cpap and apap not effictive

[Ezil71]

A few updates since my last post.....

I did manage to find/see a doctor about 2.5 hours from me. I was able to get in relatively quickly to see him and as luck would have it, also was able to get another sleep study, this time as a bipap titration.

Oddly, as with my first titration, my numbers were very good. I was started at straight cpap at 5cm, then to bipap 8/4. Very few events were present, although even at 8/4 I did have aerophasia. Not too bad, but certainly not great.

I'm still waiting to get my bipap machine so I've done some more testing on my own with my current machine.

For the 30+ days I had my machine at apap 7-10 epr 3 and was around 8 ahi, but sometimes as high as 15. At least 75-80% showing as centrals.

With lower pressures, I do quite well for the first 2/3 of the night, then have a bunch of events (showing as centrals) for the last couple hours.

The odd exception was last week. I tried running at cpap 8 with epr 3, so effectively bipap at 8/5. I almost never drink but was quite drunk and my number for 8.5 hours of sleep was only .28! I've always thought drinking would make things much worse (certainly of obstructive events). Not sure what to make of this. I can't say I was rested since I was pretty hung over.

The sleep tech at my study told me I "didn't need much pressure", so knowing too much may cause centrals I've tried running 5cm. Last night was pretty good. For the first 5+ hours I have few events, then a whole bunch in the last couple hours and an ahi of 6.3.

I'm going to try staying at 5cm for a few more days to see what happens but I feel much better today so hopefully I'm on the road to relief.

I will update once I have the bipap for a bit.

Thanks again for all the help - Ed

[Ezil71]

I've now had the new machine for a little while and unfortunately the results aren't what I was hoping.

I'm able to tolerate the machine all night which is good. No significant aerophasia most nights.

What doesn't make any sense is that seemingly regardless of pressures a huge majority of events are registering as central apneas. Usually 75%-95%+ in any given night.

My AHI with the new machine (Resmed 10 VAuto at 8/4 PS4) has been all over the place. A few nights down in OK range under 5, but most around 10-12, same as the previous machine. I even had one up at 24.8 which was really odd.

Any ideas on what to do next? I'm trying to get another appointment as soon as I can but it may take a while.

I'm new to the auto bipap so perhaps there are some settings that could help? What are TI min and max for?

Currently I've trying to go back to lower pressure (very low) because that at least eliminates aerophasia. My obstructive and hypopnea numbers are still good at the lower settings. When I wake up in the middle of the night my ahi usually shows pretty decent but by morning it climbs up. Always with majority centrals. Neither of my two titrations showed centrals but my first diagnostic study did.

Here is a screenshot from last night as a summary.

https://1drv.ms/i/s!AgFs7hWqVGNflg8tBz9jbOr_JNOA

- Ed

[Sleeprider]

Your latest chart indicates you are using PS 1.2 over 4.0-5.2 which is a much lower fixed pressure than your post suggest, PS 4.0 over 4.0-8.0. This is very low pressure, and yet you are managing to have a tidal volume of 580 at a respiration rate of 11.6. This rather slow breathing rate averages over 5-seconds per breath, so it would not take much of a breathing pause to record a central event. It might be interesting to look closer at those CA events and see how long they are, and if they are just an extension of the rather slow breathing rate.

Ti max and Ti min are usually at default values of 2.0 / 0.3. Mine are set at 2.3 / 0.3, and it just gives a bit more time on inspiration. There is no reason not to experiment with it, and decide if you like it or not, but there is no right or wrong here, and it's not likely to make a big difference.

I think we have previously discussed ASV and it could be that is what you need to eliminate the numerous CA events. Meanwhile, you might try to add back in PS up to 3.0 so you have just a bit more IPAP pressure. Keep in mind, we don't treat CA with CPAP or BPAP, we just try not to make is worse. If you have central apnea, the appropriate treatment is ASV.

[Ezil71]

yes, I've lowered PS because having it higher doesn't seem to make any difference except adding to aerophasia. I'm basing that on some experimenting I did before getting the bipap as well as the tech during the titration telling me I did well at only 5cm.

The oddest part is that my titration didn't show any centrals, which all 3 machines I've had (dreamstation, resmed auto v10 and now the aircurve 10) show.

Here is a shot of an event from last night.

https://1drv.ms/i/s!AgFs7hWqVGNflhDU7QDwzHH3GKvr

I looked at several and they are all 10-15 seconds for the most part.

If I do indeed need ASV it may be difficult to convince the doctor since the centrals didn't show during either titration.

My sleep quality hasn't been good with a few exceptions (a couple 90 min windows where I wake up in the middle of the night feeling rested). Lowering the PS helps some.

I can post some graphs with the 8/4 PS 4, but basically they are the same, just with more 'centrals' and higher ahi.

[Sleeprider]

I wouldn't expect CAI to improve with increased PS, and you have found relief for the aerophagia. I'm at a loss what to suggest. You are at very low pressure, and the only real mitigation that might remain is fixed pressure, no EPR. I don't know that it would make any difference, but have you tried straight CPAP at 5.0?

[mymontreal]

Some parallels with my own challenges, so following thread...

Good luck with finding a solution!

[richb]

You are going to need an ASV machine to deal with the Central Apnea. Te problem is that it will jack up the pressure when it senses that you are not breathing. This will cause you to inhale but might also cause aerophagia. You need to talk with a sleep specialist who can deal with your Central Apnea. Your present machine cannot help you.

Rich

[Ezil71]

I have been doing some more testing and have a bit of hope. While trying lower pressures didn't solve anything re: centrals, I took a closer look at some of the other variables - TImin and TImax as well as trigger and cycle.

After finding a min/max that felt OK I spent quite a while testing sensitivity for trigger and cycle and discovered that having both set to the highest sensitivity seemed to feel the best.

My numbers from last night were 2.7 ahi! and at least for part of the night I had a session of really restorative sleep, such a great feeling.

I ran at my perscription settings of 8/4 ps 4 because with the sensitivity set I was no longer feeling I was fighting the machine, but breathing smoothly so I wanted to see if the aerophasia would be better. Not really, but certainly not the worst I've had.

I think the trigger setting may be slightly off, I will try the second most sensitive setting tonight.

I'm still not clear some of the report values/settings but here are my numbers from last night:

TImin 1.3
TImax 3.2
Trigger very high
Cycle very high

leak - 0 (I've been very consistent with that thankfully)
Vt 500ml
RR 14
MV 7.1ml
Ti 1.5
I:E 1:1.9 (this is different than before, not sure what a good value is?)
Spont Cyc 64.0% (this had been up at 95+% before)
AHI 2.7
Total AI .9
Central .6

Hopefully this isn't just a one off/one night thing but it is nice to feel I may be moving in the right direction.

[Ezil71]

To report more good news..... more testing and I have successfully had multiple nights with ZERO centrals!

It seems the biggest difference was getting the machine trigger and cycle settings to 'very high'. That combined with getting the TI min/max about right and a slight increase in pressure to 9 over 5 with PS 4 has me sleeping much better. I've had at least a few nights of what feel like real sleep and even remembered a dream (which has almost never been the case for me). Getting the timing right also has my aerophasia much more under control. It still is there, but much better.

If my numbers stay stable at these settings, is it worth trying to move the pressure to lower the hypopneas?

Here is a shot from last night:

https://1drv.ms/i/s!AgFs7hWqVGNflhH33kSlThYYDdLd

[PaytonA]

You might want to update your profile. It sounds like you currently have an Aircurve 10 S or Vauto versus the autoset that you list. Sounds like you are doing well. Great job.

Best Regards,

PaytonA