Re: CAs with P10 Pillows/Taping but not with DreamWear FF

All,

Though I had recently tried the Dreamweaver FF mask and reported by great success to Pugsy with AHI less than 1.0 and virtually no mask leaks and only a couple of CAs, I still prefer the comfort of the P10 pillows. The only issues I had with the Dreamweaver FF was the discomfort from over-tightening the mask to prevent major leaks.

Unfortunately, a typical night on the pillows shows 30 to 40 CAs as shown here and, though I think most are SWJ, 42 CA events like last night is a lot. This is with my mouth taped solid with Micropore tape so there's no mouth leakage or even lip fluttering occurring. The P10 leaks some but those leaks don't seem to be major and I don't believe they're causing the CA's.

I don't really feel bad upon awakening but I'd like to see these CAs go away so I can continue with the P10 pillows. I'm a slide sleeper and take Ambien and not aware of any sleep disturbances.

In an effort to reduce the CAs, I' tried my APAP pressure at 10-14, even tried 6-14 but get just about the same results as shown here. I also tried turning off EPR with no improvement in CAs.

If I can't get this figured out, I'll definitely go back to the FF but would just love to know what would cause the CAs on pillows combined with mouth taping and not with the FF. I've read some about low Co2 but as a possible cause for CAs but not sure that applies to my particular situation.

Any suggestions appreciated!

Thanks!
Paul

Have you tried reducing EPR (or even turning it off) with the P10 and see what effect it might have on the CAs/centrals?

Pugsy,

Yes, I tried turning off EPR completely which resulted in a few less CA's but still got 25-29 CA events for the nights I tried that so I turned it back on.
The only regular sleep disturbance I'm aware of usually occurs with the first 30 to 60 minutes of going to sleep, it's like I'm jolted awake. It's also interesting that the CA's seem almost predictable in their frequency, like they're on a set clock.

I've assumed that using the Dreamweaver FF mask seems to made these go away that this isn't a neurological issue but a mechanical one.
I'll definitely go back on the FF and monitor closely.

Thanks,
Paul

The only thing I can think of is the P10 mask I'm using hasn't been replaced in a year or so. Though I clean it regularly, I'm wondering if the exhalation vents get rigid to a point to somehow cause the CA's. I usually clean the vent mesh material with mild soap and water with a toothbrush. But if the vents were the issue and as a result the Co2 levels were elevated, I don't think that would show up as CAs but I don't know. Maybe its worth a shot to replace my P10 mask though. Also using the slimline hose and hav the S9 set appropriately for Pillows/Slimline hose.

When we see centrals that are related to carbon dioxide levels they happen because there is too much carbon dioxide wash out and the levels don't get high enough for the brain to send the "breathe" signal.
So I would think that vent holes clogged up would increase the carbon dioxide levels rather than decrease it.
We actually need the carbon dioxide levels to be a certain point for the brain to send the breathe signals.
When there is too much wash out from the venting (in some people) the levels don't get high enough.
Using EPR tends to "wash out" the carbon dioxide somewhat. That's why we sometimes suggest turning EPR off to see if it helps.
Since you saw some reduction in centrals with EPR off...makes a person suspect that is likely what is happening with you.

What is the average duration in seconds of those centrals when using the P10 with EPR off?
How many per hour would 25 to 30 events actually add up to be?
If using an 8 hour night with 24 centrals that would be an average per hour of 3. If they were of short duration...probably not a big deal as long as you sleep through them and feel decent during the day.
The 2 examples you showed of centrals/CAs....so brief that even back to back extremely unlikely to cause the oxygen levels to drop.
Hold your breath for 10 seconds...that's essentially a 10 second central apnea.

The full face mask...probably doesn't allow for so much wash out and you rebreathe more carbon dioxide laden air....which increases the levels and the brain recognizes it...and tells the body to breathe.

All the above assuming the centrals are real and not SWJ centrals.

Have you ever tried a different nasal pillow mask? One that might have a large volume of air inside it so that the chances of too much wash out are lessened? Maybe something like the Brevida?

You might want to run all this by your doctor. He might not care about 3 or 4 short duration centrals per hour as long as you are sleeping good and feeling good with the nasal pillow mask.
You have to weigh the comfortable sleep with P10 against the problems that using the full face mask might cause in terms of leaks and other sleep disruptions.

Pugsy,

I think you're on to something.
Here's CA events and durations with EPR on:

And here's earlier this week with EPR off (note I was also on a different minimum pressure that night).

Pugsy,

No, I've only used the P10 for nasal pillows.
I'll look at the Brevida, what you're say seem logical.

Jason's video on CA's seemed to indicate that when we see a spike right before a CA event that it wasn't a real CA so I've not been overly concerned but they're there and reason enough to try and avoid them especially if its mask related. Th Dreamweaver FF mask, though not ideal, convinced me something was up.

Thank you for your words of wisdom!

Paul

Which would you rather do...use a full face mask or a nasal pillow mask and tape?

What size nasal pillow are you now using with the P10?

Pugsy,

Hands down, I'd rather use pillows with tape vs. using any FF mask.
I'm using he size Large P10 pillows with the slimline hose.

I have do a larger "regular" size hose but haven't tested with that to see if it makes any difference.

Thank you,
Paul

I doubt that hose size would make any difference.
If it is wash out going on here then that's something related to the mask and the venting. Sort of like too much venting I guess.
I always hesitate to bock vent holes...but that's essentially what I think is going to be needed ....if that is what is going on here.
Palerider had a guy with similar issues...If I remember right he was using the DreamWear mask which has 2 vent openings so what he did was block the vent under the nose and left the vent at the top of the head alone. This let extra carbon dioxide accumulate in the mask...and with the breathing of it enough to raise the levels in the blood stream for the brain to send the breathe signal. Substantial reduction in centrals when he did that along with reporting generally sleeping better.

Pugsy,

I understand your reservation in recommending that but I really appreciate you mentioning it.
It sure sounds easy enough to test on the P10, maybe with tape over one side of the vent and see if that has any affect on the CA's.

Pugsy wrote: ↑

Sun Nov 18, 2018 12:12 pm

When we see centrals that are related to carbon dioxide levels they happen because there is too much carbon dioxide wash out and the levels don't get high enough for the brain to send the "breathe" signal.
So I would think that vent holes clogged up would increase the carbon dioxide levels rather than decrease it.
We actually need the carbon dioxide levels to be a certain point for the brain to send the breathe signals.
When there is too much wash out from the venting (in some people) the levels don't get high enough.
Using EPR tends to "wash out" the carbon dioxide somewhat. That's why we sometimes suggest turning EPR off to see if it helps.
Since you saw some reduction in centrals with EPR off...makes a person suspect that is likely what is happening with you.

This is absolutely correct.

Pugsy wrote: ↑

Sun Nov 18, 2018 1:12 pm

Palerider had a guy with similar issues...If I remember right he was using the DreamWear mask which has 2 vent openings so what he did was block the vent under the nose and left the vent at the top of the head alone. This let extra carbon dioxide accumulate in the mask...and with the breathing of it enough to raise the levels in the blood stream for the brain to send the breathe signal. Substantial reduction in centrals when he did that along with reporting generally sleeping better.

You remember right, but that guy had a real problem (CAI up into the upper teens... long stretches of waxing and waning breathing).

I suggested plugging up the bottom vent based on this:

Added dead space or inhaled carbon dioxide

Added dead space by attaching a plastic cylinder of variable volume (400-800 mL) to a tightly fitting mask can act as a source of increased carbon dioxide concentration in the inspired air and can increase the carbon dioxide reserves above the apneic threshold. Such a treatment in an experimental setting was effective against both primary central sleep apnea and CSB-CSA. The increase in PaCO2 is miniscule (approximately 1.5-2 mm Hg) but can be effective in stabilizing the breathing pattern.

Minimizing hypocapnia, by adding 100-150 mL enhanced expiratory rebreathing space (EERS), was documented to improve CSA and is a potentially useful adjunctive therapy for positive pressure–associated respiratory instability and salvage of some CPAP treatment failures. [29]

Similar results have been obtained by adding supplemental carbon dioxide (5%), but safety and accuracy of carbon dioxide delivery devices remains a concern.

Another potential problem of added dead space or inhaled carbon dioxide is worsening of obstructive sleep apnea by the increased mechanical load. Hypercarbia stimulates sympathetic discharge with potential deleterious effects on the heart.

https://emedicine.medscape.com/article/304967-treatment

I just got an email from him today, and he's been running consistently under 3 for the last couple months.

I get a bad case of the heebie jeebies even thinking about blocking vent holes.
Especially on a mask with such tiny holes as the P10 with a CAI of around 3 to 4 which isn't all that horrible.
Now if someone was using the gel pillow DreamWear version that has the 2 vent holes...maybe it wouldn't be quite so scary for me and the heebie jeebies wouldn't be so big.