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Typical BiPAP pressure ranges to treat centrals?
#1
Typical BiPAP pressure ranges to treat centrals?
I've been on APAP with an AirSense for more than three months now. I have virtually zero obstructive events. However, I have a mix of clear-airway and what appear to be central hypopneas on a regular basis -- some nights not too many, but some nights quite a lot.

I therefore thought I'd talk to my sleep clinic to see if I can do a trial with a BiPAP machine for a few nights. However, I'm wondering about what pressure ranges are typical for this treatment. Currently my AirSense 10 is set for 6-10cm, and never seems to go above 8. If it gets to 10, I'm uncomfortable and wake up. Above that, I wouldn't do well.

So, if BiPAP therapy for centrals usually involves pressures in the 10+ cm range, that would be really helpful to know before I talk to the clinic. In that scenario, I might be between a rock and a hard place.
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#2
RE: Typical BiPAP pressure ranges to treat centrals?
Unfortunately, the correct therapy device to resolve central events is the adaptive servo ventilator (ASV) which is very difficult to get without demonstrating an underlying condition that causes the centrals. Don't get me wrong; idiopathic central events are very real, they just don't fit in the insurance coverage requirements until you have failed to tolerate CPAP (E0601), bilevel without backup (E0470) and finally demonstrated efficacy on bilevel with a backup rate (E0471). Even when you get to the backup rate, much of the medical community seems to have no clue about ASV vs ST. Its not an easy journey.
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#3
RE: Typical BiPAP pressure ranges to treat centrals?
Thanks, interesting to know about that gauntlet to be run. I'm also concerned that my clinic will deem my current occurrence of centrals to be too low to require treatment -- some nights they'll drive AHI up above 5, but usually it's in the 3-ish range. All I know is that, overall, my level of daytime fatigue is roughly the same as before I started APAP treatment. Something is making me wake up a lot from 4 a.m. onward, which is when most of the centrals occur.

I'm wondering if the APAP treatment could be causing the centrals? Or were they there all along? (They weren't mentioned in my pre-treatment sleep study, which in the version given to me was an extremely high-level gloss. I should probably ask the clinic more about that.)

Or is my difficulty sleeping toward the end of the night unrelated to PAP treatment? I do hear that older people (I'll be 65 in two months) sleep more lightly. No other smoking guns to weed out, though (not a caffeine user, for example).
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#4
RE: Typical BiPAP pressure ranges to treat centrals?
Have you ever posted a graph for analysis? I don't recall seeing one. If you want to tackle this issue, let's take a look at what is going on. There are several alternatives to complex bilevel therapy, but I don't even know your EPR settings.
Sleeprider
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#5
RE: Typical BiPAP pressure ranges to treat centrals?
Well, every night is different (and I've posted a few), but here's one that shows the hypopneas and clear-airway events pushing the AHI up to 5+. They tend to congregate later in the night, though not always.

In this particular case I had set the max pressure to 8.0 cm, and you can see the machine bumping along at that level a great deal of the night. But I have many other examples where the max pressure was set to, say, 10.0, and the pressure stayed entirely between 6 and 8 all night.

   
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#6
RE: Typical BiPAP pressure ranges to treat centrals?
You have persistent flow limitation, to the point that your inspiration/expiration ratio is significantly reversed at median of 1.44:0.6. This is a I:E ratio of 1 to 0.4. Normally a ratio in the range of 1 to 1 to 1 to 3 is normal. In your case we can see a very high respiration rate of 32 breaths per minute with a tidal volume of 337 mL resulting in a pretty high minute vent of 9 L/min. This is approaching hyperventilation and a "panting" respiration rate. With the existing information, we cannot identify the root causes of these anomalies, but they are a concern and something that need to be addressed.

Without any doubt, I think you need a significantly higher minimum and maximum pressure, and to increase the EPR from 2 to 3. I am inclined to recommend a pressure range of 7.0 minimum, to 14.0 maximum with EPR at 3 as initial approach unless you have some physical reason for keeping pressure so low. You are simply not properly ventilated at your current settings, and while your AHI is not especially high, your respiration is dysfunctional in this example. We should look at additional samples and consider zooming in to look at the respiration flow rate (2-minute zoom) to see what is really going on.
Sleeprider
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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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#7
RE: Typical BiPAP pressure ranges to treat centrals?
(04-11-2019, 08:49 AM)Sleeprider Wrote: You have persistent flow limitation, to the point that your inspiration/expiration ratio is significantly reversed at median of 1.44:0.6. This is a I:E ratio of 1 to 0.4. Normally a ratio in the range of 1 to 1 to 1 to 3 is normal.  In your case we can see a very high respiration rate of 32 breaths per minute with a tidal volume of 337 mL resulting in a pretty high minute vent of 9 L/min.  This is approaching hyperventilation and a "panting" respiration rate.  With the existing information, we cannot identify the root causes of these anomalies, but they are a concern and something that need to be addressed.

Without any doubt, I think you need a significantly higher minimum and maximum pressure, and to increase the EPR from 2 to 3. I am inclined to recommend a pressure range of 7.0 minimum, to 14.0 maximum with EPR at 3 as initial approach unless you have some physical reason for keeping pressure so low.  You are simply not properly ventilated at your current settings, and while your AHI is not especially high, your respiration is dysfunctional in this example.  We should look at additional samples and consider zooming in to look at the respiration flow rate (2-minute zoom) to see what is really going on.

Thanks for the comments. My apologies for the delay in replying -- I was away on a short trip until today.

Interesting point about the inspiration/expiration ratio. I've looked at the rest of the past month or so, and that night looks like it was an outlier. I'd say in 50% or so of the nights, median inspiration and expiration are within 5% of each other. In the rest, inspiration outweighs expiration, but more moderately -- say 2.10 : 1.66 or siilar.

Regarding EPR, it's been back up to 3 for several weeks now.

Attached is a report from another night, 10 days ago. AHI is 3.29 (2.63 clear airway, 0.49 hypopnea, 0.16 unclassified, 0 everything else). Median inspiration 2.10, expiration 1.98. Median respiration rate is 14.40.

There was also quite a bit of mask leakage, as there has also been on other nights recently. I've been using my DreamWear cushion mask for just over three months, and I suspect the nosepiece area is getting weak or something. Before I can get a new one I need my sleep clinic to fix a glitch with my mask prescription, but I'm having trouble getting a call back from the sleep clinic. As one other thing to deal with, the respiratory clinician who saw me a while back noted that I'd changed the pressure on my own and told me I had to bring the machine in and let them do that. That'll be a major hassle! Once I get these point sorted out I'll try higher pressure, though as noted I start ripping the mask off when it gets above 10cm.

If you'd like to see any reports, I'll be happy to post them. Am interested in the idea of trying to identify possible root causes for what shows up.

[attachment=11374]
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#8
RE: Typical BiPAP pressure ranges to treat centrals?
Here is last night's report, and it illustrates some of the patterns I'm seeing regularly and am wondering about.

The early part of the night is fairly quiet, and then a large number of centrals occur in the final couple of hours of sleep. In this case I was able to sleep for 7 hr 23 m, but often I find it hard to sleep longer than 5-6 hours.

AHI is 3.25, consisting of clear airway 2.57, hypopnea 0.68, and nothing else.

The pressure (still set at 6-10cm at this point) hovers beween 6 and 8 cm the entire night.

Median inspiration is 2.06, expiration 1.88.

[attachment=11381]
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#9
RE: Typical BiPAP pressure ranges to treat centrals?
I'd like to see you cut back on EPR a bit. It should help with the central events. Your more "typical" results look a lot better, but I really don't like seeing EPR higher than what will provide EPAP at 4 cm. You are getting pretty good results at pressures less than 10 IPAP and it seems you tolerate or require fairly low pressures. Using EPR at 3 with these low pressures is probably contributing to the CA events.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Optimizing Therapy
Organize your OSCAR Charts
How To Attach Images And Files to your posts
How To Deal With Equipment Supplier
Mask Primer
Beginner's Guide to Sleepyhead

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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#10
RE: Typical BiPAP pressure ranges to treat centrals?
(04-16-2019, 07:09 PM)Sleeprider Wrote: I'd like to see you cut back on EPR a bit.  It should help with the central events.   Your more "typical" results look a lot better, but I really don't like seeing EPR higher than what will provide EPAP at 4 cm.  You are getting pretty good results at pressures less than 10 IPAP and it seems you tolerate or require fairly low pressures.  Using EPR at 3 with these low pressures is probably contributing to the CA events.

Thanks. I actually had the EPR at 2 for a couple of months, but put it back up to 3 a few weeks ago in response to one recommendation. I'll drop it back to 2 and see how it goes.
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