[Treatment] Possible Complex Apnea Treatment Path Forward Thoughts

[khakitat1]

Background:

• Issues noticeably began Summer 2024 with waking early and inability to fall back asleep
  
• Home study showed no issues
  
• In Lab results: OA count: 23, CA count: 9, Mixed A count: 5, Hypopnea count: 38, RERA count: 32, Total AHI 4%: 13.5, Total RDI: 19.3, Arousal Index: 28.1/hr
  
• Vast majority of events scored on back (RERA position was not reported though)
  
• Diagnosed Moderate OSA (despite presence of MA,CA)
  
• I suspect I have complex sleep apnea with strong flow limitation component based on sleep study
  
• Exclusively a side sleeper (except for involuntary shifting while asleep)
  

Treatment and methods thus far:

• Received Airsense 11 APAP with starting pressure 4, autoramp, treatment 5-20
  
• after time being sub-optimal, worked with OSCAR data and Dr. to turn off ramp, treatment now feels best at 11-15 after 10-15 for some time
  
• tried soft cervical collar to stop air swallowing, worked but bit of neck pain, stopped that for now
  
• using chin strap to stop air swallowing, I believe I have trained myself to keep my mouth closed more easily now
  
• I have tried EPR of 2 for 1 day to help flow limits and Hypopneas, and while it did help those things, my Clear Airways events got worse and persisted for longer times
  
• Currently on EPR 1
  
• EPR off did not appreciably help for the 2 days I had it off
  
• been using CPAP for ~3 months now, compliant every day at least 8-9 hours
  
• I have little difficulty tolerating the device in general, and I believe I manage leaks well based on my charts for the most part
  

Persisting Issues to be optimized:

• Knowing this does not tell the whole story, my AHI floats around 5+ (with some events being sleep/wake junk)
  
• Continued Nighttime waking, mild fatigue most days
  
• Clear Airway and some Hypopnea are now dominant events, OA is rare
  
• Some wakings still associated with high heart rate and feeling of needing to breath as though out of breath
  
• I believe myself to be a high loop gain individual
  
• Many CA events I see seem to be obvious sleep/wake junk, but my transitional centrals are real and associated with O2 desat. on Wellue Checkme (I don't wear this often)
  
• Other real CA events I see are post sigh/arousal CAs which, to my understanding, are really a result of the arousal associated with ventilatory instability caused by the hypo/hyperventilation cycle that occurs post arousal
  
• Some CA events also seem to be due to random large leaks (likely when I'm rolling around) but I think its hard to determine causality here since ResMed reports leaks as horizonal lines on their graphs, and I do not know the methodology they are using for choice of time stamp of leak events. I know they are having to make some assumptions here to find and report a leak rate, so I'm not criticizing, but I'm curious of their methodology
  
• My breathing in general does seem to be periodic in nature, and while it often seems worse during what I think is REM, I wonder if it is periodic enough in general to be considered abnormal
  

My Current Thoughts on Path Forward:

• I believe I could benefit from lowering my flow limits further with higher EPR or a BI-LEVEL Device ideally, but my Clear Airway propensity is limiting me
  
• My first step would be to work with my Dr. and try an EERS modification since I believe I have evidence of high loop gain (breath periodicity with associated CA) 
  
• If I can tolerate EERS with benefit (less CAs, less periodicity of breath flow), I would like to then increase EPR/move to BI-LEVEL and see if I have less awakening/flow limitation
  
• Since my sleep study showed high RERA, I feel higher pressure support would help me knock out any flow limits I have that persist, but I must manage the CAs
  
• If EERS does not work and CAs and breathing periodicity persists, maybe I should push to get an ASV machine at some point
  

My Questions to Users Viewing This Post:

• Based on my statements and graphs, do you agree or disagree with any points I raised above about my likely condition?
  
• What would you suggest with my current APAP settings that may further help me optimize?
  
• Assuming you agree with me, does path of EERS to higher PS to potential ASV if all else fails make sense?
  
• Any tips to control those random large leaks I have (assuming the leaks are causing some of those arousals and not the other way around)
  

I do generally feel better these days than I did before, but I feel there is room for improvement if I can handle my Clear Airway events (which do not seem to be TECSA since they were present originally and persisted) and increase pressure support in some way to see if that improves my Hypopneas and flow limitations.


Thank you for your time and effort.

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[SarcasticDave94]

Welcome to Apnea Board,

You have some Central and some mixed in the test, as you mention. Current setup isn't bad to try avoiding the CA you get. Your test levels of CA and mixed weren't 50% of your total events, so ASV is probably way off in the future of a 90 degree fight uphill for now. That 50% issue is why you weren't diagnosed with Central Apnea.

I would try to make a case to get the ResMed AirCurve VAuto, 10 or 11 is fine. It does have higher PS to help would Flow Limits and the Trigger setting on High or Very High will help the inhale switchover sensitivity, which helps avoid more CA than now. Probably your short term best bet.

And I'd make the case to act now, advocating for VAuto. Complain about the discomfort regarding events, still tired, etc. Include the CA in the complaint as you see fit.

A PS, you can adjust your CPAP by yourself. Access the clinical menu via waking screen, click and hold both blue and purple squares for 5 seconds. There's the clinical menu for setup.

[jdougc]

Your flow limits are driving many of your pressure increases, and need EPR of 3.
The wake junk breathing makes your AHI much higher .
I use a 5 minute ramp set to my minimum pressure or .2cm lower. Shows up on charts better .
Ignore treatment emerging CAs for a bit.

[khakitat1]

   

[Dormeo]

Your general picture of the landscape seems very good to me.

The sleep-wake transition CAs skew the numbers, so keep that in mind. I'm seeing a few OAs right after you start the machine, when I doubt you are actually asleep, and I suspect you aren't asleep for at least some of those transition CAs.

You might have a smoother transition if you could focus on your breathing at the beginning of the night, taking slow and easy breaths. You might practice this during the day or evening.

I'm not sure why you prefer the higher pressure range; your breathing might be a little more stable if it were lower. Also, your inhalations are notably flow-limited, and using EPR of 3 is the best tool you have to address that, in case it contributes to your sleep problems.

But let me ask this: do you have a stuffy nose? I'm wondering in case your FLs originate there. Nasal FLs are hard to treat with pressure.

Like others, I'm hoping you can try a ResMed Aircurve 10 VAuto. The pressure support options might help with your FLs, and the trigger settings might help with the CAs. Wish I could comment on the EERS idea, but that's out of my wheelhouse.

[khakitat1]

Thank you all!

Aircurve 10/11 VAuto would be the plan assuming I can try the EERS first and see if that stabilizes my breathing and cuts some of the centrals. Before trying EERS, I'd worry the Aircurve would worsen things. I have tried EPR of 2 cmH2O one day, and that gave me significantly more/longer Centrals during the two periods of falling back asleep I had that night. Needless to say I felt off the day after, so it was a one day experiment lol. The one thing about this process though, is I should probably try it at least one more time to see how it goes. I wasn't horrible, and its pretty tough to judge things on a one day basis due to all the confounders that could exist.

It seems possible to me that my persistent waking and propensity to arousal is due to overall unstable breathing, and adding more CO2 into the mix could potentially stabilize things overall to the point where I have less issues with arousals and waking period. Not necessarily the case, but it is to be trialed and eliminated. I really want to talk with the Dr. first though, since the only reasonable risk I have seen is hypercapnia, and in the paper I read, they did a CO2 breath test with the setup on while awake to begin length titration. We'll see where that goes with the Dr. though as so few professionals do this right now. I'm determined to try it in a way I consider appropriate before scrapping it though.

@ Dormeo, For nasal congestion, I do tend to have a good bit of that, and I wondered what % contribution that is to my flow limits. I plan to follow up with an ENT at some point soon to see what I have going on there. In the meantime, I wear intake strips while sleeping at night right now with nightly saline rinse/Astepro spray/ oral antihistamine. To take that further though, I would like to experiment a bit with Flonase/Nasonex and see what I can get from those. I also have persistent asthma, and I am trying to manage my steroid burden overall. At this point, I've never needed any oral steroids, and I currently use a low does flovent inhaler twice daily. My understanding though is that there is a strong non-linear relation between flow resistance and diameter such that a bit of added diameter in my nose by steroid induced widening would have a much larger than proportional decrease in resistance (and hopefully flow limits). So, overall, thank you for the suggestion regarding congestion, that's a good thing to focus on for me. As for the pressure settings of 11-15, I started on 5-20 for ~ 2 months, and my 95% high was consistently around 10.5-12 those days. I started at 10-15 for awhile after, then settled on 11-15 with ramp off. It is unideal though due to the centrals, and I may try backing down once more. As of now though, I generally feel pretty good most days 11-15. I didn't feel as well with the cycling the machine was doing during that 2 months waiting to talk to the Dr. I also thought it was possible the large moves the machine was making could have contributed to waking me, and based on the fact that I've slept better this past month, that theory is plausible. For the onset centrals, I probably should try some breathing exercises to ease my transition. The asthma probably makes it likely for me to hyperventilate, and those onset centrals would be less severe if I were breathing more easily leading up to sleeping. I'm not a great relaxer lol.

@Dave, thanks for the advice about the ASV. You are right, from what I've seen, it seems those machines are near impossible to get for people who clearly need them. I am somewhat dissatisfied with the way I've been treated thus far. When I had my 2 month follow up with the Dr., it was obvious he had looked at nothing other than the AHI over the two months I was on 5-20 with ramp starting at 4. He didn't realize they were virtually all central and that a considerable chunk were definite sleep/wake junk. I had been using OSCAR since about 3 days into my therapy and had decided what I thought was best to change pressure to. I basically told him what I thought, he was like "yeah, that's fine" and that was it. I was initially hesitant to modify the settings until he and I first talked due to my experience with the DME. The DME had no idea what OSCAR was and told me I couldn't look at the data, made it sound like the Dr. paid detailed attention, and she made me worried that if I modified my settings the insurance may try to cancel payment (as I understand that can happen). She also treated me like a 3 year old when I asked her to turn on EPR of 1, which is in the clinical settings, and she held the purple/blue buttons facing the machine away from me so I couldn't see how she accessed it. As if accessing the clinical settings was something I was incapable of figuring out otherwise.... Anyway, that's enough venting for now. The good thing about my Dr. is he does seem pretty knowledgeable, and he seems like he is willing to work with me. I've had 2 long discussions with him now, and he even knew who Barry Krakow was.

@jdougc, I like the idea of the short ramp at the beginning to remove sleep/wake junk. For my onset events, the only real ones are the last 3-7 that happen 2-5 minutes before my sleep breathing stabilizes, and that would help me clean up the AHI a bit.

I have a follow up with the sleep doc next week to propose the EERS idea. I will keep this post updated on how things go as I progress and try new things.

Thank you all for the support and suggestions!

[Dormeo]

It's a good idea to see an ENT, and you might also want to get allergy tests. I benefited from allergy shots, and on the allergist's recommendation, I used Flonase and Azelastine sprays plus Montelukast (Singulair) pills.