[Treatment] Struggling with treatment - did I have central sleep apnea all along?

[ethereal]

Hey all. Kinda struggling at the moment, and not sure what to do from here. 

I have "mild-rem prominent OSA" according to my sleep report (attached) and it has gotten worse over the years, although I note it is still mild. I wake up most days feeling like a truck hit me though, and I'm always fatigued. Don't think I've ever experienced a day where I've woken up and gone "wow, I feel refreshed!".

This is my second time on CPAP, first trialed it a few years ago but failed - this time I've been much more compliant though - I have been on CPAP for a little over 2 months now. This time, I've learnt my OSA at least is due to poor nasal structure (huge turbinates and deviated septum) and apparently I've also got a large tongue which is rolling back and choking me at night as my mouth drops open (likely during REM sleep). To combat this I've been using saline nasal rinse daily and taping my mouth at night (I use the Philips Gel Nasal Mask) - this has allowed me to basically eliminate all large leaks, and actually get some sleep. While my nose is not the best, I can always breathe okay through one nostril at least, and the CPAP does really help with this. So for now, this seems to be a decent interim fix before I book nasal surgery with my ENT.

So after all of this a couple of things have been happening:

1. I seem to have developed "sleep maintenance insomnia" where I spring awake after 4-5 hours of sleep on the CPAP and then struggle to go back to sleep. I have been a poor sleeper my whole life, and it almost feels like my body knows it is getting the same amount of sleep in 4-5 hours as I used to on 7-8 and just waking up. I will say, there has been some days where I've woken up feeling OK, like as in much better than I was without CPAP. Whatever it is, I seem to still be struggling around REM sleep, it's either a muscle memory thing (so used to being disturbed during REM) or the following...
   
   
2. This is what I am most concerned about - ever since treatment I've been seeing centrals come up here and there. I'll provide the data below, but at first I thought they would just slowly resolve or reduce, but actually lately I've noticed some of my worst nights with many centrals. At the start of therapy, I used to average around 0-1 AHI per night, always a couple centrals here and there. Lately I have noticed a couple big nights of centrals, like last night with an AHI of 4.84 (mostly all centrals).
   What I don't know, is if they're "real" or not. As I look at my breathing pattern, and I am no expert, they appear to seem legitimate in the sense that I don't think I am holding my breath whilst tossing & turning for 10-15 seconds. They also don't appear to represent cheyne stokes breathing. 
   

Here are some of my recent nights with the machine, and experience with centrals. Attaching SleepHQ charts as it's a lot easier for me to share all this data in one go, over screenshots:

Here's what an average night looks like for me - 0.62 AHI, few centrals here and there, 8 hours usage to get 6h 30m sleep (oura ring):
https://sleephq.com/public/c7b9686a-c21b...b076264490 

Some nights I acheive 0.0 AHI, or extremely low:
https://sleephq.com/public/c14b113b-b5cf...6916f5173a

And recently I have been seeing nights like this - it's only happened twice so far in the last week, but 4.84 AHI, with lots of centrals! My sleep here was 6h 40mins total, with 1h 10m awake, lots of awake time between 5-7am while going in and out of sleep (typical sleep after starting CPAP therapy):
https://sleephq.com/public/253f28d3-1515...6bedaaa893 

My sleep specialist, nor the people helping me trial CPAP don't ever look at data this detailed. They also never mentioned anything about centrals.

But I seem to be struggling a bit. Only getting 6 ish hours of sleep per night (granted that may just be poor habits rather than CPAP) but I feel like something else is going on... I am definitely getting aroused at night, and I wonder if it's these centrals?

Things I've tried so far: reducing EPR from 3 > 2
Things I am considering trying: reducing EPR from 2 > 1, then OFF. Fixing pressure at 7cmH2O.

What do you recommend I do from here? I'll be grateful for any direction and advice from you kind people on here. Thank you!

[ethereal]

I haven't been able to post the links to a few samples of my night yet, even though I have the require number of posts. I will update this thread when that happens.

I spent like over an hour organising and typing this all up - so I don't want to lose it. That's a lot of brain energy for a tired CPAP guy

Edit: Was able to do it!

[clownbell]

Hi Ethereal - (love the name!!)

I notice that your sleep study says you had some centrals while sleeping on your back but none in other positions. First thing would be to train yourself to sleep on your right side. If the 4+ central index repeats itself often, then it is worth pursuing. On the other hand, if it is a one-off occurrence, shrug your shoulders and move on.

The sleep docs and techs look only at AHI and compliance. If your AHI is <5 and you regularly use the machine >4 hours a night, they think all is good. The experts on this forum (and others) would highly disagree with that approach, but that is shat the sleep industry typically thinks. If your centrals remain at a high level, advocate forcefully for yourself.

ResMed does have a machine that is purpose-built specifically to handle centrals, but we aren't there yet. It is called VAuto ASV. Very expensive. Insurance doesn't want to pay for it unless the patient has a central index that is extremely high, which IMO you do not.

[ethereal]

Hey clownbell, thanks for responding

Interestingly, I usually sleep on my side, but lately have been sleeping on my back. But I do have two questions:

1. If I'm on CPAP, why should back sleep cause/affect central apneas?
   
2. You said "sleep on your right side"... why my right side specifically, what's wrong with my left haha
   

[Dog Slobber]

There is nothing that suggests you have any kind of Central Apnea issue that needs addressing.

During your bad night, where there were a lot Centrals, you were awake during them. 

From your SleepHQ:
   

On the left is what sleep breathing flow-rate looks like, then you woke up. On the right is what awake breathing looks like, then you had some centrals. You look like you were wide awake.

You are tired in the day, because you're not sleeping well with the machine, yet. Hopefully, better acceptance and sleep will start to come soon. It took me *Along* time and I still have the occasional sleep maintenance issue.

If I'm on CPAP, why should back sleep cause/affect central apneas?

From your sleep study you only had 4 central events, all night. You happened to be on your back. This is not statistically significant. I would not draw a correlation between back sleeping and centrals. Or that Centrals are a problem at all.

You said "sleep on your right side"... why my right side specifically, what's wrong with my left haha

Some suggest sleeping on the right to better address acid reflux.

Hi Ethereal - (love the name!!)

I wonder if he will change his name to wireshark after forking.

(I don't expect too many here to get this reference)

[OpalRose]

If I'm on CPAP, why should back sleep cause/affect central apneas?

You said "sleep on your right side"... why my right side specifically, what's wrong with my left haha

Most of us are aware that Back sleeping can cause issues in some folk with sleep apnea and positional apnea.  Although, Back sleeping prevents facial wrinkles, according to Mr.Google.

Most articles that I've read seem to be in agreement that Left Side sleeping is best for:  Digestive issues, Acid Reflux, and snoring.  

Some articles suggest that Right side sleeping is preferred for folk with Heart Issues.

There are many articles about sleep position.  I usually go for comfort.  

Google "left side sleeping vs. right side"

[ethereal]

Dog Slobber pid='454731' dateline='1663418486']On the left is what sleep breathing flow-rate looks like, then you woke up. On the right is what awake breathing looks like, then you had some centrals. You look like you were wide awake.

You are tired in the day, because you're not sleeping well with the machine, yet. Hopefully, better acceptance and sleep will start to come soon. It took me *Along* time and I still have the occasional sleep maintenance issue.

Got confused for a moment there, because I've never slept with my CPAP at 12:57 PM... realised it's because of your timezone :

Okay interesting. 

So then what about these, for example? I was asleep according to Oura, with a HR of 43 BPM at this time. Would be pretty tough to be awake at that HR. This would be around 1:01 PM your time.

   

And these. Again, asleep with a HR of 44 BPM. Around 1:12 PM your time.

   

I am finding it hard to believe I stopped breathing while awake that many times during the night. Unless I was in some awake (but asleep) state without my concious awareness. 

Cheers for responding btw. Makes me feel better to know I can still actually get better on treatment as time goes on.

[Dog Slobber]

Yes, SleepHQ posts times according to the viewrs timezone.



The Centrals you just posted, occurred after a period you were awake and likely as you were falling asleep again, sleep onset is a time where the occasional Central happens.

The graph I posted you were *definitely* awake, portraying it as "finding it hard to believe I stopped breathing while awake that many times during the night" misrepresntes whats happening. During awake breathing we do it all the time, it's not significant enough for us to need to remember. Add to that during bouts of short wakeful periods we often awake long enough to form memories.

The graph I posted (and others) suggests pretty strongly you were awake, finding another central where the flow-rate prior to the event is less obvious doesn't change that. And your Oura definetly  doesn't change that.

As I said previously, there is nothing in that sleep session that suggests Central or Mixed apnea as something that needs addressing. It's some artifacts from poor sleep. Your poor sleep is causing false positives, not the other way around.

[mesenteria]

Our machines flag events past a certain length, determine their type, and then assign an accumulating AHI score over the course of one's sleep. The machines will allow you to view the duration, and even the apparent frequency, of any events of a type which they flag.  But the AHI is not meant to include the deleterious nature of each separate event, or of a series of them, as factors.  This is a problem.

I have several centrals each night, spaced out randomly, and of short duration (none more than 15 seconds, most just enough to get flagged at about 11-12 seconds).  If there is something like 30 seconds between short centrals, it isn't an issue.  If many short duration CAs happen inside of the 40 seconds it takes you to drift off, that can offer a burden on the heart, will likely cause an adrenergic response, if mild, and work to keep you from actually falling asleep.  This is where I find myself currently, months after an angiogram and a catheter ablation of the pulmonary vein ostia.  I also tend to get more groupings of CAs in the hour prior to cessation of sleep a few hours later....too few, but that's another story.

I don't honestly have any stats to back me up, but I feel that a great many of us have one-ten centrals each night, most often well spaced in the range of 15 minutes or more.  They are often associated with occasional arousals, say during the few seconds it takes us to turn onto our backs or to the other side.  This is completely innocuous.  So are those which come more frequently, but which are of short duration, say just over the flagging threshold of 10 seconds.  Instead, it is the grouping of rapid-succession CAs where one is not getting enough O2 to stay above 87% where the burden on the heart becomes problematic.  You certainly will not feel rested, and you're probably going to develop a heart 'complaint' ere long.  Happened to me, and I now have a complex arrhythmia that has not been beaten by the first ablation.

All the foregoing to say that you can place your cursor over a sampling of CAs and will hopefully see that they are less than 15 seconds, perhaps much closer to 11 seconds.  If that is so, then you have nothing to worry about.  If your AHI is <5, and your leaks are easily handled by the fan motor, and if you don't have even short CAs in rapid succession, then I feel you should reduce your own fretting by accepting that what you are experiencing is normal for you and your machine in concert.  A substantial deterioration in those parameters will need to be addressed before long, but right now you seem to be doing pretty well...by the numbers available to me.

[ethereal]

As I said previously, there is nothing in that sleep session that suggests Central or Mixed apnea as something that needs addressing. It's some artifacts from poor sleep. Your poor sleep is causing false positives, not the other way around.

I sure hope this is the case and you're right! Beats having to worrying and go back to a specialist now.

Do you have any tips you've learnt for yourself to address poor sleep? I'm such a bad sleeper, I don't know what it is. I can fall asleep in 5-15 mins, but then in the second half of the night it feels like I'm waking up every 10 minutes!

----------------------------

Also for others interested, I reduced my EPR to 1 last night and left the pressure the same, and I only had two small central events in the whole night. Will keep monitoring this to see if this is indeed helping, and then will progress to turning EPR off. It actually felt nicer to breathe with a lower EPR (albeit weird at first). I was however sleeping mostly on my side last night, so this may have also made a difference.

https://sleephq.com/public/bc0f393b-c436...f0546a0528

While we're here; does anyone know why the hypopneas in the above sleep data don't have any time lengths like the CA's do? Is this because they're just too short? When I look at the flow limit, it just looks like a little blip in breathing, rather than me completely stopping breathing.

I don't honestly have any stats to back me up, but I feel that a great many of us have one-ten centrals each night, most often well spaced in the range of 15 minutes or more.  They are often associated with occasional arousals, say during the few seconds it takes us to turn onto our backs or to the other side.  This is completely innocuous.  So are those which come more frequently, but which are of short duration, say just over the flagging threshold of 10 seconds.  Instead, it is the grouping of rapid-succession CAs where one is not getting enough O2 to stay above 87% where the burden on the heart becomes problematic.  You certainly will not feel rested, and you're probably going to develop a heart 'complaint' ere long.  Happened to me, and I now have a complex arrhythmia that has not been beaten by the first ablation.

All the foregoing to say that you can place your cursor over a sampling of CAs and will hopefully see that they are less than 15 seconds, perhaps much closer to 11 seconds.  If that is so, then you have nothing to worry about.  If your AHI is <5, and your leaks are easily handled by the fan motor, and if you don't have even short CAs in rapid succession, then I feel you should reduce your own fretting by accepting that what you are experiencing is normal for you and your machine in concert.  A substantial deterioration in those parameters will need to be addressed before long, but right now you seem to be doing pretty well...by the numbers available to me.

I'm sorry to hear about your struggles here, and I wish you all the best in managing it. Yes, you are right, all of the "centrals" I have are 10-11 seconds. Rarely are they ever longer. Thanks for having a look mesenteria.