Large number of hypopneas in the early morning

[n3kf]

I guess what is puzzling me is that the OP's charts show all signs of OSA, and nothing that supports Central. That is why I thought is would be useful to review the sleep study. I don't think it Is reasonable to conclude that the OP's treatment is misidentifying all events, or that the treatment is working perfectly for Central, but working poorly for OSA. Maybe I am wrong. Trying to learn.

You don't see obvious signs of centrals because the machine is preventing them by breathing for the person and that's why the patient triggered breaths aren't 100%. If the machine wasn't breathing for him his PTB would be 100% instead of something else.
Example...of PTB is 70% then that means for 30% of the time the machine is doing the breathing.
It doesn't flag a central when it breathes for a person. It would only flag a central if it was prohibited from breathing for the person ...say with too restrictive of a setting that ties it's little hands.

So the PTB numbers being low tells me the machine is doing some breathing for the person and that fact tells me that centrals are being dealt with.
So a back door way of knowing centrals are a factor without ever seeing the actual flags which we don't want to see anyway.

Complex Sleep Apnea..that's when a person has both problems...central and obstructive sleep apnea.
So we have to do 2 things...treat the obstructive stuff in the traditional way and then let the machine treat the centrals assuming we haven't tied it's little hands.
That's why I gave the link to the ASV titration document
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf
So it could be read since it explains the need for EPAP minimum doing a good job holding the airway open in the first place (just like when using regular apap). We need to do both things....hold the airway open for the obstructive stuff and treat the centrals at the same time. This is why these ASV machines do both but we have to set the machine so that it can do both and sometimes minimum EPAP of 4 or 5 or 6 or even 7 simply doesn't do a good job just like with APAP machines and minimum of 4 or 5 or 6 or even 7 doesn't do such a good job.
I know one guy using minimum EPAP of 12 with his ASV to deal with the obstructive side of things and may even need a bit more.

I am not so sure that those hyponeas are central in nature...but they could be...and if it were me I would at least try killing them with more EPAP or IPAP but the OP didn't want to do that because he was afraid it would cause centrals...which to me wouldn't matter because he is already on a machine to deal with centrals because we assume he already has a problem with them. But I can't come up with an urgent proven argument to tell him to do that because I can't say with 100% certainty those hyponeas are obstructive in nature since I know that sometimes the machine can make mistakes.
OP seems to prefer to investigate the back up rate thing as maybe being a factor instead of the usual thought "more EPAP minimum"...it's a reasonable thought. Worth seeing if something as simple as putting the machine back to fixed back up rate will prevent ugly hyponea clustering.

So I am not saying that the machine is wrong...just that it could be wrong...and if it were me I would go about things differently but I am not the OP and he wants to go about things a little differently...so I will try to help him in that regard. Maybe later if no joy with other ideas he will want to maybe try more EPAP or maybe just adding a little PS minimum (which would be what I would probably try first....I would try just a little PS minimum to see if those hyponea clusters would get smaller).

You guys are more experts then me. I'm up to trying stuff. I doubt that if more centrals showed up it would hurt me in a day or so. I just know I am not sleeping well the last couple months. And that has added some difficulties to my life. I need to go back through the daily charts and see if anything changed. I do know if I did fall a sleep without the system and then put the mask on around four or five AM, I'd wind up with a ridiculously high AHI. Did not have software set up. Doc said it looks like my breathing is very unstable in the early morning probably due to REM sleep.

As for the sleep study, things have changed and not sure I could find it. Its been a good while. I had a failed back surgery five years ago and am in lots of pain. I talked to the doc about the breathing issues I noticed. Was not sure I could make it through a full sleep study, so he recommended the four hour daytime one. I went in with a lack of sleep and went to sleep easily. They woke me up in about two hours and said they got all the data that was needed. I was having plenty of central apneas. They never really issued a sleep study report from that, but had more then enough data to go to the ASV system which is costly. He said I should go to a new system next year, but says there is no need for a new study since the machine is giving plenty of data. Hopefully that clears that one up.

I did order the recommended oximeter to provide a bit more data also.

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[TedVPAP]

The asv is a more capable machine, but also harder to get set right. OSA is at its worst during REM. That is why I think you need more pressure.

[n3kf]

I am going to take Pugsy's advice and add a bit of min PS and see how it goes. Have a nice Christmas.

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[TedVPAP]

I am going to take Pugsy's advice and add a bit of min PS and see how it goes. Have a nice Christmas.

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Always a good plan. Merry Christmas to you and good luck.

[ajack]

If it was normal bpap or you need more tidal volume/minute vent, I's normal to suggest increasing the PS after the OA are sorted. With ASV, the normal titration protocol is to keep lifting the epap. I assume it is the same with philips.
resmed page 43
https://www.scribd.com/document/3534028 ... -Titration

philips page 14, it shows the basic set up
http://incenter.medical.philips.com/doc ... %3d9792335

Note:
• Establish initial settings as indicated or as ordered by physician
• Initial BiPAP autoSV Advanced settings may be adjusted to patient condition
or severity
• Bi-Flex may be adjusted to patient comfort
• If numerous hypopneas are noted, maintain PS > 4 cm H2
O
*If multiple obstructive events are observed at the beginning of the
study use a higher EPAP min

[Pugsy]

Let me know if anything changes with adding a small minimum PS baseline.

Merry Christmas

[ajack]

The point wasn't that it wouldn't work, more epap and same PS or same epap and more PS will work. The point is it may not be best practice with an ASV. Why else would resmed say to titrate it differently to their S or ST? I doubt it was for the fun of it.

[n3kf]

Let me know if anything changes with adding a small minimum PS baseline.

Merry Christmas

Here is a shot from last night. There are still some hypopneas. But not a huge cluster. Sunday night was the same, but too short due to operator error. So I boosted PSmin from 0 to 1. Certainly not much of a change. So I guess I should let this settle for a bit, and see if it holds up. Would like to see some more of the hypopneas disappear, but small steps at a time. Thanks. Will report back after I have a few more days under my belt.

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