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[Pressure] New user getting central apneas
#1
Question 
New user getting central apneas
Hi, I am 45, Male, BMI 25.  I have snored and had trouble sleeping (insomnia, frequent waking, sleep paralysis) since I was a teenager.

I was diagnosed with Mild Obstructive Sleep Apnea (AHI 8.1) in December 2019 (sleep study summary is in following post).
The next step with my sleep doctor was to do a titration study, but I was unhappy with the sleep clinic for taking 3 months just for the initial consult and sleep study (the clinic is expensive and my medical plan has a high annual deductible).  
I was also not mentally ready to accept CPAP treatment, so I decided to try to different sleep positions and weight loss.

Unfortunately, my sleep has not improved over the last 18 months.
After some research on this forum, I got a prescription from my primary care physician and purchased a ResMed AirSense 10 AutoSet, P30i nasal pillow mask, ClimateLine heated tube, and hose cover from Supplier #1.  

I received the machine yesterday, put in an SD card, and practiced breathing for a couple hours with different nasal pillow sizes.

At night, I taped my mouth and set the machine to 7-17 with EPR 3 for my first night of sleep.
As expected, I had some trouble getting used to the mask, but I was able to sleep somewhat well for 4-5 hours.  
I checked the sleep log and saw Central AI of about 8.  I turned off EPR, but was unable to fall back asleep.  I then changed the pressure to 7-13 with EPR 2.  I still had a lot of trouble falling back asleep.  It felt like every time I was about to fall asleep, I would wake up with the feeling that I needed to consciously start breathing again.  I was also starting to swallow some air.  By that time, I was feeling too awake to try a lower pressure/EPR.

I only have one night of data, but would appreciate any treatment advice.  Thank you!
   
Close-up of central apneas:
   
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#2
RE: New user getting central apneas
Below is my sleep study summary from 18 months ago.  I will try to get more detail from the clinic.

PROCEDURE:  
An ambulatory PSG performed with a ResMed ApneasLink Air home testing device. The following channels were monitored: Airflow (via nasal pressure transducer), respiratory effort (thoracic band), oximetry, body position and heart rate.  The patient and/or caregiver received face-to-face instruction and demonstration of the correct application of the portable sleep monitoring device. Please note that the REI 4% or greater in this report is consistent with the current Hypopnea definition according to Medicare Criteria and the REI is consistent with the current Hypopnea definition according to AASM criteria.  The study was scored according to the AASM Manual for the scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications edition (Ver. 2.3.
  
SLEEP/MONITORING TIME DATA:  
Recording start time (hr:min): 11:15pm
Recording end time (hr:min): 7:30 am
Total recording time (TRT):  8:14 hours
Monitoring time (MT): 8:01 hours
(MT is total recording time minus periods of artifact and time the patient was awake as determined by respiratory pattern)
 
RESPIRATORY ANALYSIS:
Respiratory Event Index (REI): 8.1
(REI=AHI based on monitoring time)
*REI 4% or greater: 4.9
Supine REI:  11.1
Time in Supine (hr:min): 2:03
Non-supine REI: 7.0
**Body position cannot be verified
 
Obstructive apneas (index): 0.1
Mixed Apneas (index): 0.0  
Central Apneas (index): 1.4
Hypopneas (index) : 6.6
  
OXYGEN SATURATION:
Minimum monitoring SpO2 (oxygen saturation): 89%
Monitoring Time with SpO2 < 88% (min, % of MT): 0, 0 %
 
HEART RATE (HR - bpm):
Average HR: 61
Highest HR: 127
Minimum HR: 50
 
CLINICAL INTERPRETATION:
Polysomnographic findings are consistent with Mild Obstructive Sleep Apnea Syndrome (RD/EI = 8 events per hour) without significant nocturnal desaturations. The lowest oxygen saturation was 89%; and 0% of the total sleep time was spent at oxyhemoglobin saturations below 88%.
 
However, please be advised that unattended sleep recordings tend to underestimate the degree of sleep disordered breathing, especially in patients with mild obstructive sleep apnea/UARS. Clinical correlation is suggested and if patient appears to be at moderate to high risk of obstructive sleep apnea - a follow-up attended diagnostic polysomnography is recommended.
 
Non-specific treatment options including weight loss of at least 10% of body weight, avoidance of supine (on the back) sleeping position, avoidance of alcohol, nicotine, and sleep deprivation are advised, as appropriate.
 
A trial of nasal CPAP/BiPAP, surgical treatment modalities, or an oral appliance are alternative options.  
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#3
RE: New user getting central apneas
Hi and welcome to the Apnea Board,

When you're in touch with your doctor's office, request the full diagnosic study report. HIPAA law permits you to request and receive it. The summary is probably OK for now. I saw a small amount of Centrals listed, and with the increase while using PAP, you're likely a treatment emergent CA victim.

Let's do this, drop EPR 2 down to 1, monitor, post with OSCAR, then we may need EPR to be off if the CA aren't diminishing enough. These will typically diminish within 3 months of PAP use. Keep Ramp off too.

Other events and such look reasonable to me.
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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#4
RE: New user getting central apneas
Thank you!!

I will request the full sleep study report and update the new settings (EPR 1, ramp off) for tonight.
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#5
RE: New user getting central apneas
OK good, post your OSCAR shot tomorrow and tell us how it changes, if it felt better, different, etc.
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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#6
RE: New user getting central apneas
Don't make changes to the settings during the night. In fact, the usual recommendation is to leave the settings the same for several consecutive nights. The reason is because it takes your body time to adapt, and if you keep making changes too often you interfere with the adaptation. It's likely that your CA index will drop as you adapt.

Many people have a high AHI for the first few nights. Your body is used to having to wake yourself up to breathe. Like you said, you've probably been doing this for years. So it will take a while for your body to get used to the notion that it's ok to stay asleep.

A few fortunate people have no problem adapting. They sleep well the first night and feel refreshed for the first time in years. Most of us are not so lucky. Some of us have a hard time adapting. A lot of people give up and put their CPAP machine in the closet. That means living a miserable sleep-deprived life with an increased risk of cardiovascular disease and stroke. The problem just gets worse as we age. We are fortunate to be alive in an era where CPAP machines exist. Our grandparents and their ancestors had no such option available to them. In extreme cases they would have a tracheotomy.

One final thing. I'm not a big fan of taping the mouth. If you really must use a nasal mask (as opposed to a full face mask) then we can tell from looking at your OSCAR charts if you're mouth-leaking. If so, a chin strap may solve the problem. Sometimes the chin strap is necessary for a short time, and then after that you won't need it anymore. Kind of like a training device. Sometimes the only solution is to switch to a full face mask.
Sleepster

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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#7
RE: New user getting central apneas
On the example you provided, the close up, the breathing until the last CA That view was awake breathing. We discard any associated with wake breathing.

Try EPR=1 and see if that helps. We can adjust from there
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#8
RE: New user getting central apneas
Thanks everyone for the thoughtful guidance!

I will stop making changes in the middle of the night.

I do hope to eventually move away from mouth taping.  I'm starting with nasal pillows and tape because it seemed like the most foolproof way of minimizing air leaks.  I ordered online and have not had any mask fittings.

Gideon, that is really neat that you are able to tell that I was awake before those CA's.  Is there an easy way to tell in OSCAR when I'm awake?  I'm guessing most of the CA's, especially those later in the night, are when I'm awake (or at sleep onset).

Before CPAP, I was usually aware of waking up 2-4 times a night.
These past two nights on CPAP, I feel like I am waking up ~30 times each night (often at what feels like sleep onset).  Aerophagia has made it more difficult to fall back asleep later in the night.

I don't feel fully rested in the morning, but am not feeling nearly as tired as I would usually be with so many awakenings.
The CPAP has also eliminated my snoring, which is nice.

Here is last night's chart (EPR was reduced to 1).  Should I try reducing the max pressure, using the soft response mode, or turning off EPR?

   
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#9
RE: New user getting central apneas
If me, I'd cut EPR to 0/Off.
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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#10
RE: New user getting central apneas
Fstrife, I'm attaching a few zoomed-in views of flow rates showing arousal breathing.  You'll see larger amplitudes in the flow rates, different curve shapes, and possibly shorter or non-existent pauses between breaths.  In general, arousal breathing has a less regular and orderly appearance than asleep breathing.

Arousal breathing can clear out more CO2, which in turn can temporarily reduce your drive to breathe, which in turn can cause a CA to be flagged if the pause between breaths is 10 seconds or more.  In such cases, your sleep problem isn't the CA per se but the arousal.

CAs are also not uncommon during the transition from being awake to being asleep.  There are quite a few neurochemical hand-offs that occur during this transition, and when there's a little glitch, there can be some CAs.  These usually go away over time as your body adjusts.

One thought: to speed up your adaptation to using your machine and gear, you can set everything up outside your bedroom during the day or evening and use them while you read or watch TV.  It's a way of getting your mind to take it easy: no need for extra vigilance despite the weird sensations.


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