I'm guessing that i need to drop my pressure

[johnthomasmacdonald]

I'm using a dental appliance and a bilevel set at 8 and 6. For several weeks my ahi has been holding at 1 -2 with about 60% centrals - last couple of days it has gone above 5. Last night it was around 7 with almost 100% centrals. I thought I would drop it by .2 per night and see what happens - or should i just test straight cpap at say 7- at this low pressure i don't really need the exhalation relief - thoughts?

[johnthomasmacdonald]

Oh and HAPPY NEW YEAR ALL = may your ahi be low and your mask never leak

[Pugsy]

It would help if you would mention which machine you are using since your profile still shows the PR S1 APAP.
If I remember right the bilevel machine you are using is the S9 VPAP S.
So...if you look at your software reports (I know you have a Mac so SleepyHead reports) what is the pattern for the centrals you are seeing being flagged? Any chance they are clustered or are they scattered throughout the night? Wondering if it is possible that if there are clusters then maybe the centrals are SWJ (sleep wake junk) getting flagged.

VPAP settings of 8 IPAP and 6 EPAP are very modest pressure ranges. If you change to straight cpap you shouldn't need any exhale relief but what pressure would you propose to use? VPAP setting of 8/6 isn't much different from cpap 8 with EPR of 2.
If you are thinking your centrals are pressure triggered (I am not so sure they are) then maybe cpap at 6 cm with no EPR or maybe try VPAP with 7 IPAP and 6 EPAP????

But before changing....I would evaluate the recent change in AHI first...2 or 3 nights doesn't make a trend especially if those centrals are maybe not "real" centrals. If they are SWJ then no amount of pressure changes is likely to do anything.

[johnthomasmacdonald]

Pugsy, The centrals seemed amazingly well spaced throughout the night,little to no clustering although there was one cluster of 7 centrals in a 5 min time span in the middle of the night ( i didn't wake at all as far as i know). The centrals seemed pretty long in duration - like 20sec to half a minute each. You wrote: "If they are SWJ then no amount of pressure changes is likely to do anything." What are SWJs? and shouldn't i be trying to do something about them - switch to an asv machine for instance? What i find so strange is the variability - why do I have an asi of 1 followed by a night of 7 and I'm really sure that I am not making any changes - no drugs, no alcohol, no meals at strange hours,.
"

[Pugsy]

SWJ...Sleep Wake Junk. Centrals that are getting flagged while either awake or semi awake which if you say the centrals are not in large clusters then likely they aren't SWJ but if you have some episodes of minor sleep disturbances (low level awakenings that you don't remember) then they might still be SWJ...or simply an occasion real central that we can all have from time to time.

If your "centrals" aren't caused by pressure (and SWJ is not caused by pressure) then pressure changes won't impact them one way or the other.
Why do you have some nights with lots of "centrals" and some nights with minimal to none? I don't know. That mystery I have wondered about ever since I saw your first reports. Some nights were great and some nights were a total mess. Logic would tell us that if you were having some complex sleep apnea issues that you would have them every night and not sporadic nights unless there is some hidden component or medical issue or maybe prescription med issue. Your reports are just plain weird sometimes.

I do think that if your "centrals" were/are caused by pressure then you would have them every night because you use the pressure every night. I don't think they would come and go like they do.
So I don't think that your centrals are pressure triggered but then I don't know why they come and go and it wouldn't hurt anything to try a lower pressure as long as your obstructive component to your AHI stays nice and low.

[johnthomasmacdonald]

I sent my sd card from the PR system one auto back to the company i got it from and they also didn't know what to make of my sleep weirdness - although they blamed it on a neurological problem - they then offered to refund the full expense of the machine i bought towards a PR system one auto bipap - but i don't know whether it would make any difference ( or whether it makes any sense from their point of view since if it is neurological it should require an ASV machine i would have thought). THe only difference i find is that without the dental appliance, i find the bilevel far more tolerable at the higher pressures while with the dental appliance it doesn't seem to matter since I can use low pressure

[Pugsy]

I don't know what to tell you. You know that sometimes even those people who do develop complex sleep apnea and real centrals triggered by cpap pressure will have the centrals fade away with time. Since your hands are sort of tied right now with insurance situation and follow up by a sleep doctor, etc...I guess you do what you have been doing to make the best of things and cross your fingers. Give it some time and watch things carefully. At least you aren't consistently seeing AHI of 10 to 15 every night with all of them being centrals.

[johnthomasmacdonald]

no and regardless of the centrals, i am feeling much better - nocturia is Cured and the bags under my eyes are gone ( i just thought they were age related) -

[Xney]

You may need a sleep study to see more about the centrals, unfortunately. They could either be causing sleep disturbances, or be due to them. In a sleep study with all the gear, they can tell the difference.

An AHI of 1-2 isn't bad, you may be fine as is?

[johnthomasmacdonald]

Xney wrote: "You may need a sleep study to see more about the centrals, unfortunately. They could either be causing sleep disturbances, or be due to them. In a sleep study with all the gear, they can tell the difference.
An AHI of 1-2 isn't bad, you may be fine as is? "

ahi 1-2 is my lowest nights - many nights it's more like 6-8 and it seems rather random

My insurance company turned downed my request for a diagnostic sleep test, I paid for a home test which found an ahi of 21 and oxygen of 88%, tried to get a sleep test for treatment and the insurance company rejected it again claiming it was still "diagnostic" and also refused to pay the sleep doctor because they then claimed that it was a Pre-existing condition - obviously intellectual consistency is not a virtue with insurance companies - it's more like "tails we win and heads you lose"

[Xney]

Wow, that insurance screwing you is incredible. can you call a state office or something?

[mamagoober]

James has more centrals on nights that he's stressed, has more than one drink, or takes melatonin. Maybe it would be a good idea to keep a journal (there is a journal section in SH) of as many different variables you can think of to try to discern a pattern.

James's nights don't vary as widely as yours, but he can have nights as low as 0.2 or as high as 5.6. In his original sleep study, he had an AHI of 10.something and none of them were centrals, and then his titration was full of centrals. His doc was reluctant to prescribe APAP, but did so at my insistence (because I had read some things from Pugsy about SWJ and 'outgrowing' centrals). He has done wonderfully well even though some nights are riddled with centrals. His sleep doc says that you need to have a sleep study with CAI >5 to have insurance pay for ASV.

When we went for the follow up appt, the doc walked in the room, looked at me, and said, "You were right." He was happy with the reports.

[Pugsy]

James's nights don't vary as widely as yours, but he can have nights as low as 0.2 or as high as 5.6. In his original sleep study, he had an AHI of 10.something and none of them were centrals, and then his titration was full of centrals. His doc was reluctant to prescribe APAP, but did so at my insistence (because I had read some things from Pugsy about SWJ and 'outgrowing' centrals). He has done wonderfully well even though some nights are riddled with centrals. His sleep doc says that you need to have a sleep study with CAI >5 to have insurance pay for ASV.

When we went for the follow up appt, the doc walked in the room, looked at me, and said, "You were right." He was happy with the reports.

I also have some nights where "centrals" are all over the place and I have some nights were I don't have a single one. Some nights I can explain them away like the one time I knew I was awake because I woke up wondering if I needed to go bow to the throne because I had a bad stomach bug...I lay in bed trying to get the nausea to subside for about and hour...never did go vomit and finally went back to sleep. During that hour I had a truckload of centrals but I know for sure I was awake. I also know I was doing some weird breathing trying to fight the nausea. The machine flagged awake stuff or SWJ.
Then there was another time I had 17 centrals in 17 minutes. I call that one my alien abduction. I don't recall anything that might explain those centrals away. Maybe a weird dream or maybe I was semi awake and not remembering it. The flow graphs looked sort of like SWJ but not totally like awake breathing.
I do have some issues with pain (bad back and pelvis from arthritis) and I have noticed that on nights where I seem to have more pain and more restless sleep then I will tend to have more centrals get flagged. I suspect those are more of the turn over in bed hold my breath centrals. Again most likely SWJ centrals.

I have never had as many as JohnThomas has though. He really needs a real in lab sleep study and hopefully on a night where he would have all his centrals pop up (some nights he doesn't have very many at all) but his insurance won't pay and he can't afford out of pocket costs and especially so because it would likely be his luck that he would have a rather quiet night and the centrals wouldn't pop up for evaluation. Wouldn't it just be horrible to pay out of pocket for a night that would maybe be unremarkable and not have the centrals pop up for evaluation?

I am glad your husband is doing well with the APAP. I have never tried an ASV machine (too expensive for my experiments) but from what I have read they can be rather demanding taskmasters and not so easy to get used to and thus it might be a good idea to see is traditional therapy can get the job done before going to the high dollar machine. If I had more centrals every night then I might go down that experiment road but I just don't see the need for that experiment based on random clusters of unexplainable centrals that don't occur every night. I might go 2 weeks before my Central index gets above 3.0. Then have one yucky central night and go another 2 weeks or so before another yucky night. Especially when it is very likely that my "centrals" are SWJ centrals. Even if they were/are the read deal sometimes...just don't know if it is that much of a big deal when they are so random in large numbers and a sporadic "real" central isn't a big deal anyway.

[johnthomasmacdonald]

Pugsy - dropped the pressures to 7 and 6 from 8 and 6, ahi was 7, a tiny amount of it was flagged as hypopnea ( 0.3) while the rest was centrals. I also had the nocturia back again, CURSES!!!!! I think i need to give asv a try ( i've got a new S8 adapt enhanced ASV machine that I bought sitting in the bullpen warming up)

[Pugsy]

dropped the pressures to 7 and 6 from 8 and 6, ahi was 7, a tiny amount of it was flagged as hypopnea ( 0.3) while the rest was centrals. I also had the nocturia back again, CURSES!!!!! I think i need to give asv a try ( i've got a new S8 adapt enhanced ASV machine that I bought sitting in the bullpen warming up)

Dropping the pressure shouldn't cause more centrals. You are a true mystery.

What information can you get off the S8 adapt ASV screen regarding your data? I don't think it flags centrals separately. I think they just get lumped in with the apneas and hyponeas. I think you are going to have to rely on overall AHI (understanding its limits) along with how you feel.