new to cpap - waking up and central apneas

[SevereApnea]

Length of Clear Airways:
Mine are frequently 10 to 25 seconds: I don't worry about them. Assuming you have no lung or medical conditions, then holding your breath or not breathing for that long will not cause your oxygen levels to drop. I have unable to drop my own p02 levels in the past with sequential breath holds of 40 - 60 seconds. At that stage the Carbon Dioxide builds up and it is that which forces you to carry on breathing. 

As you have already pointed out some of our Clear Airways are not true Central Apneas because the machine cannot differentiate between the two: so it labels them as Clear Airways, not Central Apnea. 
It is still early days for you on CPAP. It can take up to 3 months or longer for the body to adapt, after which the CA events should gradually reduce.

EPR: yes, you are correct if you increase the EPR then you may want to increase the set Min Pressure by about the same amount.
If you go from Min 6 Max 12 EPR 0 and want to go to EPR 2 you would change settings to Min 8 Max 12 EPR 2 to keep things about the same.  Else your expiratory pressure may fall and could find some more Obstructive Airways events. A balancing act.
(You would not need to change the Max Pressure unless you are regularly maxxing out or bumping your head at the max. pressure.)

In your original post you were trying to correlate the number of CA and the sleep disturbance. The only way to find out if this is the case is try different settings.

When you went from EPR = 0 to EPR =2 your pressure excursions and flow limitations both improved which showed this worked for you.

What I am suggesting you try for a few days is to increase the Min Pressure by around 1 cm H20. Ignore the CA for now. See if you feel better. If you feel a little better, try increasing Min Pressure some more, maybe by 0.4 or 0.6 and so on.
When you stop feeling any benefit or feel some discomfort you can always back off again.

BTW, your leak rates are excellent and the envy of many, which means you have already conquered one of our biggest hurdles!
If you increase pressure a bit you may find you have some more leaks: if they don't worry you then that would be a trade off you may need to learn to live with.

You can do all this yourself over a matter of days or weeks and see what works best for you. That would give you way more data to look at than a 1 night titration study. Life if full of choices! Feel free to ask any more questions and keep us posted.

[Sleeprider]

When you say "exhausted the potential for self-titration on CPAP", do you mean trying to figure out the best pressure on my current machine myself (before doing the split-night study)?
Thanks.

I said in my post I did not think you had exhausted the potential for self titration with your existing CPAP.  You are receiving some coaching, including my suggestion for adding exhale pressure relief (EPR) because your apnea are associated with flow limitation and arousal.  In my opinion we are more likely to help you to find optimum therapy settings than a tit ration study.  The reason is that your residual event rate is not that bad, we know how to improve it, and by self-titrating, you will develop long-term trends for therapy in your normal sleep environment.  In a titration test, you will be evaluated in a clinic for a range of pressure alternatives.  The ultimate goal of the titration is to minimize AHI and hopefully demonstrate REM sleep.  Either way you will probably improve but we cost less and are more convenient.

[chavill02]

Length of Clear Airways:
Mine are frequently 10 to 25 seconds: I don't worry about them. Assuming you have no lung or medical conditions, then holding your breath or not breathing for that long will not cause your oxygen levels to drop. I have unable to drop my own p02 levels in the past with sequential breath holds of 40 - 60 seconds. At that stage the Carbon Dioxide builds up and it is that which forces you to carry on breathing. 

As you have already pointed out some of our Clear Airways are not true Central Apneas because the machine cannot differentiate between the two: so it labels them as Clear Airways, not Central Apnea. 
It is still early days for you on CPAP. It can take up to 3 months or longer for the body to adapt, after which the CA events should gradually reduce.

EPR: yes, you are correct if you increase the EPR then you may want to increase the set Min Pressure by about the same amount.
If you go from Min 6 Max 12 EPR 0 and want to go to EPR 2 you would change settings to Min 8 Max 12 EPR 2 to keep things about the same.  Else your expiratory pressure may fall and could find some more Obstructive Airways events. A balancing act.
(You would not need to change the Max Pressure unless you are regularly maxxing out or bumping your head at the max. pressure.)

In your original post you were trying to correlate the number of CA and the sleep disturbance. The only way to find out if this is the case is try different settings.

When you went from EPR = 0 to EPR =2 your pressure excursions and flow limitations both improved which showed this worked for you.

What I am suggesting you try for a few days is to increase the Min Pressure by around 1 cm H20. Ignore the CA for now. See if you feel better. If you feel a little better, try increasing Min Pressure some more, maybe by 0.4 or 0.6 and so on.
When you stop feeling any benefit or feel some discomfort you can always back off again.

BTW, your leak rates are excellent and the envy of many, which means you have already conquered one of our biggest hurdles!
If you increase pressure a bit you may find you have some more leaks: if they don't worry you then that would be a trade off you may need to learn to live with.

You can do all this yourself over a matter of days or weeks and see what works best for you. That would give you way more data to look at than a 1 night titration study. Life if full of choices! Feel free to ask any more questions and keep us posted.

Thanks for the advice.  I'll try increasing min pressure over time, and experiment with EPR some more too.  

I attached the last 3 days of OSCAR data (using EPR 1 with same pressure settings as before).  2/15 was a rough night since I think my allergies were flaring up and it was more difficult breathing through my nose. I didn't feel I slept much at all that night.  The other 2 nights were better with sleeping.  Although I'm still having the issues of waking up several times.

I have switched from the nasal pillow mask to the full nasal mask (N20) a week ago.  I like the new mask better.  However, leak rates are now higher.  Are these leak rates still okay in this data?

---

I said in my post I did not think you had exhausted the potential for self titration with your existing CPAP.  You are receiving some coaching, including my suggestion for adding exhale pressure relief (EPR) because your apnea are associated with flow limitation and arousal.  In my opinion we are more likely to help you to find optimum therapy settings than a tit ration study.  The reason is that your residual event rate is not that bad, we know how to improve it, and by self-titrating, you will develop long-term trends for therapy in your normal sleep environment.  In a titration test, you will be evaluated in a clinic for a range of pressure alternatives.  The ultimate goal of the titration is to minimize AHI and hopefully demonstrate REM sleep.  Either way you will probably improve but we cost less and are more convenient.

That makes sense.  I'll keep trying adjustments myself with the help from people here.  I feel I get much more help here than from my doc.  I'm very glad I found this forum!

[Dormeo]

Your CAs -- and, I hope, your arousals -- are settling down nicely. You will probably continue to see some inconsistency from one night to another; don't worry about it. Keep your eye on the overall trend.

I think you could try increasing your EPR to 2 any time now. But I have another thought about your FLs. They look fairly clustered to me, which suggests a positional element, perhaps tucking your chin down toward your chest. If you have a high pillow, try using a lower one. More information here:
http://www.apneaboard.com/wiki/index.php...cal_Collar

Your machine can compensate for your leaks with any leak level below 24. So the main question is whether they wake you up. If you sleep through them, no problem.

[chavill02]

Your CAs -- and, I hope, your arousals -- are settling down nicely.  You will probably continue to see some inconsistency from one night to another; don't worry about it.  Keep your eye on the overall trend.

I think you could try increasing your EPR to 2 any time now.  But I have another thought about your FLs.  They look fairly clustered to me, which suggests a positional element, perhaps tucking your chin down toward your chest.  If you have a high pillow, try using a lower one.  More information here:
http://www.apneaboard.com/wiki/index.php...cal_Collar

Your machine can compensate for your leaks with any leak level below 24.  So the main question is whether they wake you up.  If you sleep through them, no problem.

The arousals have settled down a bit.  

I'll try the soft cervical collar.  That's a good idea and I never thought of something like that.

I don't know if the leaks are causing me to wake up.  I can't even tell the mask is leaking since I use a cushion cover.  Do you know the best way to tell what exactly is causing me to wake up a lot?

[Dormeo]

If I knew what caused frequent wake-ups I'd be rich by now! But seriously, for you, it may just be the novelty of the PAP experience. It's a lot to get used to, and your brain may need some time to adjust.

You might also see whether any of these recommendations for good sleep are ones that you could start using:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

[chavill02]

The arousals have settled down a bit.  

I'll try the soft cervical collar.  That's a good idea and I never thought of something like that.

I don't know if the leaks are causing me to wake up.  I can't even tell the mask is leaking since I use a cushion cover.  Do you know the best way to tell what exactly is causing me to wake up a lot?

I sleep on my side all of the time. Does the cervical collar still help with sleeping on your side, or is it more for sleeping on your back?

[chavill02]

Here are some more Oscar images over last 2 weeks.  I've been increasing EPR from 1 to 2 and then 3.

The 3 images attached here are for EPR 2.  (I'll do another post with 3 more images at EPR 3).

It seemed that flow limits may have improved a bit.  However, central apneas are much higher now on EPR 3 (instead of EPR 1 or 2).

I'm still waking up a lot and tired during the day.  On 2/27: I used the cpap the whole night (most nights I only use it half the night) and was much more tired the next day.  Although I think that may have been partly since I had to wake up an hour earlier than normal.

Any ideas on what to try next to help with flow limits, centrals, arousals, tiredness during the day?  I've thought of:
-changing pressures some more?
-using EPR 2 instead of 3 (since EPR 3 has high centrals)
-trying the EERS modification (to help with centrals on EPR 3)
-using a fixed pressure
-eventually doing a titration study in lab to then switch to a bilevel or ASV machine?

Any other ideas or things you guys notice on my Oscar images?

Thanks.

---

Here are the Oscar images with EPR 3.

[chavill02]

It looks like the images all attached on my last post.

EPR 2 is for these nights - 2.22, 2.23, 2.24
EPR 3 is for these nights - 2.27, 2.28, 3.1

[Sleeprider]

Clearly more cetrals with EPR 3, but they are trending down as you adapt to it. I'm not so concerned about AHI as I am about what provides the best sleep and comfort.