New CPAP/APAP User - High CA Events (Post Arousal)

[yycsnore]

Hello Everyone,

I am excited to have found this forum that has knowledgeable folk that are willing and able to help each other with treatment issues and inquiries. I come to you today seeking insight/knowledge regarding what's been going on with my treatment.

Some background - I am a young, healthy male with a very slightly above average BMI (~26). I am athletic, have no background health issues in any way, shape, or form (apart from mild anxiety). I have a family history of OSA, and started to notice symptoms (daytime fatigue, brain fog etc.). My father has had much success with a MAD dental device, and I inquired with my doctors (I am in Canada) and had a sleep study that resulted in an AHI of ~11. I was a candidate for a MAD device, but could not afford the $3,000 price tag as I was in university. I purchased a well reviewed boil and bite device online and had good success with it for about 2 years until it broke. It largely resolved my symptoms, but given that it was a boil and bite device, had negative effects on my orthodontic alignment. Now, I am receiving orthodontic treatment for around 1 year and cannot use a MAD device as it would interfere with the orthodontic treatment. So I have been prescribed (and have been using CPAP/APAP) for around 6 weeks now. 

On most days, I still feel quite tired and fatigued despite having a good amount of sleep with the machine. I tolerate my mask well (philips dreamwear nasal) and do not have any issues falling asleep in the evening. It appears that on any given night, I have anywhere from 5-10 CA events per hour. As you can see in the attachments, I am under the impression that about 95% of these are post-arousal "centrals". My sleep tech has not been of any use at all, and when I inquired about the post arousal apneas they admitted that they didn't even look at the graphs, they were simply looking at the summary AHI report.

I notice on most nights that I have a very dry mouth upon waking up, and sometimes I even wake up because of the dry mouth. I know I have a tendency to mouth breathe during REM sleep (I guess snoring for so long accustomed my mouth to open). I do not breathe very well from my nose, and even at a pressure of ~9 I still feel like I am somewhat struggling to get enough air through my nose. I suggested I try a full face mask to my clinician, but she seemed opposed to the idea because she said insisted my mouth leaks were minimal and it would be burdensome. She recently set my machine to CPAP instead of APAP to try it out, but it seems like the data has stayed largely the same.

I have included the following attachments:
1) Initial diagnostic report
2) a "normal" night on APAP therapy - AHI of ~5.5
3) a typical CA cluster event


It would be infinitely appreciated if anyone is able to provide insight into why these CA events may be occurring, and what I can possibly to to reduce or alleviate them. I would be ok with an AHI of around 3-4 constantly. I know some folk around here have averages less than 1.5 nightly, but that's possibly not realistic for me, since my average night falls anywhere from 5-10.

Thanks!

[jaswilliams]

In your sleep study your showing Some CA’s so your CA’s are pre existing. Your machine won’t treat these you may find they reduce if you are on a reduced range of pressure but you need to be on a different machine, they may reduce over time but may not. I see your in Canada are you at altitude ?

[yycsnore]

Hello,

Thank you for the insight. I am indeed at altitude, about 1000m. As I understand it, my clinician mentioned that my central apnea index is not high enough for them to prescribe a bipap/ASV.  Given that my centrals are mostly "post arousal" in nature, do you believe those machines would be more beneficial?

[70sSanO]

You want an ASV not just a Bilevel. Years ago a lot of sleep docs thought a straight BiLevel would treat central apneas, but it doesn't.

If you absolutely can't get an ASV machine, I would probably take my max pressure down to 9 and see what happens. You may have some obstructives or hypopneas, but you might lower the number of your centrals. It is a balancing act. I fought centrals for a lot of years on CPAP and APAP and tried a lot of things that are not really used for central apnea. I started wearing a cervical collar for obstructive clusters, but it also lowered my centrals, maybe just a coincidence. You can raise the pillow height and that might have an impact. You don't seem to have a lot of leaks, but try a FFM if you want. It shouldn't make an impact, but strange things do happen. None of these are cures, but if you get some relief, maybe you can hold off the inevitable for a few years.

You may also want to look into EERS. I really don't know much about it other than CO2 is causing the centrals; that might be worse due to the altitude.

One thing that I found, at least in my case, was when I was able to keep my centrals at a pretty much constant level, 2 or 3, I was able to manage my sleep with an APAP. But when they became erratic, it was a sign that I needed to move on to an ASV.

Hang in there.

John

[yycsnore]

You want an ASV not just a Bilevel.  Years ago a lot of sleep docs thought a straight BiLevel would treat central apneas, but it doesn't.

If you absolutely can't get an ASV machine, I would probably take my max pressure down to 9 and see what happens.  You may have some obstructives or hypopneas, but you might lower the number of your centrals.  It is a balancing act.  I fought centrals for a lot of years on CPAP and APAP and tried a lot of things that are not really used for central apnea.  I started wearing a cervical collar for obstructive clusters, but it also lowered my centrals, maybe just a coincidence.  You can raise the pillow height and that might have an impact.  You don't seem to have a lot of leaks, but try a FFM if you want.  It shouldn't make an impact, but strange things do happen.  None of these are cures, but if you get some relief, maybe you can hold off the inevitable for a few years.

You may also want to look into EERS.  I really don't know much about it other than CO2 is causing the centrals; that might be worse due to the altitude.

One thing that I found, at least in my case, was when I was able to keep my centrals at a pretty much constant level, 2 or 3, I was able to manage my sleep with an APAP.  But when they became erratic, it was a sign that I needed to move on to an ASV.

Hang in there.

John

Thank you for the reply. I was skeptical when my sleep tech told me I have centrals, as I thought they were only for people with heart or neurological issues. This is all very strange to me, considering that I was managing fine and felt great using a mandibular advancement device.

I will see if I can get a trial with an ASV.

[Sleeeppp]

The ASV machine will treat the centrals as well as the other apneas - worth a trial.

[Gideon]

Based on the detailed chart your centrals, at least the few in the detailed chart, do not appear to be CO2 based, and as such unlikely to be altitude-induced or Treatment-Emergent, I suspect these are idiopathic. That means the cause is unknown.  

This likely eliminates the possibility of EERS being effective and means that, as noted many times above, that you need the ASV. The ResMed ASV is the most popular here and many of those users have used the PR machine.

[70sSanO]

If I might ask...

What in those 2 detailed CA's indicate not CO2 driven; and what would a CO2 driven CA shape look like?

It is just for my own knowledge.

Thanks!

John

[yycsnore]

Update:

I spoke with my respiratory therapist about what's been going on and my centrals. As it turns out, I had misinterpreted my sleep study. The AHI index of 18 consisted of primarily hypopnea events (13.5 hypopnea per hour, 4.5 apneas per hour). Of the 4.5 apneas per hour, 2.3 of them are central - as in throughout the sleep study I was experiencing 2.3 centrals per hour. This is a significantly lower number than the amount of centrals I am experiencing on a nightly basis now of anywhere between 6-10 per hour. I dug through my data and looked at all of the "good" (sub 5 AHI days) and found that almost all of them had a 95% pressure of lower than 8.5.

I lowered my max pressure to 9 last night, and had some decent results (AHI of 6). I am surprised that at his low pressure, I am only having a combined hypopnea/obstructive index of .6 per hour which means that I don't need a high pressure to resolve the obstructive events. I will continue to try lower and lower maximum pressures to see what effect (if any) it has on my AHI.

Cheers