2.5 years on CPAP, still very tired

[Gideon]

OK, here we go.

Your Central Apneas this time.  
You have had it for a very long time.  I am surprised that it is not lower.  Looking at your closeups it looks like it is being driven by CO2 concentration in your blood.  When it goes low you have Centrals.

Looking at your EPR=1 I see a notably better AHI.
Let's verify this a little better.  I'd like you to us EPR=0 for a week, then EPR= 3 for a week.  I think you have the EPR=3 in your history and that will work.

If this is based on CO2 levels there is a treatment called EERS which is fairly easy and fairly low cost, which slightly increases the CO2 levels in the blood.

A Primary driver for breathing is a high level of pCO2 in the arterial blood that is sensed by Chemoreceptors. This is sensed and a signal to breathe is initiated. It is not a low level of oxygen that provides a signal to breathe, it is a high level of CO2. How does this occur? Our CPAP/APAP/BiLevel Devices are designed to improve our breathing. One part of this is to improve the exchange of blood gasses. When too much CO2 is washed out no signal to breathe is delivered, thus a Treatment-Emergent Central Apnea. Keep in mind that we are dealing with people who have been suffering from poor breathing for years. Their bodies have adjusted to this environment, they are used to higher levels of CO2 in their blood so lowering the CO2 to more 'normal' levels passes through a threshold that fails to produce a breathe now signal

Please read this http://www.apneaboard.com/wiki/index.php...tral_Apnea
and this http://www.apneaboard.com/wiki/index.php...ace_(EERS)

Up front EERS is used by a few sleep centers and doctors in the Boston area.  Very few other doctors use it, very few have even heard of it.  We have seen it work for a couple individuals here.  Think about it.

[Sleeprider]

I will add to Fred's assessment that you have a combination of both flow limitation which drives your pressure higher, and is best treated with EPR or more precisely pressure support; and CA events which can be increased with the use of bilevel pressure (EPR/PS). So what do we do when we have conflicting therapy directions to consider? Surprisingly, EERS not only increases CO2 to fight CA events, it also increases respiratory drive to improve tidal volume, and increases your tolerance for bilevel pressure. So EERS addresses multiple problems, and enables a treatment pathway that otherwise causes CA events.

One other observation from your charts. Your median and 95% flow limitation with EPR3 is 0.07 and 0.24 respectively with pressure from 9.36/6.36 to 11.30/8.30. With EPR at 1, the flow limitation rises to 0.20 to 0.48 with pressure from 11.56/10.56 to 13.90/12.90. So EPR not only reduces your flow limitation and hypopnea events to very good level, but it reduces your pressure needs significantly. That is why EPR is so comfortable and improves OBSTRUCTED breathing. If you can achieve both better efficacy and lower pressure by rebreathing a small volume of expired CO2, I think the results are logically predictable; you will feel much better. EERS helps to prevent the side-effect of bilevel pressure of increased CA events, and allows better treatment at lower pressures.

[ahunix]

Thank you, bonjure and Sleeprider! Finally, I got a clear explanation of my situation. My doctor told me AHI close to 5 is considered treated, but then he can't explain why I'm so tired.

Bonjour, I will start the 7 day EPR0 experiment and report back. My question is, should I start EERS treatment now (seems I need to build the device on my own?) or should I wait for the EPR0 experiment?


Another question, what do we expect to learn or confirm from the EPR0 experiment? My understanding is that EPR3 reduces flow limitation and then lowers pressure. But it increases CA in my case because it flushes out too much CO2, to the extent that my brain fails to trigger breathing. EERS let me retain the benefits of EPR3, while the increased CO2 level causes my brain to trigger breathing. So ideally, I will be treated by EPR3 and EERS. Is that right?

Thanks!

[Gideon]

I'm trying to demonstrate that EPR=0 definitely lowers your Central apnea and is not a random one off improvement. This Demonstrates that your centrals are driven by CO2 levels. Yes I do expect your obstructive apnea to be worse for this period.

The end expectation is that with EERS, which we will need to titrate, will minimize your Central Apnea and allow an EPR of 3 to treat your obstructive events and flow limits.

I would not be surprised if you need a BiLevel such as ResMed VAuto to use PS higher than 3.

What I looked for in your detailed charts was some waxing and waning of the flow rate which indicates a CO2 level fluctuating around the apneic threshold. Look at your CSR close up. Not all of your CA events are that obvious and you may have other causes at work.

Let's start talking about implementation

You will need a mask that you will never use without EERS that seals well for you. A mask leak will Purge the dead space rendering the EERS ineffective. EERS is thus more sensitive to leaks than a conventional mask set up.

What mask do you intend to use? You should also maintain a conventional, nonmodified mask.

To continue along this line of EERS treatment, because it is considered as unconventional by many, likely including your doctor's, I want to know that you desire to proceed.

[ahunix]

Thanks, bonjour. This all makes a lot of sense, and I definitely would like to proceed with the EERS treatment with your help.

Here is my last night's result (EPR=0). CA decreased, OA did not change much, but Hypopnea increased:

https://imgur.com/a/9PkYU3B

I will continue with the experiments.

Also, I am currently using a nasal mask. In addition, I have a new DreamWear (under the nose nasal mask).

Thanks!

[Sleeprider]

We can track the relationship of flow limitation to EPR.
With EPR 3, FL median 0.05, max 0.19, Hypopnea 0.35, CA 1.30
With EPR 1, FL median 0.02, max 0.48, Hypopnea 1.39, CA 1.08
With EPR 0, FL median 0.19, Max 0.36, Hypopnea 1.81, CA 0.91

The relationships of these three parameters is pretty obvious. With higher EPR, flow limitation and hypopnea is lower, but CA is higher. None of these results are unacceptable, but I think you will find more fatigue with greater FL and H. Your CA events are sometimes higher with greater EPR, but in general, I would trade CA for H at this level. With EERS, I think you treat both. It is worth noting lower pressure is possible with EPR than without.

[Gideon]

On the mask that you intend to use for EERS, where does the CPAP hose connect?  At the Mask directly? or is there a short hose to connect to the main hose like the 18 inch one on my P10.  Connecting directly to the mask is best because then we don't have to be concerned with the additional dead space.

Coraflex comes on a roll and you need 3ft of it.  Ask your DME or Lab for 3 ft of Coraflex.  It is cuttable in 6-inch segments.  You need a 6, 12, 18-inch segments, normally comes in 100ft rolls.  search for Corr-A-Flex  There may be a user here with some available.

Here is a thread to read  http://www.apneaboard.com/forums/Thread-...light=eers

[ahunix]

Bonjour and Sleeprider,

I finally finished the EPR = 3 experiment. It took longer because somehow for a week my CPAP was not recording the numbers. I really appreciate if you can give me a diagnose based on the results.

Here is the comparison between EPR=3 and EPR=0: Google Spreadsheet

Overall, after changing to EPR=0, I feel the same: very tired and sleepy during the day.

In terms of numbers, as you can see from the Google Spreadsheet, AHI does not change much, hypopnea increased (from 3 to 11), OA reduced (from 5 to 1), CA reduced (from 15 to 9), RERA increased (from 0 to 2), EPAP, Flow Limit, and Pressure all increase.

Here are the screenshots:

• Google Spreadsheet as an image  
  
• 11 days screenshot of EPR = 3: https://imgur.com/a/ePBfqzt
  
• 11 days screenshot of EPR = 0: https://imgur.com/a/9PkYU3B
  
• Overall screenshot (note for a few days CPAP did not record results): https://imgur.com/a/2IsDmiE
  

From these results, do you think EERS is the right solution for me? If so, I will be working on getting the equipment.


Thanks so much!

[Gideon]

You, as is typical of Central Apnea are having consistently inconsistent results. Your "bad" per the numbers days are worse with EPR=3, but EPR=3 is giving you better results with the flow limits.

The spreadsheet would be better if indices were provided instead of counts, CAI, OAI, and HI. This compensates for nights of different lengths.

EERS would somewhat better manage the centrals while allowing a higher EPR to manage the hypopnea and flow limits.
I cannot say how much impact EERS would have or if you would even notice it. I will help you with it IF you wish to go down this path.
read this thread http://www.apneaboard.com/forums/Thread-...a-sherwoga

[Chamomile]

Welcome to the forum. Sorry you are struggling with your cpap.
I have also struggled to come to a place of restorative sleep with my cpap.  Reading your post, my first thought was to look at your leakage rates, which are actually much better than mine were the first few years.   

Pondering further . . .This may not be an issue for you, but eventually we discovered I had LOW ferritin levels. Iron pills did not improve it. Ultimately I had an iron infusion which brought me up to normal. Might be something to ask about, as apparently the sleep centers do not normally test for that, even tho’ low ferritin is linked to restless leg.

I changed mattresses . . . changed pillows . .  . Anything I could think of that might help.
Another thing I have added is a neck brace, recommended through the Forum, called Dr. Dakota’s. I did have to edit the neck strap, because the way it is made is very awkward to attach securely. I cut the strap and added velcro, which works well.

Not sure if any of these will help you. I assume you had a complete physical looking for any other underlying causes.

I understand your frustration, and hope you find a solution that works for you.