Help with next steps with BiPAP for treatment emergent CSA

[SleepingStormtrooper]

Hi everyone on this wonderful forum, I'm looking for help deciding what to try next with my therapy. I recently moved from an APAP to an auto BiPAP, after my doctor concluded that in addition to OSA I have treatment emergent CSA.

I have a ResMed auto bipap (so that, as I understand it, the EPAP and IPAP pressures move up and down together). He started me with these settings: MIN EPAP = 6cm, MAX IPAP = 25 cm, PS = 4cm. My AHI varied over 5 - 12, and always it has been mostly central events. I attached two nights of SleepyHead data below. (I think I put these in the preferred format - let me know if I missed something or there's some other info that's needed!)

To try to address the centrals, my doctor raised the MIN EPAP to 8cm, and that is what I'm using currently. Overall my AHI's haven't noticeably changed and I don't feel much different. (Well, a little less comfort breathing out against the higher pressure.)

What settings should I be experimenting with to eliminate or reduce the centrals? Should I be changing the PS instead of the EPAP? If so, in which direction? Some things I've read suggest decreasing the PS, others suggest increasing it.

Incidentally, a different sleep doctor wants to try me on an ASV, so hopefully I will get scheduled for that soon...

[Pugsy]

There's really no setting tweaks that will reduce the centrals with this machine unless maybe there was a line where below so and so pressure you didn't have centrals emerge and above it you did. Even if there was such a line and you reduced the pressure then there's a good chance that the Obstructive apnea stuff would increase...so you would just be swapping category of events.

Now sometimes treatment emergent centrals will go away on their with just some time as the body gets used to the pressure.
Sometimes they don't.

ASV or similar bilevel machines that have back up rates available are really the only machines that can actually do anything about the centrals.

When you were using cpap/apap.....did you use any exhale relief? Sometimes the bilevel situation that gets created with using exhale relief and trigger centrals. Very small percent of people though.

[palerider]

I recently moved from an APAP to an auto BiPAP, after my doctor concluded that in addition to OSA I have treatment emergent CSA.

...
What settings should I be experimenting with to eliminate or reduce the centrals? Should I be changing the PS instead of the EPAP? If so, in which direction? Some things I've read suggest decreasing the PS, others suggest increasing it.

Incidentally, a different sleep doctor wants to try me on an ASV, so hopefully I will get scheduled for that soon...

The Vauto does nothing at all to help central apneas.. though, if you have centrals because your co2 is going too low, it can make them far worse.

Anybody that says to increase pressure support for centrals doesn't have a clue. Reducing ps *may* help.

[Okie bipap]

My wife had the same problems when she started her treatment. They started her treatment at a low pressure which only cut her OSA in half. They brought her pressure up slowly over a six month period. She still has a few CAs, usually less than two per hour. Her sleep quality is very good and she is now able to go all day without falling asleep while watching TV and can ride in the car without falling asleep.

[SleepingStormtrooper]

When you were using cpap/apap.....did you use any exhale relief? Sometimes the bilevel situation that gets created with using exhale relief and trigger centrals. Very small percent of people though.

Nope, I didn't use any exhale relief when I was using the APAP. It was an F+P Icon, which didn't have this feature.

[SleepingStormtrooper]

Thank you Pugsy, Palerider, Okie bipap!!!

Anybody that says to increase pressure support for centrals doesn't have a clue. Reducing ps *may* help.

Okay, good to know! I will talk to my doctor about trying this.

There's really no setting tweaks that will reduce the centrals with this machine unless maybe there was a line where below so and so pressure you didn't have centrals emerge and above it you did. Even if there was such a line and you reduced the pressure then there's a good chance that the Obstructive apnea stuff would increase...so you would just be swapping category of events.

So, to the extent that a BiPAP could still work, it seems to me that the doc isn't tweaking things in the best way... I wasn't having all that many obstructive apneas when the min EPAP was at the lower 6cm level. It sounds like I should try bringing the min EPAP back down to 6cm, and lowering the PS.

(*I just corrected this post to say "min EPAP", not min IPAP, which doesn't exist... thanks palerider!)

[jnk...]

. . . Incidentally, a different sleep doctor wants to try me on an ASV . . .

Which may be the most salient point, since sometimes docs have to, uh, "orchestrate" a "failure" of both CPAP and BPAP before being able to convince payers you should be allowed to try ASV.

[SleepingStormtrooper]

. . . Incidentally, a different sleep doctor wants to try me on an ASV . . .

Which may be the most salient point, since sometimes docs have to, uh, "orchestrate" a "failure" of both CPAP and BPAP before being able to convince payers you should be allowed to try ASV.

Yeah... the second sleep doctor actually said something like that. She likes ASVs and said she used to prescribe them all the time, but over time it became a bigger deal cost-wise and there was push-back... I guess the doctors are captive to the system too.

[jnk...]

. . . Incidentally, a different sleep doctor wants to try me on an ASV . . .

Which may be the most salient point, since sometimes docs have to, uh, "orchestrate" a "failure" of both CPAP and BPAP before being able to convince payers you should be allowed to try ASV.

Yeah... the second sleep doctor actually said something like that. She likes ASVs and said she used to prescribe them all the time, but over time it became a bigger deal cost-wise and there was push-back... I guess the doctors are captive to the system too.

Yep. So the sad thing is that it is possible that your improving your results with BPAP, although naturally the right thing to do, could inadvertently work against the overall argument for ASV, if that argument is going to be made. I am, of course, not recommending you take action one way or the other, if that is the case, but it can help you make decisions for an approach when you are fully in the loop with what the doc(s) may be trying to accomplish for you behind the scenes, if they are willing to be on the level about it. Patients aren't the only ones who sometimes find it necessary to work the system according to the system's arbitrary rules.

[palerider]

min IPAP back down to 6cm, and lowering the PS.

There's no minipap setting.

[SleepingStormtrooper]

min IPAP back down to 6cm, and lowering the PS.

There's no minipap setting.

Oops! I meant min EPAP! I'll fix that so it doesn't confuse someone.

[SleepingStormtrooper]

. . . Incidentally, a different sleep doctor wants to try me on an ASV . . .

Which may be the most salient point, since sometimes docs have to, uh, "orchestrate" a "failure" of both CPAP and BPAP before being able to convince payers you should be allowed to try ASV.

Yeah... the second sleep doctor actually said something like that. She likes ASVs and said she used to prescribe them all the time, but over time it became a bigger deal cost-wise and there was push-back... I guess the doctors are captive to the system too.

Yep. So the sad thing is that it is possible that your improving your results with BPAP, although naturally the right thing to do, could inadvertently work against the overall argument for ASV, if that argument is going to be made. I am, of course, not recommending you take action one way or the other, if that is the case, but it can help you make decisions for an approach when you are fully in the loop with what the doc(s) may be trying to accomplish for you behind the scenes, if they are willing to be on the level about it. Patients aren't the only ones who sometimes find it necessary to work the system according to the system's arbitrary rules.

Oh got it... wow... I hadn't thought of that! Thanks for clubbing me over the head. Yeah, it certainly seems possible. When I saw the second doctor as a one-off consultation, they suggested I pass along to the first doctor that they thought it was worth trying out an ASV now. I was worried the first doctor would want me to keep trying the BiPAP for longer, but they were totally fine with me scheduling an ASV overnight study. Who knows if it's meaningful or not, but I found that surprising, given I'd only been on the BiPAP 2 weeks.

[jnk...]

Didn't mean to do any clubbing.

After all, even a dyed-in-the-wool conspiracy theorist like me isn't always able to discern when people in power are trying to do sneaky things behind my back to help me.

[SleepingStormtrooper]

Indeed!