[CPAP] explaining a burst of CAs

[mittens rex]

I thought I had things figured out after 17 days of using my CPAP (and a lot of poking around here looking up answers to my questions).  Night before last I had the best measurements yet, AHI=2.47.  No more adjustments needed!  Then this morning Oscar tells me that last night's AHI was 33.28, with a long, long string of CA's. 

My instinct is to leave all my settings as-is and give it a few more days to see what happens, but I wanted to see if anyone had thoughts.  

My initial prescription was for pressure min 6/max 10.  At 10 I had enough noisy mask leaks to wake me up constantly, as well as a lot of discomfort.  I only learned about storing the data on an SD card about a week ago, so I don't have a ton of detailed data, but I do get clusters of CA's, usually starting around 4 am.  After some fiddling, a max pressure of 8.6 with EPR of 1 was comfortable, and at least for one night, dealt with both the OA's and CA's.

I'm including a screenshot of last night's values.  I've zoomed in on two roughly 10-minute intervals, one with a mix of OA's and CA's, one that's a long string of CA's.

Two questions:
1.  Am I just overthinking?  Should I just leave the settings as-is and wait to see what happens?  Go back to my original prescription?  I know you're not supposed to tinker with it daily or you don't get a good idea of how it goes, but the difference between the two nights was so surprising.
2.  How do I interpret these clusters of CA's?  My sleep doc hasn't had much advice other than to treat the OA's and see if the CA's respond along with them.  I don't see him again for a couple months.


           

[Old Steve]

You are having Positional Apnea, evident by the clusters of apneas starting around 3:20AM.  Pressure alone will not fix Positional Apnea, you need to find a position that eliminates your chin tucking.  Imagine a water hose being bent over to stop the flow of water.  I eliminated my Positional Apnea by sleeping only on my side.  You can try that or a shorter pillow, staying off your back or a soft cervical collar to stop the chin tucking.  See the link below for more information on Positional Apnea.  
Leave your minimum pressure at the 8.6cm or higher and raise your EPR to 3, to help with your high flow limits (like mini apneas that are not included in your AHI).  You also need to work on your leaks, although not terrible they are not good, leaks can cause arousals and if high enough actually stop the CPAP from treating your apnea.  Finally an AHI of 2.47 is nothing to write home about.  The medical profession & insurance says that less than 5 AHI is good, actually they are saying that below 5 AHI you do not qualify for a CPAP machine, I would shoot for an AHI of 1 or less.

So find a solution to your Positional Apnea, leave your pressure at 8.6cm or higher change the EPR to 3, eliminate the ramp as soon as you can and work on the leaks.
Then post some more charts.

Also when you post more charts eliminate the calendar, we can see more information concerning your treatment when it is gone.

[mittens rex]

I was hoping I'd be able to fix the problems and come back with a good update...but no such luck.  I've tried three different collars (one I already had from hurting my neck, one more adjustable one that was recommended here, and then a ReLeaf) but couldn't sleep with them on.  So I've been trying to keep a pillow under my chin so I can't chin-tuck.  (Now that I'm paying attention to it, I see I chin-tuck even when I'm on my side.)  But the pillow isn't staying in place very well.

Leaks are still a problem.  I can't figure out how to stop them--I move around so much at night, I end up having to adjust the mask a lot.  I did figure out I have fewer leaks with the nasal pillow rather than the full-face mask, but it's still noisy when I move and it becomes dislodged.  Trying to put the pressure back to where my doctor had it (6/10) last night just had the thing blowing at my face, hardly making contact.

I'm including the past three nights of charts--this time with the calendar removed, hopefully it's easier to see.
           

[Old Steve]

You are now getting almost all Clear Airways

[Old Steve]

I wanted you to set your Minimum pressure at 8.6cm, not your maximum pressure at 8.6.  Leave the maximum where it was at 10cm and change your EPR to 3.  There are times while you are sleeping that your CA's and Apneas are not real bad.  So I think that the positional Apnea is still causing the vast majority of your problem.   I do want to know if you had several CA's on you sleep test to make sure that Central Apnea is not a problem.

 I have to put two folded blankets against my back to stay sleeping on my side, if I do not stay on my side I will have a chart very similar to yours.  They do make some "Sleep Apnea Pillows" that will help keep your head in position.  

Anyway, try the following

Min Pressure 8.6 cm
Max pressure 10cm
EPR 3
Blankets against your back

Give it two nights then post new charts.

[mittens rex]

I'm gonna blame my reading comprehension skills on the apnea!  Back in a couple days with more data!

[SarcasticDave94]

Do you have your detailed sleep study report to show us in redacted of personal info? The physician recommendation and the event table at minimum would be helpful. This is regarding the CA.

[Dormeo]

Like others who have replied, I agree that there's a positional element here -- the clusters of OAs are almost certainly related to your sleep position.

The clusters of CAs may have a different explanation. Sometimes a CA can set off a period of unstable breathing, where each pause (CA) is followed by arousal breathing, which in turn sets off another CA, and so on. Arousal breathing is deeper (and often messier looking) than normal asleep breathing. The deeper breathing can deplete the amount of CO2 in the blood, which slightly reduces the drive to breath until more CO2 builds up.

CAs can show up when PAP treatment begins, even though they didn't show up during a sleep test. This is called "treatment-emergent central sleep apnea" (TECSA). It's pretty common and tends to resolve on its own.

I'd turn off EPR in your place, because EPR can exacerbate TECSA. I'd leave the settings alone for now and concentrate on resolving those OAs through changing your sleep position.

Please keep us posted. Although I do want to be pretty reassuring about the CAs, there certainly are a lot of them, and we'll want to help you as you keep an eye on them.

[ejbpesca]

Positional apneas may occur by chin tucking which closes off the airway but would most likely show as OAs, not CAs. (Clear Airway apnea)  CAs may appear at the beginning of therapy and slowly reduce as I think your OSCAR charts are showing.  EPR can also cause CAs at first then lessen with time.

My positional apneas are not a chin-tucking issue. They occur when I roll to my back during sleep which I cannot prevent and consciously do to relieve pain at times.  Gravity pulls down sagging tissues, I snore, and clusters of apneas with up to one a minute (AHI 70) for up to over an hour appear on an OSCAR reports.  They had plagued me for years.

What addresses positional apneas for me was raising my min. pressure.  It was the F40 mask that allowed me to raise the pressure.  My full face masks (5 of them) leaked too much at the pressure I needed. They would blow up and off my skin, air blowing into my face and eyes at the pressure I need for therapy.

Did your sleep study report show many CAs?  If a large number of CA's persist your machine may be changed for another type.

Were you switched to a full face mask during the sleep study due to mouth breathing? A hybrid mask like the F40 is an alternative to a full face.  It acts like a nasal mask until mouth breathing occurs.  It is much smaller, does not go over the nose, is lighter, and more flexible than a full-face mask.

Chin straps, taping, and/or collars work for some, but for me they are ineffective.

.

[mittens rex]

Hi all--

Thanks so much for your comments!  The CA's showed up on my original sleep study--I'll include the info on this reply.  They were the really surprising part of the study.  I hadn't even gone in for sleep apnea; my PCP thinks I may have nocturnal seizures, and we're still waiting for a workup for that.  Those take place usually in the first hour or two of the night, and are all I thought was wrong; I'd never realized I was having any problems in the second half of the night, but as you see, even during the sleep study things really started getting worse in that 3-4 am range.  The sleep doc's recommendations were the 6 min/10 max settings, with no EPR mentioned.  And ejbpesca, the mouth mask was recommended by my medical supply place because I couldn't stop opening my mouth, especially in that 10 pressure range--but the leaks and discomfort sent me back to the nasal pillows, and I think I'm doing a better job keeping my mouth shut.