Still Having Centrals—even on APAP (Graphs Included)

[eddie19852004]

Looking to receive some insight into my OSCAR graphs. (I believe my sleep study showed about 95%+ of my events are “central” and that seems confirmed by the data from CPAP), I’m new to the whole world of apnea. I started using a ResMed Airsense 11 AutoSet (pressure range 4-20) with AirFit N30i nasal cradle about three weeks ago. Since starting my journey with sleep therapy, my AHI has ranged from 6-36 with my three-week average being 18.XX).  I was using the “myAir” app, but it was pretty lacking in the information it provides me so I downloaded the OSCAR software.

Currently in the process of trying to find out the cause.  My doctor admittedly isn’t super experienced with sleep disorders so she’s referred me on to a specialist, so I’ll be seeing a pulmonologist/sleep doctor later this month to begin that process of (hopefully) figuring out the cause, but I’m curious to find out more details of my sleep and breathing in the meantime.  I’ve included a few graphs in hopes of some of you guys’ expert insight!

Anything I could try with my sleep therapy to get better results or maybe even questions I should ask or things I should bring up when I see this new doctor?!?

Thanks in advance!

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Image 1

[eddie19852004]

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Image 3 (sorry—it wouldn’t let me add all 3 in one post).  ?‍♂️?

[multicast]

The CA may be induced by the therapy. First guess is to set EPR = 0.

[eddie19852004]

The CA may be induced by the therapy.

Thanks for that input, Multicast!  I had wondered that at first, but remembered that my sleep study had mentioned that almost all of my apneas were central, even before starting therapy.

[Sleeprider]

Eddie, if the majority of your events in the sleep study were also central apnea, then you likely have idiopathic central or complex apnea. That's just a fancy way of saying, we don't know the cause of your apnea, but we do know that CPAP is rarely effective in treating it. About 5 to 15% of individuals evaluated for sleep apnea have primary central apnea, or have therapy onset central apnea when starting CPAP due to the improved ventilation with CPAP causing CO2 to be flushed from the respiratory system. The therapy that treats CA is called an Adaptive Servo Ventilator (ASV). This is a bilevel positive air pressure (PAP) machine that provides a low inhale pressure and variable or adaptive inhale pressure on a breath by breath basis. The machine works like a CPAP providing positive pressure until it detects a cessation of breathing. During an apnea the inhale (IPAP) pressure is increased to cause a breath, much like artificial respiration. The machine can cycle to exhale (EPAP) and IPAP as needed to maintain a normal minute vent, even when you lack spontaneous respiratory effort.

With that basic understanding, you need to discuss with your doctor your clear need for ASV therapy. This usually involves additional medical evaluation and a titration test to demonstrate the efficacy of ASV. Your CPAP machine was issued with default settings of 4.0-20.0 pressure and it is clear that your doctor has not performed a clinical evaluation of your CPAP pressure needs. Even though you had primarily central apnea, you were issued CPAP for your first machine. This is routine because insurance requires everyone to start with CPAP and demonstrate the medical need for more advanced, and more expensive therapy options. You have obviously failed CPAP and are now ready for the next step. Ask your doctor about switching to ASV to treat your very high central apnea. This reference can help you learn more about how ASV works starting at page 28. https://document.resmed.com/en-us/docume...er_eng.pdf

Looking at your results, we can see that your apnea is triggered by higher pressure. You should just used a fixed pressure of 4.0 to avoid this. If your diagnostic study has a lower AHI than 33 events per hour, you should cease use of CPAP since it make it worse. It would help if you would post a copy of your sleep study results with any personal information redacted, and we can probably help further.

[Gideon]

Pretty much what Sleeprider said.
Assuming the high Central apnea on your sleep test was on your was on a diagnostic test without a CPAP, the specialist you should be seeing would be a neurologist sleep specialist, especially if you do not have any other pulmonary conditions.

No matter what, getting an ASV IS the solution.  Ask your doc to schedule a titration test with an ASV and the prerequisite LVEF scan that is required to speed things up.  You will need these either way.

[Sleeprider]

I'll decipher Gideon's last statement.  ASV therapy was identified as having an increased risk to individuals with heart failure and a left ventricular ejection fraction (LVEF) less than 45%.  In individuals with heart failure, a precautionary evaluation of LVEF is normally recommended. In the absence of that problem, an echocardiogram is not normally performed.

[eddie19852004]

With that basic understanding, you need to discuss with your doctor your clear need for ASV therapy.  This usually involves additional medical evaluation and a titration test to demonstrate the efficacy of ASV.  Your CPAP machine was issued with default settings of 4.0-20.0 pressure and it is clear that your doctor has not performed a clinical evaluation of your CPAP pressure needs.  Even though you had primarily central apnea,  you were issued CPAP for your first machine. This is routine because insurance requires everyone to start with CPAP and demonstrate the medical need for more advanced, and more expensive therapy options.  You have obviously failed CPAP and are now ready for the next step.  Ask your doctor about switching to ASV to treat your very high central apnea.  This reference can help you learn more about how ASV works starting at page 28. https://document.resmed.com/en-us/docume...er_eng.pdf

Looking at your results, we can see that your apnea is triggered by higher pressure. You should just used a fixed pressure of 4.0 to avoid this.  If your diagnostic study has a lower AHI than 33 events per hour, you should cease use of CPAP since it make it worse.  It would help if you would post a copy of your sleep study results with any personal information redacted, and we can probably help further.

Thanks, Sleeprider—my doctor has made it clear from the beginning that she doesn’t have much experience with sleep medicine (more so the central apnea aspect of it) and wrote the order for the CPAP based off of the recommendations listed in my sleep study.  Once the DME company I went with sat down with me to get my CPAP set up, it was only a 60 minute (approx) to show me how the thing runs.  I had asked about the centrals and how the machine could handle those, and they explained the machine would detect and automatically increase the pressure (but if what I’m understanding about the ResMed Airsense 11 AutoSet, that’s not fully the case?).  They did mention another machine may be necessary, I’m assuming it may have been ASV, but can’t remember now.  I just kind of went with the flow (no pun intended) thinking this was the machine for me…lol.

My diagnostic test showed an AHI of around 15, almost all of which were centrals, if I remember correctly…so this night’s data was higher than that, but it does fluctuate from night to night—my AHI has been as low as 5 or 6 and as high as 36, I believe.  Haven’t really noticed anything that could’ve been a real pattern to cause those higher numbered days and vice-versa.  I can definitely see if I can get the more detailed sleep study results to post.

Assuming the high Central apnea on your sleep test was on your was on a diagnostic test without a CPAP, the specialist you should be seeing would be a neurologist sleep specialist, especially if you do not have any other pulmonary conditions.

No matter what, getting an ASV IS the solution.  Ask your doc to schedule a titration test with an ASV and the prerequisite LVEF scan that is required to speed things up.  You will need these either way.

Correct, Gideon—the sleep study showed almost all centrals…only one obstructive throughout the entire night, if I remember correctly—and I do have an occasional obstructive here and there some nights.

Seeing a pulmonologist/sleep doctor in two weeks and I’m sure they’re much more experienced than my PCP is with sleep disorders and will be able to head me in the direction of the ASV—especially after failing CPAP.  I will reach out to my PCP to see if she can order the titration study you mentioned and/or LVEF ahead of time to give me more leverage when I see the pulmonologist and see if she can do a referral to a neurologist (since it sounds like that would be of more of benefit than the pulmonologist would be—or would it be best to broach that subject with the pulmonologist?).

I'll decipher Gideon's last statement.  ASV therapy was identified as having an increased risk to individuals with heart failure and a left ventricular ejection fraction (LVEF) less than 45%.  In individuals with heart failure, a precautionary evaluation of LVEF is normally recommended. In the absence of that problem, an echocardiogram is not normally performed.

That makes total sense—I’ve never had any cardiac issues (but do have a family history of them) and would have to look up symptoms, so we’ll see if they’ll go for getting that done so it have it to hopefully speed things up.  I’ve had some daytime shortness of breath which wasn’t resolved with an inhaler, hence the referral to the pulmonologist.  The number of days with an AHI up in the mid 20-30’s range happens a few days a week, I’d say…but definitely not every night.  I have had a few nights with a lower AHI since this night, so I’ll post those graphs to see if there is anything that stands out with those lower numbers.

I’m definitely appreciating the input, guys…it has been tremendously helpful!

[eddie19852004]

Here are some graphs from the last two nights with some lower numbers and a couple of OA--not sure if that helps anything or gives you a better picture?  Like I said--some nights are higher, some nights are lower.

[SarcasticDave94]

Central Apnea will be consistently inconsistent, expect it.

Have you gotten the actual diagnostic and/or full, detailed Titration copies yet?

It can be helpful to see the write-up, etc. This is not to dispute ASV necessity.

I would begin a sleep therapy diary, depicting the failed therapy on the CPAP, your ongoing fatigue, other symptoms and complaints regarding your Apnea therapy. This is ammo for obtaining an ASV.