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[Diagnosis] Questioning CPAP when experiencing proportion CA events
#21
Question 
First Oscar Reports
Thank you for all the advice so far.


I seem to be tolerating the mask and cpap well with using it about 6.5  hours each night for 4 nights.

I had a good first night and felt amazing the next day but put that down to actually getting better sleep after months/years of very poor sleep.
I was coming off a AHI of 61 so the  first night AHI 8.48 was amazing.
The subsequent 3 nights I'm still waking tired but have more stamina than usual during the day.


Last night's stats were:
PAP mode Auto for her Min 4 max 15
for 6:15 hours


AHI: 5.76
CA: 4.96
UA:O
OA: 0.48
Hypopnea: 0.32
RERA: 0.32




Summary Chart screen shot is attached.

I asked the therapist about the Central Apnea events at my initial appointment and what strategy we would be using to address those.... and she said that we would see how the cpap/apap worked for me and then make a decision as we got more results.

I would appreciate any feedback/advice .  Due to the Christmas holidays, I don't touch base with the sleep therapist until 7 January .

Many thanks

Leonie


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#22
RE: ??? CPAP when experiencing proportion CA events
Well the machine has certainly clobbered your obstructive apneas, but there are still some centrals showing, as well as pretty persistent flow limitations. The starting pressure of 4.0 is very low, and a lot of people feel starved for air at that pressure. However, if you're comfortable that's OK for now. It looks like EPR (expiriatory pressure relief) is off - normally I'd recommend raising the minimum pressure to around 7 or 8 (which is your median) and setting EPR = 3. However I fear that would exacerbate the central apnea.

Your therapist is working through a set protocol, so I'd advise against making any pressure changes yourself so long as the results stay reasonably good. Making your own changes will mess up her protocols and potentially drag out the process. Keep a close eye on the centrals and at your next appointment discuss how they are going, and also the flow limitations. The thing with central apnea treated with APAP machines is that they can fluctuate a lot and it's often very difficult to get them pinned down.

If the results do change before your next appointment, let us know and we'll see if we can improve things for you.
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#23
RE: ??? CPAP when experiencing proportion CA events
You're still going to feel bad until your settings are optimized, which is probably going to take a while.
Nothing I post is medical advice and should not be taken as such, always consult a medical professional for guidance.
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#24
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RE: ??? CPAP when experiencing proportion CA events
Thanks Thank you Deep Breathing and Joey Wallaby. For you replies.

Yes I am feeling as if I'm trying to get more air when i first start.
It takes me a little while to settle the panic and get into a rythmn

AsI don't get to see the therapist for another 2 weeks due to the Christmas holidays I will increase the minimum pressure to 5 or 6 see how that goes.
I'll leave the EPR as isfor the moment.
Thanks again for the feedback.     Dancing
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#25
Update - Waiting for Clinician review in 1 week
I'm having as bit of a rough time at the moment.
I am unable to contact my sleep clinician until 6 January due to holidays.
I am reluctant to change the  settings as DeepBeathing advised that clinicain would be following a set protocol

Scenario so far:
  • Diagnosed 30 November with untreated Apnea
  • AHI 61.2 with a mix of 2/3 OA and 1/3 CA

Started with Resmed Airsense 10 Autoset 19 December
  • standard open pressures of 4 -15
  • EPR 3 Ramp Only
  • Ramp on 45 min
  • AHI ranged from 3.8 to 19 .  Average 10.5
  • Have almost eliminated OA
  • Average CA index 8.2 , OA index 1.52 over last week
    DeepBreathing wrote:"Your therapist is working through a set protocol, so I'd advise against making any pressure changes yourself so long as the results stay reasonably good. Making your own changes will mess up her protocols and potentially drag out the process. Keep a close eye on the centrals and at your next appointment discuss how they are going, and also the flow limitations. The thing with central apnea treated with APAP machines is that they can fluctuate a lot and it's often very difficult to get them pinned down."
Made the following changes:
Increased minimum pressure to 6 and reduced ramp time to 30 minutes as was feeling air deprived and this has definitely helped with falling asleep.

Of course the centrals are now the issue and definitely disturbing sleep which could be leading to the mask leaks of last night.

Is there anything I could or should do before I can talk with my sleep tech?

OSCAR chart for last night attached

Many thanks Dancing


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#26
RE: Questioning CPAP when experiencing proportion CA events
Without addressing your centrals with something like EERS you are in a holding pattern.

Talking points,
You are 1 month in, it can take 2-3 months for Treatment Emergent Central Apnea to dissipate.  If it doesn't the choices are ASV or EERS (adding rebreathing space to your mask) Talk about the direction to treat the centrals.

Your Flow Limits are high, though your obstructive events are low.  EPR is the first step in treating the flow limits and unless they are bothering you it is ok to leave them alone (won't really know until the centrals are managed)  Increasing EPR is very likely to significantly increase your centrals at this time.  

You need to know what the approach to Centrals will be.  When do I see you next?  Is that when we look at ASV?  Why or why not?  Do I need to fail at BiLevel first?  What about EERS? (likely they will no idea about this.)  Since centrals are treated so different from obstructive events, Who here specializes in treating centrals.

It is not uncommon for your doctor or techs to not have a clue about treating centrals though they will not admit that.  This is one thing that you are trying to determine.  The question about ASV is to lead them to that solution. 


http://www.apneaboard.com/wiki/index.php...tral_Apnea
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#27
RE: Questioning CPAP when experiencing proportion CA events
EPR being ramp only and having a ramp time programmed in gives only one advantage, EPR when trying to fall asleep. EPR makes breathing a bit more comfortable so this makes sense but what makes no sense is that they had you set up this way with minimum pressure of 4 which does not allow for EPR(EPAP cannot fall below 4 cm)... Raising your pressure to 6 cm has given you the advantage of some EPR during ramp which might be helping you be more comfortable/fall asleep. Soon as your ramp time is finished EPR is turning off, they programmed it this way because EPR can induce central apneas. I personally would try turning ramp off and EPR off, if you find this comfortable enough to fall asleep then there is no point in using ramp since the machine ignores your breathing issues(does not flag or react to breathing issues) during ramp. If you find you need EPR to be comfortable to fall asleep it might be worthwhile to change the ramp time to auto.

Providing screenshots zoomed in on the central apneas might be helpful to some members on here to see what flow waveform the central apneas are occurring in (looks like clusters of periodic breathing). To me it looks like they might be a sort of sleep transition apnea and that they may have been occurring post arousal caused by leaks(almost all of them occurred in clusters after leaks stopped abruptly). Have you been waking up because of leaks and if so do you know what has caused them(mouth leaks, mask leaks etc)? 

Turning off/modifying ramp and trying to determine the source of and mitigate leaks are the two main things I would focus on right now. As deep breathing mentioned trying to collect some reliable data for the technologist is probably better than changing stuff every few nights.
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#28
RE: Questioning CPAP when experiencing proportion CA events
I think Geer1 and Bonjour have given you good advice.

If your therapist is doing what mine did, she is trying to narrow down the pressure range with a view to finding a single fixed pressure. When that doesn't work, she'll cast around for options eventually realising that ASV is what's needed.

The thing about ASV here in Oz is that your health insurance won't pay any more for an ASV, even though it's MUCH more expensive than an Autoset. So to some extent they (clinic) have your interests at heart trying to go for the lower cost option, but ultimately it might be a false economy. You should also be aware that you're under no obligation to purchase the machine from that clinic. However if you do they will probably rebate the price of this consultation phase, which was enough to swing the deal in my case. If they don't offer - ask! Regardless of which machine you end up needing you should shop around for the best deal. That might include buying from overseas, but with the current exchange rate plus other costs involved that is not as attractive an option as it was a few years ago.
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#29
RE: Questioning CPAP when experiencing proportion CA events
(12-29-2019, 08:00 PM)bonjour Wrote: Without addressing your centrals with something like EERS you are in a holding pattern.

Talking points,
You are 1 month in, it can take 2-3 months for Treatment Emergent Central Apnea to dissipate.  If it doesn't the choices are ASV or EERS (adding rebreathing space to your mask) Talk about the direction to treat the centrals.
Thanks Bonjour...your input is very much appreciated.


I don't believe that the Central Apnea is treatment emergent  as the initial sleep study showed a significant proportion of CA events ( >30% ) vs OA events.  Of course i am very new to this and could be very easily be mistaken.
The CPAP has been very efficient at addressing the OA and so yes I agree we're gathering evidence to hopefully push my clinician  more towards using an ASV machine if required.
As to why I am experiencing Central Apnea...I haven't a clue!
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#30
RE: Questioning CPAP when experiencing proportion CA events
(12-29-2019, 08:01 PM)Geer1 Wrote: Providing screenshots zoomed in on the central apneas might be helpful to some members on here to see what flow waveform the central apneas are occurring in (looks like clusters of periodic breathing). To me it looks like they might be a sort of sleep transition apnea and that they may have been occurring post arousal caused by leaks(almost all of them occurred in clusters after leaks stopped abruptly). Have you been waking up because of leaks and if so do you know what has caused them(mouth leaks, mask leaks etc)? 
Thanks Geer1
I have attached a couple of screenshots of zoomed in CA events (2 min 20 sec) and the lead up to the cluster of CA Events (approx 11 minutes).

As for the leak issues I am unsure how this is happening.  I feel that last night was a mask issue as I havent previously had a significant leak issue.

I believe that i tend to wake or rouse after a CA cluster and may pull the nasal prongs away from the nose while i get my composure back.  This may account for some of the leak issues.


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