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Influence of EPR-Level on Central Apnea
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vsheline Offline

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Post: #11
RE: Influence of EPR-Level on Central Apnea
(06-21-2015 12:11 PM)tedburnsIII Wrote:  Wow! Might suggest speaking to another board-certified sleep doctor or pulmonologist. It sounds as if your case is not run- of- the mill.
...
Dial-winging and fussing with the EPR just doesn't sound like it's the best solution. Seems as if it's a 'shot in the dark'.

Too early to tell if an Adaptive Servo Ventilator (ASV) machine may be needed, but probably not.

More often than not, the number of centrals continues to lower during first few weeks or months of therapy, as our system gets used to breathing against pressure.

There are probably many potential causes for centrals, but in common cases where Carbon Dioxide washout is a contributor then reducing EPR or Pressure Support or turning off A-Flex tends to reduce the number of centrals.

The nice thing about EPR or A-Flex or Pressure Support is these all tend to make it easier to breathe and increase comfort. But some (a minoriy) have found that using high amounts of EPR or Pressure Support can significantly increase the number of centrals.

An average of two or three centrals per hour of sleep is widely considered nothing to be concerned about, unless the centrals are long in duration (longer than 30 or 40 seconds, I think) and result in deep desaturations in SpO2 levels. Usually the average number of central apneas per hour (the CA Index) needs to be at least 5 before health insurance companies will consider covering an ASV machine which can treat both obstructive and central apneas.

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 06-21-2015 05:46 PM by vsheline.)
06-21-2015 01:44 PM
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vsheline Offline

Advisory Members

Posts: 1,908
Joined: Jul 2012

Machine: S9 VPAP Adapt (USA Model# 36007, not better 36037 or 36067)
Mask Type: Full face mask
Mask Make & Model: F10 or SimPlus w/ 2Liners. MirageQuatro & Gecko gel pad
Humidifier: H5i
CPAP Pressure: 15 EPAP, PS 5-10
CPAP Software: ResScan

Other Comments: Marfan Syndrome, chronic bradycardia, occasional Cheyne-Stokes Respiration

Sex: Male
Location: California, USA

Post: #12
RE: Influence of EPR-Level on Central Apnea
(06-20-2015 03:04 PM)richb Wrote:  Lower overall pressure as shown on the SH graph did not improve CAs. The only thing I can think of is that I am getting CO2 washout as a result of the EPR of 4. I am reluctant to change the settings myself because I am still being monitored by the Provider of the equipment and the techs.

Since you are reluctant to temporarily lower Pressure Support to 3 or 2 yourself, you can try calling the doctor to request that it be temporarily lowered, to see if this will significantly lower your number of centrals.

If that is not feasible then my suggestion would be to simply do it yourself.

A higher amount of Pressure Support would make it easier to breathe in. The probable risks from lowering PS would be that it will be slightly less easy to breathe in, and obstructive events like RERA (Respiratory Effort Related Arousal) may worsen slightly. But a lower PS may significantly lower the number of centrals you are having and may lead to more restful sleep.

If a lower PS results in you feeling more refreshed in the morning then (at least temporarily) a lower PS is beneficial while your system adapts to therapy.

Take care,
--- Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 06-21-2015 02:47 PM by vsheline.)
06-21-2015 02:22 PM
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tedburnsIII Offline

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Post: #13
RE: Influence of EPR-Level on Central Apnea
vsheline-

Thank you for the informative posts #'s 11 & 12, above!

I am not famiiar with 'C02 washout' so do you have a definition of it that is commonly accepted?
(This post was last modified: 06-21-2015 02:50 PM by tedburnsIII.)
06-21-2015 02:49 PM
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richb Offline

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Post: #14
RE: Influence of EPR-Level on Central Apnea
My CAs have only shown up when on Bipap. I did not have them during titration or the sleep study. They are obviously associated with the treatment. I first plan to discuss changes with the techs and the Dr. I have 2 scholarly articles for reference and lots of anecdotal evidence from posters here and other sites. The first thing I would propose is a systematic reduction in the EPR to see if that changed my readings. I do not believe that I have complex apnea. The Dr also thinks that my CAs are somehow related to the machine. One of his thoughts is to change out the machine.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here: http://www.apneaboard.com/wiki/index.php...SleepyHead
06-21-2015 02:54 PM
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richb Offline

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Post: #15
RE: Influence of EPR-Level on Central Apnea
(06-21-2015 02:49 PM)tedburnsIII Wrote:  vsheline-

Thank you for the informative posts #'s 11 & 12, above!

I am not famiiar with 'C02 washout' so do you have a definition of it that is commonly accepted?

There is an article that discusses reduction of CO2 levels due to mask leaks. Search for "Air Leak during CPAP Titration as a Risk Factor for Central Apnea". I don't have enough posts to include the link.
The Idea of CO2 washout has been floated by posters on this site and has been described in other literature. The idea is that normal breathing is moderated by the brain/body measuring CO2 levels in the blood. During normal breathing a certain amount of CO2 remains in the airway and nasal passages. This CO2 is re-breathed which helps maintain the ideal level of CO2. Washout refers to the removal of this normally present CO2 and the subsequent lowering of blood CO2. The lowered blood CO2 can trigger CAs.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here: http://www.apneaboard.com/wiki/index.php...SleepyHead
06-21-2015 03:14 PM
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tedburnsIII Offline

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Post: #16
RE: Influence of EPR-Level on Central Apnea
(06-21-2015 03:14 PM)richb Wrote:  
(06-21-2015 02:49 PM)tedburnsIII Wrote:  vsheline-

Thank you for the informative posts #'s 11 & 12, above!

I am not famiiar with 'C02 washout' so do you have a definition of it that is commonly accepted?

There is an article that discusses reduction of CO2 levels due to mask leaks. Search for "Air Leak during CPAP Titration as a Risk Factor for Central Apnea". I don't have enough posts to include the link.
The Idea of CO2 washout has been floated by posters on this site and has been described in other literature. The idea is that normal breathing is moderated by the brain/body measuring CO2 levels in the blood. During normal breathing a certain amount of CO2 remains in the airway and nasal passages. This CO2 is re-breathed which helps maintain the ideal level of CO2. Washout refers to the removal of this normally present CO2 and the subsequent lowering of blood CO2. The lowered blood CO2 can trigger CAs.

Thanks for your post.

The less EPR (e.g., 1 EPR vs. 3 EPR) the less chance of C02 washout and the less chance of a central apnea? Can those conclusions be drawn if considering EPR alone without other factors?

IOW, do you agree with vsheline's comments, above (post #11)?
(This post was last modified: 06-21-2015 03:42 PM by tedburnsIII.)
06-21-2015 03:40 PM
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richb Offline

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Post: #17
RE: Influence of EPR-Level on Central Apnea
"The less EPR (e.g., 1 EPR vs. 3 EPR) the less chance of C02 washout and the less chance of a central apnea? Can those conclusions be drawn if considering EPR alone without other factors?
IOW, do you agree with vsheline's comments, above (post #11)?"
Yes I do agree. I do not have any other factors that would cause CAs. I also did not present with CAs during my sleep study or during titration. It therefore seems likely that my CAs are treatment related. Another point is that my AHI was 44 during my sleep study and there were virtually no CAs. My AHI using cpap is about 1.0 when subtracting the CAs. Including the CAs it is around 30. It is therefore reasonable to assume that the CAs are treatment related. Higher pressure alone has been implicated in CAs. Lowering my average pressure from 13 to 12 showed no improvement. Pressure might still be a factor but my first inclination is that EPR is the cause. I am trying to work with my Dr and Techs to get to the bottom of this issue. Increased CAs during cpap treatment is not a common issue. There is not much literature on the subject.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here: http://www.apneaboard.com/wiki/index.php...SleepyHead
06-21-2015 04:21 PM
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vsheline Offline

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Humidifier: H5i
CPAP Pressure: 15 EPAP, PS 5-10
CPAP Software: ResScan

Other Comments: Marfan Syndrome, chronic bradycardia, occasional Cheyne-Stokes Respiration

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Post: #18
RE: Influence of EPR-Level on Central Apnea
(06-21-2015 02:49 PM)tedburnsIII Wrote:  I am not famiiar with 'C02 washout' so do you have a definition of it that is commonly accepted?


In healthy individuals the brain regulates breathing by monitoring the level of blood Carbon Dioxide (CO2), not the level of Oxygen (O2).

Hyperventilation can wash out (expel by breathing) too much CO2, causing hypocapnea which can cause
central apneas.

https://en.wikipedia.org/?title=Hypocapnia

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 06-21-2015 05:32 PM by vsheline.)
06-21-2015 04:23 PM
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richb Offline

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Post: #19
RE: Influence of EPR-Level on Central Apnea
I want to thank the Apnea Board, its members and advisors for the wealth of information on this site. I spent quite a few hours reading previous posts regarding CAs, CO2 washout, EPR after I was surprised by the high number of CAs being reported to the Sleepyhead software. I think I can now have an intelligent discussion with my Dr and Techs involved with my case.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here: http://www.apneaboard.com/wiki/index.php...SleepyHead
06-21-2015 04:48 PM
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vsheline Offline

Advisory Members

Posts: 1,908
Joined: Jul 2012

Machine: S9 VPAP Adapt (USA Model# 36007, not better 36037 or 36067)
Mask Type: Full face mask
Mask Make & Model: F10 or SimPlus w/ 2Liners. MirageQuatro & Gecko gel pad
Humidifier: H5i
CPAP Pressure: 15 EPAP, PS 5-10
CPAP Software: ResScan

Other Comments: Marfan Syndrome, chronic bradycardia, occasional Cheyne-Stokes Respiration

Sex: Male
Location: California, USA

Post: #20
RE: Influence of EPR-Level on Central Apnea
(06-21-2015 02:54 PM)richb Wrote:  The Dr also thinks that my CAs are somehow related to the machine. One of his thoughts is to change out the machine.

In bi-level CPAP machines, the term EPR is not used. Pressure Support is the pressure difference (the amount of pressure boost) between EPAP and IPAP. EPAP + PS = IPAP

The AirCurve 10 VAuto is a fine machine, a very versatile machine. Can be set in fixed-pressure CPAP mode or S mode (bi-level synchronized to our Spontaneous breathing, meaning our natural self-initiated breathing), or VAuto mode. VAuto mode is like S mode except EPAP self-adjusts within a range, similar to the AutoSet.

The AirCurve 10 VAuto can be adjusted to behave just like an A10 Elite or an A10 AutoSet, if desired. So there is no reason to downgrade the machine if the doctor wants to try a more basic therapy mode.

If the doctor wants to switch to ASV therapy mode a machine like the AirCurve 10 ASV would be needed. Although the AirCurve 10 ASV machine has 3 modes (basic CPAP therapy mode, ASV therapy mode and ASVAuto therapy mode), the machine in ASV modes has only basic adjustability. For example, the ResMed ASV machines cannot be adjusted to behave like an AutoSet machine; it is a "one size fits most" ASV machine with relatively little adjustability.

I think the Philips Respironics System One BiPAP autoSV Advanced with Heated Tube is a far more versatile ASV machine; it has much greater adjustability in ASV mode. For example, it can be adjusted to behave like a standard PRS1 Auto, if desired.

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 06-21-2015 07:14 PM by vsheline.)
06-21-2015 05:16 PM
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