Options after Failed ASV Titration-Current Oscar Reports

[JCFlorida]

Hi,
About 60 days in. AHI 43 on initial study. OSA resolved immediately, leaving just persistent centrals which increased since CPAP (per doctor). Have been requiring less naps the last couple of weeks and getting up less frequently.

Recently failed (1/10) titration study. Waiting to hear next steps for treatment of central apneas. Doctor had made changes (1/9) to my apap prior to the ASV study based on my trends, although the day before AHI was <5. But CA's has been averaging >6 last 30 days.

He reduced max pressure to 8 to be in line with my 95% use and increased EPR to 2. Before that I had changed (12/31) my settings to: Max pressure from 20 to 10, EPR 2 to 1, ramp On to OFF.

Now AHI, OA's, and CA's are trending upward. Messaged doctor about upward trend. IF ASV is not an option, then I am certainly willing to keep using current machine to see if another month or so will settle down the "treatment emergent CA's". Any advice would be appreciated.

Here are by last 6 days of reports: https://imgur.com/a/rcyY6L3

Initial introduction, Diagnosis, and ASV titration issues:
viewtopic.php?f=1&t=187471

[ozij]

bump

[Miss Emerita]

(Whoops. I had two tabs open and posted my response in the wrong thread. Here it is, in the right thread now.)

Your original sleep study showed both central and obstructive apneas. As Ozij noted, the study would not have counted pauses in your breathing that occurred while you were awake. You also showed significant periodic limb movement and some respiratory-effort-related arousals. Based on that study, I'd have thought your diagnosis would be mixed apnea and PLM.

Even with mixed apnea, patients are often started with a regular PAP machine, because sometimes that works to reduce central as well as obstructive apnea, for reasons that are unclear. Your regular PAP machine isn't having that effect; your CA index seems basically unchanged since your sleep study. It's good that your doctor tried to see how you'd respond to an ASV machine, but it's a shame you didn't get more help the night of the study in how to breathe more comfortably with an ASV. (Alternatively, they could have started you with regular PAP and then switched to ASV once you were asleep.)

I'm mystified why your doctor isn't paying attention to the PLM, which can mess with sleep quality. There are medications that might be able to help you. I strongly recommend that you follow up with the doctor about this.

I'm also mystified why your doctor hasn't had you try turning off EPR. For some people, using EPR can lead to CAs. Unless I missed something, that isn't an experiment you've tried yet. Do you want to give it a whirl?

[JCFlorida]

Thank you for your response. On cpap all of the apneas, except centrals, dropped immediately below 1 event per hour. My centrals have remained consistently above 6-7 an hour, at 10 to 24 seconds each. I have been 100% compliant with wearing mask. How have I felt? In the beginning, a lot worse then before cpap. Now I sleep more soundly and have dreams. But still spend the day feeling tired and half the time need a nap during the day. I have just had a handful of days where AHI was under 5 (all centrals). AHI averaging 10 last week, but last 30 days is 7.78. I chalk that up to change of EPR to 3 by doc.

The day before my ASV study with doctor he surmised I had treatment emergent central apnea and also referred to it as complex apneas. He also lowered my max pressure to 8 (<95% max threshold) and raised EPR to 3 from 1 (I had set from 2). I had experimented with EPR on 1 and results were better than it on 3.

I had a zoom call with my doctor today. He said not to change my settings on my own, although I told him my numbers had gone up since EPR was set to 3. We agreed to move EPR to 1. So, now I am pressure of 5-8 epr of 1, no ramp. The options he provided were:

1) He has not given up on ASV and said he can still order it and see if I give it a trial run
2) Stay on CPAP for another month or so and see if the treatment emergent CA's subsides with the current settings
3) Potentially explore Inspire if another month or so doesn't change things.

I want to give it at least another month. From what I read here and elsewhere, sometimes it takes several months before your body adjust. In the meantime, I can share what that looks like on Oscar once I have a week of data on the new EPR setting. That does sound reasonable? I can also post what I had on EPR 3, but don't know if that would be as worthwhile because of the change to EPR to 1 now.

[ChicagoGranny]

I can share what that looks like on Oscar once I have a week of data on the new EPR setting. That does sound reasonable?

Don't wait a week if there is any significant change.

[JCFlorida]

Hi,
Thanks again for all the advice. It is a challenge to accept that doctors really don't help you track this. You are taught to follow their advice, but when it comes to sleep apnea they just seem too busy. My doctor said his practice handles 300 new patients a month. They expect you to set something for a month and potentially suffer through that, before they make any changes. Then "Inspire" gets put on the table. I told him that my understanding was it is just for OSA, not centrals. How is that going to treat centrals that were already at the same level during diagnostic. CPAP got rid of almost all my OSA. Why would I trade that for a surgical procedure to arrive at same result. Sorry for the rant.

Attached is just last night's data (EPR =1) vs 2 days ago when my EPR was 3. With max pressure at 8 and EPR now at 1 that means pressure at exhale is 7. Some drop overall, including time in apnea halved. Usually mask leaks are well controlled, last night a bit more leaks. So, my median EPAP is now 5.18 (vs 4), with 95% max epap at 6.34. I can let that ride for the next few days to see what else happens. Thanks again!

[ChicagoGranny]

Please post the link to your initial diagnostic study again.

They expect you to set something for a month

Yeah, dealing with sleep doctors and insurance has frustrated many a CPAP patient. Far be it from me to defend sleep doctors, but insurance may want all CPAPers showing centrals to try CPAP for 30 days before trying ASV. As you probably know, ASV machines are quite expensive.

[JCFlorida]

Thanks for your help. Here is the original diagnostic appended below, as well as last night's data. I also use SleepHQ (link provided). Leaks still a bit higher than usual, been experimenting with different mask liners. Though numbers are trending in right direction. Marked improvement AND I felt less groggy this morning. How does the min pressure of 5 play into this, could a higher min help with CA's?

https://sleephq.com/public/c275bece-ba6 ... 14415405cf

[Miss Emerita]

Your centrals aren’t treatment-emergent, since they were there at about the same rate during your sleep study.

You might want to follow up on the offer of a trial with an ASV. If you do that, start a new thread here with ASV in the title of the thread so you can get some help from people who know how to breathe comfortably with those machines.

I’d also urge you to ask your sleep doctor or your regular doctor about medications for periodic limb movement. This needs to be more front and center in your treatment, I think.

[JCFlorida]

Thank you for your advice. I will get the doctor's opinion on my next appointment. I do feel like I sleep more soundly and don't recall waking up as much as I use too. Also, my wife is a light sleeper has told me I barely move now. Whatever was reported during the sleep study might have been alleviated with cpap, who knows. In the past I would toss and turn alot in bed. Given that, I definitely lean toward wanting to give the apap a little more time before I introduce new medication or try the ASV machine.

[ozij]

I'm mystified why your doctor isn't paying attention to the PLM, which can mess with sleep quality.

Maybe becaus the PLM arousal index is low? (see sleep study, posted after Miss E's comment)
https://i.imgur.com/W7Ges8s.png

I'm also mystified why your doctor hasn't had you try turning off EPR. For some people, using EPR can lead to CAs. Unless I missed something, that isn't an experiment you've tried yet. Do you want to give it a whirl?

I'm mystified too.

[ChicagoGranny]

Your average heart rate in the diagnostic study was reported as 46 BPM. That's low. Any idea why? Are you an endurance athlete?

Given that, I definitely lean toward wanting to give the apap a little more time before I introduce new medication or try the ASV machine.

I can't disagree with that. When is your next appointment?

[Miss Emerita]

I'm mystified why your doctor isn't paying attention to the PLM, which can mess with sleep quality.

Maybe becaus the PLM arousal index is low? (see sleep study, posted after Miss E's comment)

Ozij, I'm curious about this, and I know very little about PLMS. The overall PLMS index seems high, even though the PLMS arousal index is fairly low. Could PLMs be messing with sleep even if there aren't associated arousals, e.g., by messing with sleep architecture? What do you think?

[JCFlorida]

Your average heart rate in the diagnostic study was reported as 46 BPM. That's low. Any idea why? Are you an endurance athlete?

Given that, I definitely lean toward wanting to give the apap a little more time before I introduce new medication or try the ASV machine.

I can't disagree with that. When is your next appointment?

From what I understand normal sleeping heart range for healthy adults can range from 40-60 bpm. Have always had good heart rate and pressure. I am pretty active, by no means endurance athlete, and have no other comorbidities. My next appt is in on 2/27.

[ChicagoGranny]

Yes, you are correct. But I thought it would be higher due to your sleep and sleep-breathing problems. You averaged 19 arousals per hour in your diagnostic study.