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New AirCurve 10, same results as AirSense 10
#1
I kinda feel like my sleep center is really only interested in prescribing sleep studies and could use some community feedback on where I'm at.

Sleep study 1 Split study, no CPAP, never fell asleep. If They collected any real data of value, they never shared it with me.
Sleep Study 2 resulted in a CPAP Rx 7, but the study did note 13 centrals in the hour they were at that level. Some how they called it an AHI of 5.2 though.
Sleep Study 3 resulted in a Bi-level Rx of 10/14. Tech mentioned in the morning that I had a central come out of nowhere, so he did try ASV, which woke me up. I'm not sure I fell back asleep and no mention of that in the followup.

After study 2, I got an Airsense 10. I quickly figured out 7 was nowhere near right. Put it in automode, and eventually settled on 12 with an EPR of 3. Very close to what the 2nd study determined @ 10/14.

I'm into my 2nd night with an AirCurve 10. 1st night, I put the machine into autoset with an EPAP min of 6 and PS of 4. According to sleepy head the 90% mark was an EPAP/IPAP ~8/12. AHI was around 5 with some snores, but centrals being most of the story. I've gotten similar results with the AirSense set to 13 and and EPR of 3. Last night for giggles, I figured I'd try 8/13, and got an AHI of 7. Snores were pretty good, but there was some obstruction, so EPAP needs to come up. I can't tolerate 9 as the AHI goes through the roof, so 10 it is.

I think I'm on board now with the study determine result of 10/14, so I expect the story to shift over to centrals. If the results are similar to the AirSense 10 set to 10/13, then I can expect an AHI of between 3-7.   I've ordered a CMS50i to attempt to quantify the impact of the centrals. I'm aware of the AHI 5 watermark, but looking at my data they cluster around the first hour or 2 of sleep then drop to 2-3 an hour which averages it out. My AHI curve in sleepy head resembles 2 peaks with a valley of around 2 from 3-5AM. i.e I start out terrible, and finish bad. Perhaps it's SWJ, but both data sets are at least an hour of it.

I guess my question is, does the AirCurve 10 really do anything for me that the AirSense wasn't already doing? If the story is centrals that do actually raise my heart rate and drop my Sp02, do I just need to stand on a chair for an ASV? I'm sure that buys me a 4th sleep study too. This process really pulls people through a knot hole.

I have scheduled an appointment next week with a pulmonologist to discuss some of this. The sleep center has some doc that I've never seen (signs the Rx) and the followups are with a NP that really is kinda irrelevant to the whole thing.  

Thanks,
Jay
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#2
When a PAPer is reporting problems with centrals while on xPAP, the important questions come down to these:

1) Did the diagnostic test (the one without xPAP) show any centrals?

2) How many centrals are we talking about and at what pressure(s) do they start?

3) Can the OSA stuff (the OAs, the Hs, and most of the snoring) properly be treated at a pressure level that is below that needed to trigger the CAs?

4) Does the number of CAs go up, down, or stay about the same after a few weeks on xPAP therapy?


Here's the thing you need to be aware of:  Some people's bodies do have a bit of a problem regulating the CO2 levels in the blood when they are first put on xPAP therapy for obstructive sleep apnea. And the result of not properly regulating the CO2 level in the blood leads to the emergence of central apneas.  Essentially, you only inhale when the CO2 level in the blood is high enough for your brain to tell the lungs and diaphragm, "Inhale Now".  When the brain misinterprets the CO2 level or if the CPAP washes out too much CO2, the brain doesn't send the signal to "Inhale Now" and you don't take a breath when you are supposed to take one.

The problem with pressure-induced centrals seems to be aggravated by the addition of pressure.  In other words, the higher the pressure setting on the xPAP machine, the more likely pressure-induced centrals are to occur.   In some people, the CAs can be completely controlled simply by limiting the max pressure the machine is allowed to use. Pressures over 10 cm are more likely to cause problems with CAs, and hence if the OSA stuff is controlled with a pressure less than 10, the usual fix is to just use only enough pressure to control the OSA stuff. (A few people have trouble with pressure-induced centrals at lower pressures; other people find that their pressure-induced centrals might only be a problem if the pressure is really high--like above 15cm.)

Sometimes the problem with pressure induced centrals is self-limiting: The body takes a while to figure out the whole xPAP thing, but after a few weeks it *does* adapt and by that point many people who had some issues with pressure-induced CAs notice that the number (and length) of the CAs in their data starts to decrease.  And after a few more weeks of using their machine, the CAs essentially disappear---in other words, the person gets some isolated ones here and there, but the number of them is small and the overall AHI is consistently less than 5 (and often significantly less than 5) and the person reports feeling and functioning better in the daytime.  The fact that many people's bodies take a while to adjust and that the number of CAs recorded often goes down with continuing to use the machine is a major part of why many sleep docs and most insurance companies don't just immediately switch an xPAP newbie from a CPAP/APAP or BiPAP/VPAP to an ASV machine at the first sign of pressure-induced centrals.  Other reasons for not immediately switching include the cost of an ASV and the fact that learning how to sleep with an ASV can be much harder than learning how to sleep with a CPAP/APAP or BiPAP/VPAP due to the drastic pressure increases used to "trigger" inhalations as a way to prevent the central apneas. 

Given that you are seeing some centrals and your overall AHI is sometimes in the 5-10 range instead of the 0-5 range, it's worth watching the centrals, but it is also worth giving your body some time to adjust to the AirCurve.  And if you jumped from the AirSense to the AirCurve right away because of the centrals, then it really may be best to be patient for 2-4 more weeks of using the AirCurve with your current settings.

It's also worth mentioning that some people find that frequent changes to the therapeutic settings aggravates their problems with centrals.   In your case, two important questions to ask are:

A) How long have you been using xPAP?  (In your case, that means both the time you used the AirSense and the time you've used the AirCurve.)

B) How frequently do you change the settings?  What is the longest you've used a particular setting?
Questions about SleepyHead?
See my Guide to SleepyHead
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#3
(05-04-2017, 01:45 PM)Jrw1 Wrote: I think I'm on board now with the study determine result of 10/14, so I expect the story to shift over to centrals. If the results are similar to the AirSense 10 set to 10/13, then I can expect an AHI of between 3-7.   I've ordered a CMS50i to attempt to quantify the impact of the centrals. I'm aware of the AHI 5 watermark, but looking at my data they cluster around the first hour or 2 of sleep then drop to 2-3 an hour which averages it out. My AHI curve in sleepy head resembles 2 peaks with a valley of around 2 from 3-5AM. i.e I start out terrible, and finish bad. Perhaps it's SWJ, but both data sets are at least an hour of it.

That "AHI graph" is kind of useless in my opinion.   You can tell a lot more by looking at the events table.   If there's serious clustering of events (like it sounds like), they'll pop up as peaks in the AHI graph, but they'll show up as dense clusters of tick marks in the event table at the top of the SleepyHead data.

What you've left out of your description of your data that IS IMPORTANT are the following things:

1) Are the events in the clusters OAs? Hs? or CAs?  

2) How long do you estimate it takes you to get soundly asleep at the beginning of the night?

3) How soundly do you think you are asleep during the last hour of sleep?

If there are a bunch of CAs clustered near the beginning of the night and you know it takes you 30-40 minutes or more to fall asleep, then those CAs may well be SWJ. And the last of them may be normal sleep transition CAs that would not be scored on an in-lab sleep test.

If there are a bunch of OAs or OAs mixed with Hs near the end of the night and you're pretty sure you were sound asleep at the time, they could be a nasty REM-related cluster.  As the night progresses, the REM cycles get longer and longer.  Hence the last REM cycle is usually the longest and it frequently ends shortly before you wake up for the morning.

So ...

What do your OAI, your HI, and your CAI look like for a typical night?   And can you post a SleepyHead shot showing the following graphs?
  • The event table at the top of the detailed data
  • The flow rate graph
  • The pressure graph (NOT the pressure at mask graph)
  • The leak graph
If you can get a shot that also includes the snore graph, so much the better.  But if you have to make the four requested graphs too small to squish the snore graph into the screenshot, then don't bother.
Questions about SleepyHead?
See my Guide to SleepyHead
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#4
Based on what has been presented, I think there is a fairly high likelyhood of complex apnea, which involves both obstructive and central apnea and hypopnea. Robysue's information is all spot-on with regard to complex apnea patients generally showing higher event rates at higher pressure. Pressure support also seems to greatly aggravate the situation. This is ironic, because when sleep centers see centrals in a sleep study, it seems the first thing they do is prescribe bilevel with PS of 4.0.

First, I think you have been given a machine that your doctor probably doesn't expect to work, but it has to be tried (and failed) in order to qualify for ASV. In my experience, people with complex apnea do best with simple fixed CPAP pressure and no pressure support or EPR. I would expect that a fixed pressure of 8 might work out as good as can be expected. On the other hand, if you continue to have high AHI and a lot of centrals, you're going to end up back in a sleep lab to try ASV. This raises a couple questions; how is your insurance situation, and do you want to optimize what you have instead?
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#5
(05-04-2017, 02:54 PM)robysue Wrote: ...

1) Did the diagnostic test (the one without xPAP) show any centrals?

2) How many centrals are we talking about and at what pressure(s) do they start?

3) Can the OSA stuff (the OAs, the Hs, and most of the snoring) properly be treated at a pressure level that is below that needed to trigger the CAs?

4) Does the number of CAs go up, down, or stay about the same after a few weeks on xPAP therapy?


...

A) How long have you been using xPAP?  (In your case, that means both the time you used the AirSense and the time you've used the AirCurve.)

B) How frequently do you change the settings?  What is the longest you've used a particular setting?

1-2) Yes, Immediately. 4 of them at a CPAP of 4; 0 @ 5;0 @ 6; 13 @ 7
3) I'll post some sleepy head data in a sec, but I had a clean report from a centrals perspective with 4-7 In terms of EPAP awhile back. The AHI was 4.4 all Obstructive. 
4) I've stayed at 10/13 for a bit. I'd have to back track through sleepy head, but at least 3 weeks. I sit around AHI 5-7, only got the AirCurve Tuesday.
A-B) February. I however have  been dancing around the EPAP 9 issue for awhile. The changes were minor as the machine has been left to auto adjust within a narrow range and the results don't change as long as 9 is not in the range.
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#6
(05-04-2017, 03:08 PM)robysue Wrote:
(05-04-2017, 01:45 PM)Jrw1 Wrote: I think I'm on board now with the study determine result of 10/14, so I expect the story to shift over to centrals. If the results are similar to the AirSense 10 set to 10/13, then I can expect an AHI of between 3-7.   I've ordered a CMS50i to attempt to quantify the impact of the centrals. I'm aware of the AHI 5 watermark, but looking at my data they cluster around the first hour or 2 of sleep then drop to 2-3 an hour which averages it out. My AHI curve in sleepy head resembles 2 peaks with a valley of around 2 from 3-5AM. i.e I start out terrible, and finish bad. Perhaps it's SWJ, but both data sets are at least an hour of it.

That "AHI graph" is kind of useless in my opinion.   You can tell a lot more by looking at the events table.   If there's serious clustering of events (like it sounds like), they'll pop up as peaks in the AHI graph, but they'll show up as dense clusters of tick marks in the event table at the top of the SleepyHead data.

What you've left out of your description of your data that IS IMPORTANT are the following things:

1) Are the events in the clusters OAs? Hs? or CAs?  
CAs are what I'm primarily concerned about in the OP. Night 1 with auto Bi-Pap has 7 OA, and 1 H. In all cases the machine adjusted up to around 8/12 and resolved it.

2) How long do you estimate it takes you to get soundly asleep at the beginning of the night?
I'm out the second my head hits the pillow and I find a spot for the hose and fix any leaks.

3) How soundly do you think you are asleep during the last hour of sleep?
Like a rock most of the time. I'm usually wake up to sounds in the house between 630 and 730 (dog etc).

If there are a bunch of CAs clustered near the beginning of the night and you know it takes you 30-40 minutes or more to fall asleep, then those CAs may well be SWJ. And the last of them may be normal sleep transition CAs that would not be scored on an in-lab sleep test.

If there are a bunch of OAs or OAs mixed with Hs near the end of the night and you're pretty sure you were sound asleep at the time, they could be a nasty REM-related cluster.  As the night progresses, the REM cycles get longer and longer.  Hence the last REM cycle is usually the longest and it frequently ends shortly before you wake up for the morning.

So ...

What do your OAI, your HI, and your CAI look like for a typical night?   And can you post a SleepyHead shot showing the following graphs?
  • The event table at the top of the detailed data
  • The flow rate graph
  • The pressure graph (NOT the pressure at mask graph)
  • The leak graph
If you can get a shot that also includes the snore graph, so much the better.  But if you have to make the four requested graphs too small to squish the snore graph into the screenshot, then don't bother.

For whatever reason I have never been able to get sleepyhead to display worth a crap on my laptop. It has a 4K display. Usually I just print the daily reports. Let me see if I can rearrange that to fit on one page, and I'll scan it and post in a sec.

(05-04-2017, 04:01 PM)Sleeprider Wrote: ...This raises a couple questions; how is your insurance situation, and do you want to optimize what you have instead?

I'm for whatever works. Insurance is no issue. I hit max out of pocket in Feb.
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#7
See if this works...


Attached Files Thumbnail(s)
   
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#8
Sleep studies...


Attached Files Thumbnail(s)
   
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#9
...If PS or Bi-Level is bad for centrals, would  it be worth setting that to 0 tonight and see how it goes? I'm thinking 10-16 auto CPAP.
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#10
Last night I started at CPAP 8, and woke up about 0430 to find the mask off and lying on the pillow. I then reconfigured the machine to ACPAP 10-16. Pretty much tells the story. Centrals are better at 8, but OA and snoring takes place. In APAP the machine ramps up immediately to get the flow up, but centrals are happening. It tries to lower back down to 10, but the effect on the centrals is negligible.

http://imgur.com/a/OLsZx

It would appear at least in my case that I turn in a better result with Auto Bi-PAP PS of 4
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