New APAP User - Looking for Help

[hawkinCO]

Hi all - I'm relatively new to APAP therapy and have been lurking around here looking for the best way forward before starting on APAP. Was strongly considering just buying an ASV vs failing APAP, then doing a sleep study titration and either ending up on biPAP or ASV. I had a home sleep study performed in August, and started on APAP in early Sept. and was diagnosed with moderate Central apnea with an AHI of 19.1. My obstructive was pretty low with an AHI of 0.6. What was scary was that I was showing desats for a pretty decent amount of time. My lowest was 86%, but spent 35% of the time <90% and Cheyne-Stokes respirations showed up at the beginning of the night for 30 min. Haven't seen them show up in Sleepyhead though. 

Anyhow, I started off on the APAP and had my numbers weren't bad but still wasn't feeling great. Often my AHI was < 1.5 and was using the Dreamwear FFM. The Dreamwear started making the underside of my nose pretty sore so switched to the F20 FFM. My AHI went to >5 for a few nights with last night showing the best night on the F20. 

I guess I'm looking for any advice here. Do I need to go in for a BiPAP/ASV or will APAP suffice with different/better settings? I noticed flow limits showing up in my charts so have toyed with pressure a bit. Seems like the machine wants to counter those with more pressure, but even at 15.6 (max I was tolerating when first starting), they seem to still be there or even worse than at low pressure. I've toyed a little with EPR at off, 2 and 3 with not a lot of differences noticed with the 2 and 3. I'm trying to bump my pressure up a little at a time to get to the 10-11 range since that was around my 95% with the Dreamwear. However that seems to be a lot higher now as the higher pressures during apneas and flow limitations don't seem to be countering them.

I've attached some sleephyead plots. The first was with the Dreamwear FFM:
     

The second is the full view from last night:
     

Third was a Central that was flagged although not sure if it's considered real or not:
     

Then I have one that is a little zoomed out and shows something similar to Cheyne-Stokes in terms of a waxing/waning pattern, so not sure if this is something to worry about:
   

The last one shows my flow limit from last night:
   

Thanks in advance, looking forward to having some better nights and not being so foggy during the day.

[sheepless]

we can spend a lot of time analyzing your charts but to me it's as simple as this: you were dx'ed with moderate central sleep apnea and should not have been rx'ed an apap. you need an asv for central apnea and possible periodic breathing.

in 1987 I was dx'ed with moderate ca but cpap was not widely available at the time so it wasn't until 2016 when my home test produced an almost equal number of ca and oa I was dx'ed with severe obstructive apnea and rx'ed an apap. apap brought my ahi down from 72.4 to 5 - 6 so it did reduce ca as well as oa, something that no one has been able to explain to me. still, I continued to feel sick and tired after a year and a half so I bought a used asv. no more ca or periodic breathing. very few oa and h. always under 5 ahi and usually under 1.

seems like some form of incompetence to have put you on apap, but probably more likely driven entirely by insurance.

[hawkinCO]

Thanks sheepless. Definitely driven by insurance and from what I could tell from this forum was I probably needed an ASV, but my numbers improved on APAP similarly to yours. So I thought maybe it was working as intended. 

Any idea of how long I need to keep trying the APAP before reaching out to my GP and sleep doc saying this just isn't working to try to get the titration with an ASV? It's only been 3 weeks so I don't want to go to them and have it seem like I have jumped to a conclusion for them... Or is it acceptable to say, "Hey, this isn't working and here are the charts to show that."

[sheepless]

as you probably know pressure induced ca is not uncommon so it's not unusual for docs to want to give it some time to see if the ca settles down. you, however, were diagnosed with ca so that shouldn't be the method to their madness. if you have a 30 day follow up, don't hesitate to complain / describe your concern with sleepyhead charts to back you up. also, try to show your concerns with resscan if you can because docs are more familiar with it. punctuate your description with reports about how you feel. if you don't have a 30 day follow up scheduled, make an appointment for a time after you have at least 30 days under your belt. why wait? it doesn't get much more clear cut than a ca diagnosis.

looking again at your charts I see you have good ahi's so insurance will very likely reject asv. they kind of have a point so it becomes all about how you feel and if you feel lousy how well you can convince them of that. docs follow insurance dictates unless we push them and tell them we want relief even if it's completely out of pocket. sometimes docs can make a case independent of the low ahi that some insurance will accept. otherwise, it'll be up to you to decide how far you want to take it without insurance.

[Sleeprider]

The problem is that your AHI is less than 2.0 with CPAP and that's not going to get an ASV machine. Although unexpected, your results look pretty good, and I suspect they will be better with lower EPR (1) and a maximum pressure of 12. In spite of the diagnosis, the insurance trials CPAP, and in your case it worked, based on this example. My experience is that with a Dx of central apnea, your results will be inconsistent, but at this point you're looking pretty good, other than respiration rate being on the high side of normal.

[sheepless]

I'm not picking an argument here sleeprider. I defer to your superior knowledge and experience. I mention to learn:

1. I agree that mixed apnea produces inconsistent results. I'm not so sure this is (as?) true for predominant central apnea.

2. if the OP is not feeling well, it's harder to say it's working.

[Sleeprider]

I'm not picking an argument here sleeprider.  I defer to your superior knowledge and experience.  I mention to learn:  

1.  I agree that mixed apnea produces inconsistent results.  I'm not so sure this is (as?) true for predominant central apnea.

2.  if the OP is not feeling well, it's harder to say it's working.

You're welcome to disagree, and I don't have all the answers.  I would have expected much higher CA with CPAP, especially with the EPR set at 2.  I'm surprised give the Dx that AHI is this low.

How one feels is what it's all about.  Spy Car had low AHI but experienced life-changing results on ASV.  His story is worth reading, because he got insurance coverage for ASV in spite of relatively acceptable results on CPAP. http://www.apneaboard.com/forums/search....9aa5ba5221

[hawkinCO]

Thanks for the inputs Sleeprider. I'll give the lower max pressure of 12 and a lower EPR a shot and see if anything improves.  I don't know if not feeling like it's improved is that I've only done the therapy for a few weeks and am still adjusting or if it's the flow limitations where I'm getting desaturations of any significance. My first night my AHI was 1.8 and was pretty excited to see that until I opened sleepyhead and saw a bunch of clusters of hypopneas and flow limitations where I started wondering if I still wasn't getting what I needed. 

I know you all have seen all sorts of experiences on here, so if everything is looking as it should, then I'll press on with the APAP and see if anything changes. In the meantime I'll read up on Spy Car's (excellent) adventure. As much as I thought I had read about centrals and ASV on this forum the past month somehow I don't think I came across the posts. So thanks for sharing.

I appreciate the advice!

[Walla Walla]

Along with Sleeprider's advice you might want to try a soft cervical collar to see if it helps with the flow limitations and Hypopneas. Not sure if it'll help but if the cause of the flow limitations is positional due to your chin dropping down than it's a cheap fix. You had 3 flareups of flow limitations and not much the other times. So I'm guessing it's either your chin dropping or rolling to your back that's causing it.

[hawkinCO]

Thanks Walla, I'll give one a shot and see if that helps.