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New to CPAP, dx'd OSA, lots of clear airway events
#1
Question 
New to CPAP, dx'd OSA, lots of clear airway events
Hello everyone!


I'm new to CPAP, have had my machine for just under a month. I had an in-lab sleep study done in summer 2019, dx'd moderate OSA. My AHI was 17.4, with a total of 46 obstructive apneas, 1 mixed apnea, 1 central apnea, and 61 hypopneas. It was originally supposed to be a split-night study, but I couldn't fall asleep fast enough, only the PSG was done.

In the time I've had my machine, my numbers have been much worse than what was seen during my sleep study. I've also had a much higher number of clear airway events rather than obstructive apneas. I had a ResMed AirFit N30i nasal mask until March 29th, and due to having a lot of issues with the mask leaking/mouth breathing, I got a ResMed F30 full face mask instead... and my AHI has gone up with the full face mask with the vast majority of the apneas being clear airway. I'm attaching the overview so you can see the trends as well as a couple of nights with the full face mask. I have played around with minimum pressures and EPR, and nothing really seems to make a difference except I feel more comfortable with a minimum pressure above 8 and EPR off.

   

I know that for a significant number of people, central apneas emerge upon initiation of CPAP therapy and often resolve on their own. However, my AHI remains very high- typically between 50 and 100 most nights- and while I feel terrible without the machine, I think I might feel even worse when I use it!

ResMed AirSense 10 Autoset/APAP mode
Current settings:
Min Pressure 8.8
Max Pressure 20
Ramp Off
EPR turned off a couple of days ago with no major change in stats.

In case it's relevant, I have a complex medical history. I'm 35, male, with a history of the genetic connective tissue disorder Ehlers-Danlos Syndrome and dysautonomia/POTS, with a history of upper airway collapse that almost required a tracheostomy last year. I'm a weightlifter and have a BMI of 37. I moved to Mexico from the US last year (2 weeks after my sleep study), so it's been a bit of a challenge getting all my health issues under control... the pulmonologist who wrote me the script for the CPAP last month charges $150-200 USD for a CPAP calibration.

I would appreciate any thoughts or advice, and please let me know if any other info would be helpful. I did read as much about formatting, wiki articles, etc. as I could before posting. Thank you, and I hope you're all having a good weekend.

ac


Attached Files Thumbnail(s)
       
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#2
RE: New to CPAP, dx'd OSA, lots of clear airway events
Hi assistcontrol and welcome to Apnea Board.

The OSCAR charts show you really are not getting good therapy from this APAP. This is a big understatement I'd think.

OK, let's address a few things. When you changed to the F30, did you change to the full face setting in the machine mask settings? This is minor compared to what you're dealing with, but I needed to get that aspect on the post.

Next, do you have a detailed copy of the PSG sleep study? If not, unless it's difficult with you now being in Mexico, you may want to request that report from the issuing doctor. If you can obtain it, I suggest posting all pages in redacted for personal info format on this thread. You have a very high CA count that should have reduced if these were treatment emergent. This makes me think they are not, and if that is the case, the APAP cannot help. You will then need to get a ResMed AirCurve ASV like what I have.

Let's see what your answer is regarding the PSG report, and we'll go from there. Best wishes to you on this.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: New to CPAP, dx'd OSA, lots of clear airway events
Hi Dave,

Thanks for the response and the welcome! I attached the PSG. I'm trying to make the APAP work, but I'm a little worried that I might have mixed or complex apnea and need to buy an AirCurve, as you mentioned. It's all coming out of pocket, which sucks, but I'm willing to do whatever it takes not to feel like a zombie and get this under control.

As far as your question about the mask setting, yes, I have always made sure the setting matches up with the mask used, so it's been on full face.

Thanks again for any thoughts you can provide!
ac


Attached Files
.pdf   PSG redacted.pdf (Size: 341.72 KB / Downloads: 19)
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#4
RE: New to CPAP, dx'd OSA, lots of clear airway events
Very welcome.

OK, copy on the full face mask setting. This PSG report has the same stats you mentioned in your initial post with more details. Not doubting your accuracy, but it's always good to see it off the PSG.

Very low counts on PSG on events except Hypopnea, and now high CA shows up on the APAP. Let's see what others comment on this, but I'm thinking those Hypopneas on the PSG maybe could have been CA based, but of less than the 10 second duration. Now on the APAP, these get the CA flag not the H for Hypopnea. Caveat is this: it's a maybe correct analysis on my part. There's also the aspect of CA drastically increasing after mask switches if I recall correct. Does CA go back down drastically if you were to switch back to the N30i and edit mask settings accordingly?

Hold tight while your thread attracts the gurus attention. Do what you feel is best for maximizing comfort for the time being. Trust me, when this gets gurus involved, we're right around the corner to getting an answer.

If the data is there from your next nights use, post here with comments to answer "How do you feel?". Unfortunately, I think I already know that answer as I've been in similar status too. BTW I suggest keeping everything here assuming it pertains to getting your therapy in shape. Stay safe n sane if at all possible.

BTW be certain to keep EPR off right now is what I'd suggest. If these are true CA, pressure swings from EPR will make this even worse.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: New to CPAP, dx'd OSA, lots of clear airway events
Welcome to the Apnea Board.

1. Your PSG did not show significant central or mixed apnea.  This is very important.
2. you are tucking your chin, that is what the clustering of your obstructive events.
3. You have a ResMed device, your Flow Limits are VERY important as they are the primary driver of pressure.  
4. Your exhale time is just over your inhale time. Normal exhale time is close to double inhale time
5. repost your 4 Apr chart showing your Flow Limit Chart, you can shrink leak rate and snore to fit on the screenprint
6. Post a 5 min zoomed view of the revised charts showing the central apneas from (on 2 different screen prints) 2 different CA clusters.


Analysis: 
You have been using your APAP for just 3 weeks. Your PSG did not indicate you had any significant central apnea. Thus your apnea is treatment-emergent.  The most common cause is your APA has increased the efficiency of your breathing, this is both good and, I think, in your case bad. Good because you have increased the proliferation of oxygen throughout your system. Bad because it has also washed out more CO2 than desired, in your case I think, to below your apneic threshold resulting in central apneas.  The waveforms in the CA clusters may give evidence of this.  Read the Wiki article on Treatment-Emergent Central Apnea.  You CAI lowered in response to a reduction of EPR thus the suggestion to turn it off. EPR plays a major role in the increased efficiency of your breathing.

The chin tucking is something that no amount of pressure can overcome and your pressure is rising in an attempt to thus the suggestion of a max pressure of 9.  A soft cervical collar is the tool to prevent this so read the collar link in my signature.

Treatment-Emergent Central Apnea is commonly treated with time, 2-3 months, though this may not be so in your case, ASV, the most recognized method for the treatment of Central Apnea, or a process that alters your mask and causes you to rebreathe a small amount of your exhaled air called EERS or Enhanced Exp[iratoty Rebreathing System.  This is why I want to see the closeups of your CA Clusters.



Actions
1. Turn your EPR Off.  
2. Set your max pressure = 9
3. new charts as per the above discussion

Thanks
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
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Dealing with a DME
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: New to CPAP, dx'd OSA, lots of clear airway events
I'll defer to bonjour. Meet one of the gurus.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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