(05-04-2017, 06:06 PM)Jrw1 Wrote: 1-2) Yes, Immediately. 4 of them at a CPAP of 4; 0 @ 5;0 @ 6; 13 @ 7
So the
titration study showed CAs right away. What about the
diagnostic study--i.e. the study (or part of the study) before they slapped a CPAP mask on your face?
Thanks for also posting the titration studies' stats. It's important to note that those 13 CAs @7cm were scored in about 4.25 hours of sleep time. So while the whole AHI @7cm was 5.2, the CAI was about 3.1ish. It's high enough to raise a flag about pressure induced centrals being a potential issue, it's probably not high enough to immediately jump to a diagnosis of complex sleep apnea without data from your xPAPs.
It's also worth pointing out that on the Bi-Level titration, they didn't have you at IPAP = 11, EPAP = 7 for very long (19 minutes), and you were awake most of that time since the actual sleep time listed for 11/7 is only 2 minutes of non-rem sleep. That's why one CA at 11/7 results in a whopping AHI = 60. There's not enough data here to be useful in terms of saying whether that one CA at 11/7 is or is not important in terms of what's going on with your sleep.
Quote: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.
Can you clarify what you are saying?
Are you saying when the EPAP is restricted to 4-7 cm (using what settings?), you don't get CAs showing up in the AirCurve data, but the AHI is usually in the 4-5 range and made up of obstructive events?
Or are you saying that you have one day of data when you had the machine set so that EPAP stayed between 4 and 7 with an AHI = 4.4, all of which is obstructive.
And were those events OAs or Hs?
Quote: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.
The data you posted shows an IPAP range of 10-13, not VPAP settings of IPAP = 13, EPAP = 10. The 10/13 notation is usually used for EPAP/IPAP when you're using fixed bi-level pressures. The data makes it look like your PS = 4. That means your EPAP ranges from 6-9.
The pressure increase at the start of the night also makes it look like you may be using the ramp, with the Starting Ramp EPAP = 6, which induces a starting ramp IPAP = 10 since PS = 4. It looks like the pressures may ramp up to a Min EPAP = 6.5 or 7cm, which would induce a Min IPAP = 10.5 or 11.
Can you confirm your machine's therapeutic settings by looking at them in the clinical menu? In VPAP Auto mode, you should have the following settings:
Min EPAP (or a Min IPAP, but not both on a Resmed VPAP)
PS
Max IPAP (or Max EPAP, but not both on a Resmed VPAP)
Quote: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.
So you've been on PAP for at least 2 months. Yeah, it would be reasonable to expect that
if those CAs were going to disappear on their own, they ought to be noticeably decreasing by know.
But again, can you clarify what you mean by "I have been dancing around the EPAP 9 issue for a while."?
The VPAP Auto data for May 2 that you posted shows that your EPAP stayed well below 9cm for most of the night. Indeed, the only time the EPAP > 9 is between 3:20 and 3:40, and there is maybe one or two CAs scored during that time, but not enough to worry about. But there are two nasty cluster of CAs on the night you posted.
The first nasty cluster of CAs occurs between 1:30 and 1:45 at the beginning of the posted data. It looks to me like this is during a ramp period (judging from the way the pressure curves are increasing in a linear fashion). The EPAP when this first cluster happens is really low---as in it looks to my eyes that the EPAP stays below 7, and possibly below 6.5 for this whole cluster. If you said that you took about 15 minutes to fall asleep, I'd say this cluster was sleep transitional. But you also say:
quote='Jrw1' pid='203740' dateline='1493939888']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.And in that case, we have to consider that the CAs are real, and occurring at EPAPs that are as low as 7.0 or 7.5cm of pressure.
The second nasty cluster of CAs in the data you posted occurs just before 2:40. Again, the EPAP pressure is not exceptionally high here: During the cluster, the EPAP is around 7.0-7.5. Notably the machine is actually working on
decreasing the pressure after the pressure spike caused by what looks like a couple of OAs around 2:25.
The data for May 4 when you were using CPAP @8 for part of the night and APAP at 10-16 for the rest of the night shows a lot of pretty serious leaking going on. (Interestingly, your leaks were quite well controlled on the VPAP night. Were you using a different mask?) While only the stuff between 1:30 and 2:00 is flagged as a large leak, there's a lot of smaller leaks that are flirting with the 24 L/min "red line". Is mouth breathing an issue for you? I bring this up because in the presence of a lot of leaks, the FOT algorithm for determining whether an apnea is a CA or an OA becomes less reliable. Some of those CAs may be misclassified OAs. (or vice versa).
But assuming that the data is reasonably reliable, it looks like if you could tame the leaks, you might do better with straight CPAP rather than APAP or VPAP. In terms of the OAs and Hs, you might need a bit more pressure than 8cm, but in terms of the CAs it could be that you do better with a more constant pressure.
In looking at the titration study data that you provided, it looks to me like the best (semi)extended data came from 76 minutes of sleep with straight CPAP @5 and 6cm of pressure. You had no events of any sort during those 76 minutes, but you also had no REM sleep. They also had you at bilevel at 12/8, 13/9, and 14/10 for extended periods of time. At 14/10, the centrals were not too bad and the obstructive stuff was very well controlled and you did get some REM sleep. At 12/8, the obstructive stuff wasn't as well controlled and the total AHI was still too high. At 13/9, the central stuff was pretty pronounced. Does your report have an event table that shows when the events occurred along with a pressure graph that shows when each pressure was tried?
Finally, as someone else pointed out earlier, some people's CAs react badly in the presence of a pressure support (PS). When you used the machine as an APAP and CPAP, did you have EPR turned on or off? And if it was turned on, what setting did you use?
As for where to go from here:
Given that it's been two months and CAs are still an issue, it could indeed be that the idea of complex sleep apnea needs to be raised with the sleep doc.
But it's not a clear, slam dunk case that you need an ASV in my (nonmedical) opinion. If this were my data, I'd be inclined to think seriously about the following things:
1)
Just how much pressure is needed to get the OAs and obstructive Hs under control? If OAI + HI stays consistently below 5.0 at a given pressure setting, then there is no point using a whole lot more pressure if the additional pressure triggers a lot of CAs.
2)
Is the CA data better when you use fixed CPAP? Or fixed VPAP? If so, then the variable pressures may be something your body is having trouble dealing with. There's nothing wrong with using fixed CPAP or fixed VPAP, and some people do indeed do better without varying pressures.
3)
Is too much PS a potential cause of the CAs? The test here is to see if you can tolerate a very low PS---you could try setting PS = 0, 1, or 2 in VPAP mode and see if the number of CAs drops, stays the same, or gets worse. (This essentially changes the VPAP mode into CPAP with EPR set to 0, 1, or 2.)
4)
Is the leaking a real problem night after night, or only a periodic problem? Does switching masks or mask types help the leaks? And if it does, does controlling the leaks help bring the AHI down?
5)
Assuming the problem is complex sleep apnea, what kind of documentation does my insurance company require before authorizing a switch from bilevel to ASV? Is my current sleep doctor willing to provide that documentation?