Please Review The Data & Give Recommendations

[Hojo]

My AHI wasn't bad last night, essentially it was 'treated' but I have good nights, then I have horrible nights (all central).  Sleeprider and I have been hitting our head against the wall (at least I have been) trying to figure out my high respirator rate while on CPAP.  I'm thinking I am one of those that doesn't tolerate the constant pressure and I'm working too hard trying to exhale. 

When I had my ASV titration the only info I could get out of the study was I did well and my respiratory rate was fine, only going up to 16 for a a bit.  That is a far cry from 25-30 I usually experience on CPAP.  I also felt better when I had my BiPAP titration study (better than while on CPAP) as the pressure would go down.  The only problem I had was the BiPAP didn't kick in as well for all of my centrals.

I called the doctors office and the nurse called me right back, the order is being put in for the ASV, I can't wait!

[Fixit50]

In your case if I understand matters, you’ve been diagnosed with central sleep apnea.  If so, the ASV is the only device that will treat this disorder so as others have suggested, its very good that you’re on the way to getting your ASV.  
I get the same funny looking breathing waveforms that you do and when it happens my breathing rate skyrockets right to 50.  I am suspicious at least in my case that the rapid waveform and respiration rates are an artifact of the way the machine measures things that is excited by obstructive flow limits.  In my case I can virtually eliminate the strange looking waveform and the accompanying high respiration rate (and high pressures too) by wearing a chin strap or a mouth guard to keep my mouth closed.  What I think is happening here, that is in my case, and without the mouth guard or chin strap, is that the mouth opens, chin falls back and in the classic way, the air channel is obstructed resulting in flow limits and rapid short interruptions that generate pulses the machine thinks are rapid breaths.  Keep the mouth closed and the whole phenomena goes away or is greatly reduced (in my case).  Do you know if your ASV will be a ResMed?  If so, it will be informative to see if you still have these funny waveforms and high respiration rates logged by the ASV.  I hope you can follow up with us on that point.

[Fixit50]

Also, I have a question. I am sometimes annoyed by the pulsating effect that EPR has at lower pressures like 7-9 unless I’m asleep. I was thinking since EPR is only a difference of 3, that the whole effect could be much worse with a BiPAP since the pressure difference is much greater with a BiPAP. When you had your BiPAP study, did you find the change in pressure when inhaling vs exhaling to be annoying?

[Fixit50]

One more thing.  I’m certainly no expert on these matters, but from what I’ve read, I have the impression that Central Sleep Apnea is most frequently secondary to some other condition.  In your case there doesn’t seem to be an underlying medical condition responsible for your Centrals.  Your case is particularly perplexing since your AirSense has detected CSR which is most often associated with heart problems which you don’t seem to have.  Do you live at high altitude?  This is another thing that is noted to result in short cycle CSR and CSA in the absence of heart issues.  You might find this link informative:
https://www.sleepapnea.org/learn/sleep-a...eep-apnea/
In any case, I would suggest you ask your doctor about underlying causes to your CSA.  If your doctor says its idiopathic CSA (no known cause) I would make sure he/she has taken steps to rule out the known causes of CSA.  I don’t think there is any other way to declare that it is idiopathic.  I would like to hear what your doctor has to say about this.

[Hojo]

In your case if I understand matters, you’ve been diagnosed with central sleep apnea.  If so, the ASV is the only device that will treat this disorder so as others have suggested, its very good that you’re on the way to getting your ASV.  
I get the same funny looking breathing waveforms that you do and when it happens my breathing rate skyrockets right to 50.  I am suspicious at least in my case that the rapid waveform and respiration rates are an artifact of the way the machine measures things that is excited by obstructive flow limits.  In my case I can virtually eliminate the strange looking waveform and the accompanying high respiration rate (and high pressures too) by wearing a chin strap or a mouth guard to keep my mouth closed.  What I think is happening here, that is in my case, and without the mouth guard or chin strap, is that the mouth opens, chin falls back and in the classic way, the air channel is obstructed resulting in flow limits and rapid short interruptions that generate pulses the machine thinks are rapid breaths.  Keep the mouth closed and the whole phenomena goes away or is greatly reduced (in my case).  Do you know if your ASV will be a ResMed?  If so, it will be informative to see if you still have these funny waveforms and high respiration rates logged by the ASV.  I hope you can follow up with us on that point.

Without being hooked up to monitor my chest movement, it is probably to be 100% certain if the breathing pattern is real or artifacts.  I'm leaning towards the breathing waveform to be fairly accurate; it represents how I feel in the morning, and when I had a problem with the filter, it seemed to pick up on the panting I was experiencing. 

I have worn a chin strap with no changes in breathing rate, I'm now wearing a cervical collar to keep my neck in line.  I didn't have OS events during my study but I do have them with the FFM and I believe it is having to pull on the straps on the lower part of my head to prevent leaks, which then pulls my chin/neck downwards.  The moment I put the collar on my OS events went to 0, even with the CPAP at 4.

My DME is pro ResMed so I'm confident I will have the ResMed, if not, they will be told to get me one, I'm pro ResMed.

Also, I have a question.  I am sometimes annoyed by the pulsating effect that EPR has at lower pressures like 7-9 unless I’m asleep.  I was thinking since EPR is only a difference of 3, that the whole effect could be much worse with a BiPAP since the pressure difference is much greater with a BiPAP.  When you had your BiPAP study, did you find the change in pressure when inhaling vs exhaling to be annoying?

I loved the BiPAP study, I thought I had a great night as far as breathing was concerned.  What I didn't know was the number of CA events I had all night, BiPAP simply couldn't fix it which is what we were expecting and so the doctor had in the 'results' to to put in an order for an ASV titration study. 

Having the BiPAP pressure drop on expiration for me was a godsend, I'm starting to see a trend that besides not breathing, having a machine that keeps me from exhaling all of my normal volume doesn't bode well.  I can't proove it, but I know that the moment I put on CPAP I feel overwhelmed with pressure on expiration, even at 4.

One more thing.  I’m certainly no expert on these matters, but from what I’ve read, I have the impression that Central Sleep Apnea is most frequently secondary to some other condition.  In your case there doesn’t seem to be an underlying medical condition responsible for your Centrals.  Your case is particularly perplexing since your AirSense has detected CSR which is most often associated with heart problems which you don’t seem to have.  Do you live at high altitude?  This is another thing that is noted to result in short cycle CSR and CSA in the absence of heart issues.  You might find this link informative:
https://www.sleepapnea.org/learn/sleep-a...eep-apnea/
In any case, I would suggest you ask your doctor about underlying causes to your CSA.  If your doctor says its idiopathic CSR (no known cause) I would make sure he/she has taken steps to rule out the known causes of CSR.  I don’t think there is any other way to declare that it is idiopathic.  I would like to hear what your doctor has to say about this.

Yep, my condition is strange, no doubt about it.  My doctor doesn't believe it is true Cheyne-Stokes Respiration because if it were, I would have it during the day as well, rather than just a here and there on sporadic nights.   I also don't fit the mold for having central apnea, not just 10 seconds here and there, but 30, lots of times 40, and many times 50 seconds at a time.

[Sleeprider]

Hojo, you are a success story already as you approach the solution to this problem. Your willingness to share it on the forum ultimately helps many others understand problems they may be having. We have been frustrated trying to "fix" the problems, only to have a good result followed by the same old high respiration rate and centrals. The patterns you shared with me were something I had no experience with, and I'm so glad you found a doctor that shared curiosity to investigate, and knowledge to find a solution with much better tools than we have on the forum. Your case exceeded my willingness to continue guessing, so I know it wasn't easy, and yet you stuck with it. Well done!

Fixit50, I think the pulsating you are feeling is FOT, not EPR. I share your curiosity to see how Hojo responds to the ASV, and am hopeful it will resolve these complex and sometimes irrational events.

[Hojo]

Thank you again Sleeprider for all of your help and sticking this through with me,but it doesn't end here...now I'm going to have to start understanding all the terminology for the settings and how to best fine tune it.  I'm guessing it will take a week or more to get the machine.

[Fixit50]

Hojo:  Thanks for the clarification and information in you post #95 above.  Based on what you said, we may have similar looking breathing waveforms but they don’t seem to behave the same way to changes.  I understand when you did your ASV study that your respiration rate was normal.  How about for the BiPAP study?  Was your respiration rate normal during that study?
Sleeprider:  In your post #96, what do you mean by FOT?  I’m not familiar with that term.

[Sleeprider]

Forced Oscillation Technique (FOT) is Resmed's method for determining whether an apnea is obstructive or central (clear airway). It is a rapid pulsing of air pressure (1-cm peak to peak at 4 Hz) that is reflected or absorbed by the airway, and interpreted by the machine's sensors. Some people like me never notice it, while others describe it like a jackhammer. It is immediately visible on your Sleepyhead mask pressure charts during any apnea event.

[Hojo]

Hojo:    I understand when you did your ASV study that your respiration rate was normal.  How about for the BiPAP study?  Was your respiration rate normal during that study?

Unfortunately I did not alert them of my concern of my respiratory rate prior to the BiPAP study and I do not see any info from the print out I was able to get (2 weeks after the study). 

While getting prepped for the ASV titration study we were discussing the machine and I mentioned my high resp rate and that I would be curious to see what the machine would do during the apnea events; would the machine try to give me what should be a normal respiratory rate or mimic what it had been seeing my most recent RR; a RR of 25-30. 

I don't know the average nor the 95% of my respiratory rate seen during the ASV study, but the way it was described to me; 'the highest rate seen was 16' and 'you did very well', along with I how felt upon waking up, led me to believe that the ASV machine allowed me to breath at a normal rate (I don't breath fast during the day, on the contrary, I have a very low RR and have deep sighs), so why do I have such a high RR while on CPAP???

Based on this 'observation' and the way I feel while trying to exhale with CPAP, I'm thinking that I need something that allows me to exhale more easily (I'm not heavy).  I do not know how low the pressure went while on ASV during the exhale mode, but what I can say is that it was very easy for me to exhale and was so much more comfortable, I don't feel that way while on CPAP.  Hence, I am postulating that CPAP (pressure during exhalation) is the cause of my high RR, and certainly, ASV is needed to take care of the CA events.

I am just now starting to read up on the ASV machine and it appears what I will like is ASVAuto Mode where the EPAP is only needed to maintain an open airway, and since I don't have OA per say, the ASVAuto mode will give me the most comfortable setting.