Treating Central Apnea

[Golden-Alpine]

I had a follow up with my Sleep DR. on Tuesday I commented I was concerned about my Central Apnea's.

Since using CPAP I have had an a AHI 2.3 and Central of 1.7. So to me my major issue is Central. Now I know this is under 5.0 so is acceptable.

The DR suggested I try the Resmed S9 on AutoSet to see what the result would be. Well after 2 nights my AHI is 1.1 and Central of 0.9.

My pressure was set to 11.0. The last 2 nights the 95th percentile was 10.1, median 7.8 and maximum 11.9.

The only other difference in the 2 nights sleep is I have started wearing my mouth splint again (for bruxism).

Whilst I know after 2 nights its a bit hard to say for certain but could autoset be the better way to go?

The current S9 I have is hired. I have to take it back soon and I was only going to buy an S9 Elite but should I consider an autoset?

I am going to leave it on autoset for the rest of the time to see the results.

[Big Daddy RRT,RPSGT]

What range is the Auto set to?

[Golden-Alpine]

Min 6.0 Max 20.0

[Julie]

Have you tried setting it for a narrower range, e.g. 8 and 12, or 8 and 15? It's usually found to be more effective that way, as a higher 'event' takes a long time for the machine to compensate, and often by the time it gets to the pressure needed to stop the apnea, it's too late.

[Big Daddy RRT,RPSGT]

I agree with Julie you might feel better with a narrower range like 2 above and 2 below your 95 th percentile for example...8-12 in your case.

[dave21]

I too would suggest narrowing the range although your figures are just fine as it is as it stands.

In terms of whether you should purchase the S9 Elite or AutoSet, I would pay the additional money (if you have it) as you are paying for it and go for the AutoSet. For most of us with the Autoset's we tend to leave them on Auto as we find when you narrow the range it adjusts to the Apneas we're having and reduces them.

Some prefer to go with fixed pressure, which is good providing the fixed pressure is high enough but some nights you can get apneas or hypopneas occuring that would be outside of this range and that's where the AutoSet algorithm comes in to increase the pressure when you need it the most.

Thanks
Dave

[sleepmba]

I just added a new topic in my blog about central apneas. You may find it helpful. Click on the link in my signature.

[JohnBFisher]

... Since using CPAP I have had an a AHI 2.3 and Central of 1.7. So to me my major issue is Central. Now I know this is under 5.0 so is acceptable. The DR suggested I try the Resmed S9 on AutoSet to see what the result would be. Well after 2 nights my AHI is 1.1 and Central of 0.9. ... The only other difference in the 2 nights sleep is I have started wearing my mouth splint again (for bruxism). ...

sleepmba, again, be certain to include pointers to the site as well.

Here's an article that discusses how central sleep apneas occur during sleep onset:

Ventilation is unstable during drowsiness before sleep onset
http://jap.physiology.org/cgi/reprint/99/5/2036

You can find that are more pointers in Rested Gal's:

Links to Central Apnea
viewtopic.php?p=457566

Here, I tend to disagree with sleepmba. While your "clear airway" events might be apnea events that occur during the transition from wakefulness to sleep, Golden-Alpine, you simply did not provide enough information to sort that out. When do the apneas occur? Do you have leaks at the same time?

Also, please note the machines can ONLY report if your airway is clear or not. Your mask might be leaking. You might be mouth breathing. You might be transitioning from wakefulness to sleep. Could it be a central apnea? Sure. But neither you nor your doctor really have enough data at this point.

Should you aim for an AHI of zero? NO! Let me be very clear about this:

Should you aim for an AHI of zero? NO!

Okay, lest you think I've come unglued, let me explain. What you REALLY want is to have a good night of sleep. If your AHI is not too high, but not zero, and your sleep is wonderful, then don't aim for an AHI of zero. Some apneas (obstructive and central) are perfectly normal. That's the point behind an AHI of 5 as the point beyond which therapy is required.

I am not saying "ignore it". Just don't worry. If you are sleeping well, then if it stays at 5 or below, AND you feel well, then the therapy is working.

Hope that helps explain it.

[Tielman]

I am not saying "ignore it". Just don't worry. If you are sleeping well, then if it stays at 5 or below, AND you feel well, then the therapy is working.

Hope that helps explain it.

Yes, that is a great explanation, and I agree with it.

What should you do if you only "feel well" when your AHI is below 3, but your average is 3 and Centrals comprise at least 1 (or more) of the score?

[JohnBFisher]

... What should you do if you only "feel well" when your AHI is below 3, but your average is 3 and Centrals comprise at least 1 (or more) of the score? ...

Well, here is where having a data capable machine helps. If you find that the apneas seem to be bunched together at one time (or maybe a couple), then those "clear airway" events are probably just transitional apneas. Not much to be done about them.

If you find they are sprinkled all throughout the night and you do not seem to awaken, then it's possible you do have central apneas - but at a very low rate.

However, as you note, your only seem to "feel well" when you AHI is below 3. (Thank you for using proper grammar. I never remember that one. So, I feel good all the time! : ) In that case, you need to see if the rest of the AHI values seem to be due to obstructive and/or hypopnea events. You should also check to see if you have a lot of problems with leaks. It could be that you are mouth breathing and that leads to the events. As a last resort you would want to increase pressure, since it is possible the current pressure is triggering the increased events.

And of course, if you can show your doctor that at 3 your are find, but above it (record your days like a fiend) you do not do as well. Showing the numbers and a log of how you feel may allow him to help you address it. It is possible you might need another type of therapy (BiLevel PAP as an example) to help manage the symptoms.

Again, hope that helps explain how I would tackle that problem. And as a matter of fact how I did tackle that problem about 15 years ago.

[Tielman]

... What should you do if you only "feel well" when your AHI is below 3, but your average is 3 and Centrals comprise at least 1 (or more) of the score? ...

If you find they are sprinkled all throughout the night and you do not seem to awaken, then it's possible you do have central apneas - but at a very low rate.

You should also check to see if you have a lot of problems with leaks. It could be that you are mouth breathing and that leads to the events. As a last resort you would want to increase pressure, since it is possible the current pressure is triggering the increased events.

Thanks for the information and the advice!!

My leak line has been very very flat, however your comment about awakenings and mouth breathing made me think. I do tend to "roll-over" on a regular basis from my left to the right and back again. I also have woken up a couple of times (in the last 3 months) with a small mouth breathing episode. I've already increased my pressure from 11 to 11.5 without much success. I'm going to be doing mouth taping for a week to see if i'm having small mouth breathing issues that are translating into centrals by the machine. Wish me luck!

PS: My Sleep Study showed no centrals, so I'm optimistic that it's something else (like mouth breathing) that can be controlled w/o having to go to a BiPap or ASV.

[JohnBFisher]

Due to mouth breathing that I could no longer control, I had to shift to a full face mask. The Quattro is what I use. And it's a love / hate relationship. It works well sometimes and horribly the next night. And I've not been completely able to figure out what seems to work and what does not.

So, if you can get your therapy to work without moving to a full face mask, I would do as you are doing. It's not been something I was able to achieve. But hopefully you will be able to make it work.

[sleepmba]

JohnBFisher,
When was your last titration study? It sounds as if "they" could be some help.

[JohnBFisher]

... When was your last titration study? It sounds as if "they" could be some help. ...

LOL! Oh, you do not want to get me started.

I've used xPAP therapy for almost 20 years. I've had a steady progression of worsening issues with central apnea. When initially diagnosed, there is no doubt that I had problems with obstructive sleep apnea. (Two different sleep studies helped identify the problem and lead to correct titration). CPAP helped.

But within three to four years my sleep deteriorated. At the time during a new sleep study, the sleep tech found that BiPAP seemed to help reduce the arousals.

About five years later I started to develop problems with neurological systems (tremors, balance issues, some slurring of speech, etc). Going to a neurologist, the new sleep study found that my BiPAP pressure had to be adjusted, but central apneas had increased. My sleep doctor at the time was ... "How to put this nicely?" ... less than ideal. Since "central sleep apnea is very rare, so you can't have it" was his response - even though the sleep study clearly indicated an increase.

After that I spent a good bit of time and money trying to find out what was wrong with me. It was not until I went to see a nuero-ophthalmologist that I ended up with a clear diagnosis of Sporadic OPCA (olivo-ponto cerebellar atrophy). In other words, I have problems with my brain stem and cerebellum.

About three years ago my BiPAP unit finally gave up the ghost. I was having severe problems with sleep apnea. I did not know if it was central or not. I just knew that sleep had become torture. At the time, I was titrated with a BiPAP. But I continued to have problems with apneas. Due to insurance issues (a bad company at the time), I put up with it for another couple years.

But by this past summer (about a year ago), my sleep degraded to the point I had only about two to four hours of sleep per night. I went back to my sleep specialist. I had two different titrations. The first was with BiPAP - and it was a disaster. I finally insisted that my sleep specialist had to consider that I was having SERIOUS problems falling asleep. I would stop breathing so long (a minute or more at a time) that my machine (BiPAP) would turn off. This was no simple transitional apnea. It was long enough that my O2 levels would crash. I would startle awake with a surge of adrenaline. And of course, that makes it harder than ever to sleep.

Well, he decided I should be titrated on an ASV unit. Though a bit more difficult to adjust to it, I find that it makes a huge difference. And my sleep doctor agreed. However, he warned me ... and I can confirm this is true ... my sleep will remain "less than ideal". As he noted, when the brain stem is involved in the problem, then there is dysregulation of breathing and the sleep cycle. From my own experience, I tend to agree. And when stress in my life increases, such as from my work, then the dysregulation also increases.

Prior to that ASV titration, my blood pressure was unregulated / all over the map. After I started to use the ASV unit, my blood pressure now remains in the ideal range for me. Ditto on blood glucose levels.

Here is an example of a "bad" night for me:



In this case, I was not having large leaks at the same time. Clearly the ASV unit works very hard during these dips to maintain my breathing, but it appears that my brain stem just does not function well. On my most nights there is some fluctuation, but nothing like this. And as you would expect, on good nights there is very little fluctuation.

There is potential that the severe drop in O2 levels might also be due to vocal chord dysfunction, which is another symptom of OPCA. At this point, this is only a real problem when I have a lot of stress in my life. I've been able to correlate it to that. In fact, sometimes when I am awake and am under stress my voice sounds a bit odd (somewhat squeaky/raspy). Time away from work/stress usually clears it up right away.

When stress in my life is low, I often can sleep nine hours at a time. On my bad nights I am lucky to get four hours of sleep. I understand how bad central sleep apnea can be. It's why I try to help others if they have issues with Central Apnea.

Also, the inability of the Quattro to be consistent is not unusual. Just check in the forum. I've tried some other full face masks, with little success. One problem I have in particular, is how the ASV unit ramps up pressure suddenly. This often causes major leaks. A consistent/lower pressure does not impact the masks as badly.

So, yes. I've had a titration done recently. And I understand how difficult it can be to attain an effective diagnosis and treatment.

[DreamOn]

Also, the inability of the Quattro to be consistent is not unusual. Just check in the forum. I've tried some other full face masks, with little success. One problem I have in particular, is how the ASV unit ramps up pressure suddenly. This often causes major leaks. A consistent/lower pressure does not impact the masks as badly.

Hi John,

Have you tried Pad A Cheek's Anti-Leak Strap for the Quattro and Ultra Mirage full-face masks?: http://padacheek.com/PAC_AntiLeak_Strap.html. It's received some rave reviews by forum members, and I'm thinking it may help you with those Quattro leaks.