UARS/OSA - doctor is trying to prescribe ASV

[kettle101]

Hi, I have dealt with poor sleep quality (and insomnia) for some time. Several years ago, I was put on CPAP after an initial sleep study indicated AHI of 8.1 with RDI of ~17.1, which i understand as frequent respiratory-related arousals. I was diagnosed with OSA. I will attach here my initial study and the titration study. 

When I moved and got a new sleep doc, he changed my diagnosis to UARS. I have a lot of difficulty tolerating tolerating PAP therapy and read on here that BIPAP is better for UARS and so requested that. My sleep quality remained not great, and periodically Iseemed to have clusters of central apneas in the second half of the night (treatment-emergent central sleep apnea?). I complained about this several times to the sleep doc but he always said it was fine. Toward the end of last year I got at-home sleep tests with and without BIPAP to compare. 

Recently, I complained about the centrals again and he ordered my a BIPAP titration (2 years or so after getting BIPAP). I use a ResMed AirCurve 10 VAUTO bipap with settings: 
Mode: VPAPauto
Min EPAP: 4.60 cmH2O
Max IPAP: 11.00 cmH2O
PS: 3.80 cmH2O



The BIPAP titration study started out with PAP level/PS at 11/4 and went up from there (12/5, 13/6, 14/7). I had huge amounts of centrals which just increased every time they increased the pressure. At the end it switched to ASV and centrals went down (though still AHI of ~7 with long apneas). 

The doctor is saying I should therefore go on ASV to solve my UARS and complex sleep apnea. I'm getting a little tired of being jerked around and feel like this is just throwing another huge billable expense at me. The ASV phase of the study had significant AHI and was very low quality as demonstrated by almost no REM over 2 hours (page 4 of BIPAP titration). In the follow-up appointment, when I asked my doctor about this (terrible sleep quality even with ASV and bad AHI) he dismissed me. When I asked whether the BIPAP titration study was causing central apneas due to over ventilation (increasing pressure baseline and PS higher and higher) he dismissed me and said that was not a thing. I asked several times about alternatives to PAP therapy as I travel some for work and also have trouble tolerating these machines. He would not give a direct answer and instead recommended anti-depressants and anti-anxiety drugs. 

Any advice regarding the above is appreciated, and please tell me if you think i'm off base on anything.

I feel like an ASV is overkill for UARS. Why not just titrate the BIPAP down? Isn't that what's done? Do you all recommend a strategy for bipap titration considering the above, concern about treatment emergent centrals but difficulty tolerating machine? 

I am also concerned and offput how I couldn't get a straight answer about alternatives and instead was told about drugs.

Should I get the ASV and just shell out even more money? Keep what I have? General advice? Do I have UARS or mild OSA?  Any treatment alternatives for UARS (I can't really do oral mandibular advancement device, I have a TMJ issue). Let me know if I can provide any more info. I will now attach the old initial study, other studies to follow.

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Initial CPAP titration study

[kettle101]

The recent BIPAP titration study. The last image is the interpretation (which I don't think lines up with the study)


Please help, I appreciate any insight you all can give. Should I proceed with ASV, titrate the BIPAP more, just junk these machines? It's been hard dealing with this. Thanks in advance

[kettle101]

Recent OSCAR charts (including a zoom to see flow peaks) for reference. I don't know how to interpret flow rate so interested in your thoughts. I recently increased the base pressure and slightly decreased the PS after doing a little reading that UARS does best with more constant pressure(??). Though it makes it a bit less comfortable

[SarcasticDave94]

When you have Apnea in these tests, it's Central Apnea only. The Hypopnea which aren't labeled Central or Obstructive are higher in count to the Centrals.

One test showed 8 CA 77 Hypopnea
Next was zero Apnea but 3 Hypopnea.
Third has 24 CA 32 Hypopnea.

You are dealing with Central Apnea, which does mean ASV to treat. That is if we focus of the Apnea portion. Again the Hypopnea are all lumped as a single count in each test, and it's possible some are Central based, but not guaranteed.

Your Titration experience is what one gets when dealing with Central events. More pressure tends to increase the CA more, unless there is a backup breath rate action, like an ASV has.

A common Central Apnea trait will be consistently inconsistent. They will vary nightly, up, down, gone, return with no settings changed. They're variable. And they cannot be treated with the bilevel like a VAuto or regular CPAP.

What does your OSCAR VAuto charts look like? Saw the included 3.

How about an event summary from OSCAR?

Edit... OK so these OSCAR charts show little CA. Yet this newest sleep study again has just 1 Obstructive Apnea with 56 Central.

My opinion you are dealing with predominant Central Apnea which will be treatable on the ResMed ASV.

Others will have things to add.