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Central and Obstructive Sleep Apnea, Recommendations?
Central and Obstructive Sleep Apnea, Recommendations?
I know this question gets asked often. I've read through most of the relevant threads on here on this topic but thought I would ask you all your thoughts on my particular situation.

6'2" Male, 240 lbs. High blood pressure. I don't get a ton of sleep generally (around 6 hours a night), which might explain some of my general fatigue. General symptoms: some snoring as reported by girlfriend; have woken up gasping for air (also reported by girlfriend); generally don't feel super refreshed; often fall asleep while watching TV, etc.

Did a home sleep study. Had the following results:

SUMMARY: The patient had 28 apneas, there are 12 obstructive, 0 unclassified, 16 central and 0 mixed apneas; and 39 hypopneas for a combined apnea-hypopnea index (AHI) of 12.4 respiratory events per hour. There were 57 snoring events recorded.

OXYGENATION: The patients average oxygen saturation was 97, and the lowest saturation was 82%. There were 5 minutes (2%) below 90% saturation. There were 1 minutes (0%) below 85% saturation.

PULSE RATE: The patient had a minimum heart rate of 51 beats/minute, a maximum heart rate of 90 beats/minute; and an average heart rate of 62 beats/minute.

I'm overwhelmed by the number of options, hence my post. I've read on here that for those with some central sleep apnea, ASV may work better? My prescription says I need an AutoPAP with pressure set to between 4 and 20. Does this make sense to you all? I ask because it says nothing of ASV, maybe cause my central sleep apnea isn't that big a deal? I'm just sort of lost.

I'm also wondering about the types of masks. I'm a very "uncomfortable" sleeper so I know having something huge and bulky may really not be great for me. I've read good reviews about the airtouch F20. I am currently a mouth breather but not sure if that would change if my apnea improves. Any help you all can provide would be very helpful. 

Most importantly, I had 12 obstructive apneas and 16 central apneas. Does the fact that there are central apneas change the recommendation? I would prefer not to get an ASV as it is so much more expensive.  I am currently considering the Resmed Airsense 10 AutoSet CPAP with Humidifier. Sorry for the barrage of questions. Thanks for any help.
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RE: Central and Obstructive Sleep Apnea, Recommendations?
When you get a machine, do a equipment list on your profile. Also down load OSCAR. You need to monitor your progress on your machine.

At the top of the home age here, big black bar click on OSCAR and download it. In order to see what Central Apneas are real, and not awake/arousels rather than stop breathing events. Does your girlfriend notice you stop breathing?

Based on your study results will determine what machine you need to start....... that might change per therapy results and Ins Co. requirements. No Ins Co then your Dr... will have to see what you need. If you can post your sleep study results here that would beneficial too...very beneficial. Dr's write up and the polysomnograph chart.

I would let the crew here see your sleep study results first before you choose a machine.
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RE: Central and Obstructive Sleep Apnea, Recommendations?
Thank you optimal.  My girlfriend has noticed me stopping breathing, or waking up gasping for air as if I had been holding my breath.  I too know I do this sometimes, especially as I'm falling asleep.

My insurance is very high deductible so, for all intents and purposes, this is all coming out of my pocket, hence my focus on cost somewhat.

I'm attaching my sleep study results, thanks for the suggestion.

Attached Files Thumbnail(s)
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RE: Central and Obstructive Sleep Apnea, Recommendations?
idk this for sure but I'd be surprised if a psg or even a home sleep test would score ca that isn't 'real'.

in the US, it's unusual for anyone to be prescribed anything other than a cpap/apap regardless of what the sleep test discovers. in many many cases, it's not the right machine and many many people fail to push for better treatment so either suffer for years or give up pap. the pressure range of 4-20 pretty much indicates that your condition hasn't been analyzed very well, but that's what will happen here with member help.

fwiw, I had a previous diagnosis of central sleep apnea and a more recent home sleep test that documented something like 204 oa, 192 ca and some h and still I was prescribed apap.

2 things to note about that.

apap brought my ahi down from the 72.x during the sleep test ahi to between 5-10, mostly around 5-6. so somehow, in my case, which may not be like yours, apap reduced both my oa and ca. I've yet to read/hear how and doc had no explanation.

otoh, while apap left me feeling marginally better I still felt pretty awful. with help from here I bought and self titrated a used asv and my ahi fell to under 1.0. fantastic. well, turns out I also have periodic limb movement (plm) which continued to fragment my sleep because the resmed machines raise pressure against flow limitations and I learned the hard way that pressure can't overcome plm triggered flow limitations. then, with member mper6794's encouragement and titration assistance I bought a used bilevel which allowed me to limit max ipap better than with the asv, reducing the disturbances that come with high pressure, including leaks, aerophagia and arousals. my bilevel ahi is higher than with asv but that's less damaging than the pressure fluctuations I experienced with the other modalities.

so, properly optimized apap (4-20 cmw isn't likely your best setting) can do a world of good. or it won't. some cases can be complicated. in addition, insurance wants you to fail apap before trying a different modality and even then you might not have the right machine and you'll have to fail another and maybe another to get to asv.

I had to rent the apap for 3 months before insurance would 'buy' it (my money against deductible). if yours is similar, you can try apap for the rental period; just don't make the mistake I did if you don't feel as well as you'd like. despite my complaints, my sleep doc was very pleased with my 5-6 ahi and told me to go ahead and buy the apap. in retrospect, I should have refused and demanded more effective treatment. trouble with that is 3 years in I'd still be struggling through the slow, expensive and inefficient system we have to contend with.

like yours, my deductible is high, so all pap related expenses are out of pocket. considering that plus the expensive and poor poor service from the sleep doc, I gave up on the system and have since relied on the kindness and knowledge of AB members.

buying used machines without a prescription saved me a bundle of money and a lot of time & aggravation. on the flip side, I felt alone without the help of the professionals but it didn't take long to figure out their help was inefficient at best and up til then not very effective. then I found this forum and haven't looked back. at some point I may have to 'face the music' to get a new prescription, but I'll cross that bridge when the time comes. I trust that years of data produced by the machines will be all the documentation I'll need, if only a doc will look at it.

I guess I've worked myself around to suggesting you try the apap, especially if you can rent it first. if after 1-3 months you feel good, buy it. if not, return it and either push your doc for additional attention or follow the excellent guidance you'll get here.

masks are difficult since we're all shaped differently. because I have a long full beard, the only mask that sealed during my titration was the resmed airfit p10 nasal pillow mask. it's one of the lightest, quietest, least intrusive masks around, as I understand it. mouth or lip leaks can be a problem with nasal pillows - I have to wear a soft cervical collar to reduce clusters of oa and lip leaks. not the most comfortable thing and not 100% effective, but nothing I've tried has worked better.

it takes a lot more trial and error than a 6 hour titration to get machine type, pressure settings, mask fit and other comfort issues sorted. I suspect most people take the conventional route, wrestling with their doctors and insurance companies. otoh, thousands have been helped through the process by anonymous internet cpap users here at AB.

best luck as you settle into apnea therapy. I look forward to reading about your progress. don't hesitate to ask questions and post oscar charts. no matter how you choose to proceed, you won't be disappointed with the attention and guidance you get here.
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RE: Central and Obstructive Sleep Apnea, Recommendations?
Hi and welcome to Apnea Board.

My thumbnail sketch is with 16 CA to 12 OA and throw some hypopneas in there, a CPAP/APAP is hit or miss for you. Let's visit the 2 likely paths I see IF I am correct in the 16 CA being called pre-existing or predominant. If I happen to be wrong, skip to the end where I'll say "use the APAP and have a great sleep with it".

I do not know or need to know specifics on your insurance, but I think it's safe to say you have concerns about lots of spending, high deductibles, or something like that when it comes to CPAP machines and costs. OK so far. Now here's 2 scenarios about getting a PAP of some strength.

Insurance is the main source for costs route:
BTW I have the ASV so I've been here. They do not give shirts, but I did get machines, etc. covered. Normal insurance pays a lot/you pay little to none route is you take the sleep study as you did. You will get a CPAP or APAP with mask. You may have a second study called titration. It's the same as the sleep study but some guy is remotely changing the settings while you sleep and recording settings, time, and apnea event results. The end result is they seemingly randomly pick a combo of pressures you did well at. Mostly, they are wrong unfortunately. Next, you are connected to a supplier that is a DME, that's a durable medical equipment provider. They receive the script from the doctor that says you get machine X set to XYZ. You have to pass a compliance time period or insurance stops paying and you lose the machine. You must use the machine 4 hours of every 24 hr. period for 21 days of 30 with 3 months chances to pass this. Afterwards, pass and continue or fail and lose the CPAP.

Now this story changes for some like I think you have, and I know I have it. Central Apnea in pre-existing flavor. See that big paragraph above? If you have frequent CA you may be OK or better on a CPAP/APAP. If not and you fail compliance because CPAP makes CA worse, great news you go to the next part. Repeat all of that except where I said CPAP/APAP substitute BPAP or Bi-level machine and do ALL this again.

And if you do in fact have pre-existing CA, the BPAP will be nasty; at least it was for me. If you have CA like I did, you WILL fail this compliance. Even so, the insurance needs you to try to meet compliance as above. If you pass and members here can help you avoid CA, great, end of the story. If you cannot be successful, go on to step 3 and machine 3, PSG sleep study 3, titration 3, and compliance 3.

PART 3: You are now either at the ASV or for some you can be dealing with an ST. I made the doc skip the ST because I was DONE with the Frankenstein experiments. So this goes one of two ways. You would repeat all the above in CPAP and BPAP and go with ST or the ASV. If you are firm but nice, and your numbers line up, let's move on to ASV. If not, well there's the consolation of the ST. Eh not so fun sounding, and I have no idea by trying it, but I refused the ST madness.

OK with me still? Great. Eventually, you should make it to the ASV. I still prefer ResMed's products, even for ASV. Recall above you probably had X number of PSG and titration tests. You still must pass compliance. Alright, now with this path, insurance has paid their percentage, and you've paid yours. Now here's the other possible story.

If your insurance will pay very little, you can ask Dr. Dolittle or whatever his name is to write you a script for the ASV with whatever pressures he wants. It must include, in my opinion, that you will get a ResMed AirCurve 10 ASV, heated hose, and mask of your choice. And Dispense As Written. You take on full financial responsibility to buy your own ASV in this segment, and you tell doc this as well. You may want insurance to pay for supplies, so the compliance may be important still. They will pay even if you bought your own machine, if you have doc provide records of medical necessity for whatever machine you buy. AND no titration is needed. We at AB are going to help you titrate yourself for free. I will tell you the ASV I mentioned has 4 therapy pressure settings, not counting Comfort stuff, like the humidity and heated hose, etc.

OK, there's my little story. Enjoy and use the APAP and have a great sleep with it.
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RE: Central and Obstructive Sleep Apnea, Recommendations?

"idk this for sure but I'd be surprised if a psg or even a home sleep test would score ca that isn't 'real'."

Simple..... I had numerous awaking/arousals during the night, mask leaks, wire harness, sleeping with my pants on COVID 19, You don't sleep well as at home. There's other issues with Caveman High blood pressure, basic stuff like rolling over, sighing, yawning, which can be flagged as a CA. And yes it takes alot more than a sleep study to reach a verdict, however, I felt alot better after a month of the right pressure to be under 5 AHI but I know I can do better.... the symptoms I have been experiencing for the last 53 years are far from the right therapy, so it's a start. My second study at the last 2 hours made a difference on bilevel titration. I felt really good waking up.... so I'm sure with sleeping in my bed without wires and the nasal resmed p30i the right pillows, chin strap and clear sinuses, and some time to get used to the machine, I'm sure I'll do better, if not a third study ASV titraton will be done.

Just from his experience I know realize why Ins. Co's start with CPAP.... OA can cause CA. And yes some people either throw in the towell or just live with it.
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RE: Central and Obstructive Sleep Apnea, Recommendations?
You are being setup with a recommendation for Auto CPAP with default pressure of 4-20. This is a pretty typical approach regardless of whether apena is central or obstructive, and as others have said, the results vary. CPAP does not treat central apnea, but it often makes it "good enough" for efficacy. Insurance is designed to keep you on the least expensive, effective option. It is also designed to transfer as much cost onto the patient as possible.

I think you will be issued Auto CPAP, and I hope you will request a Resmed Airsense 10 Autoset. There is a 50/50 chance CPAP will leave you with either a lot of CA or hypopnea that cannot be resolved. You will eventually be moved to bilevel therapy which will most certainly fail, and finally to the adaptive servo ventilator that is able to treat complex apnea (both obstructive and central) that is apparently what your problem is. In your case, having a titration study might be a good idea, but nearly without exception I have seen titration studies find a pressure that works during the test, but fails in long-term use. You would need to work with your doctor to ensure any titration study has the provision to move from CPAP to bilevel to ASV to find an effective therapy. Without that, it's a waste of time and money.

I think the best thing to do is to request that your doctor at least acknowledge you do not have simple obstructive apnea, and try to get a diagnosis of complex or mixed sleep apnea. This may help as you move forward with therapy. You will be issued a CPAP machine and the Resmed Autoset is probably your best option. That may be the end of the story, but I think you will continue to see relatively high levels of events. The wiki on justifying advanced positive air pressure treatment may help you to understand the game plan. http://www.apneaboard.com/wiki/index.php...+PAP&go=Go
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RE: Central and Obstructive Sleep Apnea, Recommendations?
You'll find some detailed information here: http://www.apneaboard.com/wiki/index.php...ackup_Info

But the bottom line is that it's reasonable for you to start with the ResMed Airsense 10 Autoset machine, using the prescription from your doctor to facilitate your purchase. The data capabilities of the machine, combined with the Oscar software, will provide a lot more information about whether successfully treating your obstructive events increases your CA events or not. CAs are quite inconsistent, so it is even possible you will see only a few of them after you start treatment. If worse comes to worst, and you are plagued by CAs, you can sell your machine and get at least some of your money back before you invest in whatever you need to try next.

Keep us posted, would you?
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RE: Central and Obstructive Sleep Apnea, Recommendations?
this is a split study result? CPAP/bilevel titration?
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RE: Central and Obstructive Sleep Apnea, Recommendations?
Thank you all for the very thoughtful and detailed replies. Unfortunately insurance isn't really a factor as my deductible is so incredibly high and I won't get anywhere near it. I did the sleep study on my own out of pocket as a result, and will have to purchase the cpap out of pocket.

I think I'll probably need to just get the Resmed Airsense 10 Autoset machine for now, along with a full mask AirFit F20 mask. I now understand that it'll like be a process of trial and error, unfortunately.

You all have been so helpful and I feel like, with your guidance, I will get a handle on this issue as it has been plaguing me. Thank you for being so welcoming.
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