16 - http://imgur.com/DQG9tsS
Nov 17 - http://imgur.com/9nF526o
Nov 18 - http://imgur.com/pomHnlb
Nov 19 - http://imgur.com/h2KR1eY
Nov 20 - http://imgur.com/qsO3ajI
Nov 21 - http://imgur.com/3YsK1p9
Nov 22 - http://imgur.com/qAO7402
Nov 23 - http://imgur.com/NetWTN3
------------no data 24-27
Nov 28 - http://imgur.com/k7b7F10
Nov 29 - http://imgur.com/2HSXOOA
Nov 30 - http://imgur.com/qjasDnR
Dec 1 - http://imgur.com/sQglzET

As always thanks for any/all assistance! Y'all are amazing!
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#30
I know that the 16th seems like a very long time away, but it's not really that long. You may, however, want to call the sleep doc's office again and let them know that you are really struggling and that the problem seems to be a lot of CAs being scored by your machine. Certainly you need to give that information to the doc before you see him on the 16th: You want to make it clear that you need to talk to the doc about the CAs and not other problems because you want the doc to have spent some time thinking about the issue.

I would also suggest that you make sure the doc has a copy of the data before you see him on the 16th. Call the office and ask them how to get the detailed daily data to the doc before your appointment so that the doc has a chance to review it before he sees you on the 16th. You don't want to simply "surprise" the doc with the data that shows you're dealing with a lot of CAs when you show up at your appointment.

Also: what were your original settings from the titration sleep study? And were CAs mentioned in the titration sleep study report? If you don't know the answer, make sure you tell the office staff in the sleep doc's office that you need a copy of the titration sleep study report, including the summary graphs and data.

If you feel like you must tweak the settings on your AutoSet before your appointment, my guess is that you may need to limit the max pressure to something like 10cm and keep EPR =1. (In general pressure induced centrals seem to be a bigger issue when people are using pressures above 10cm.) Yes, that could replace CAs with OAs and Hs, and yes it might not eliminate the CA problem, but still that's the one thing you haven't done yet.
Questions about SleepyHead?
See my Guide to SleepyHead
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