Lots of clear airway events

[zzrrrp]

The last two nights have been my worst on APAP therapy, by a substantial margin. See Sleepy Head data below. I've been getting an enormous number of clear airway events (AHI ~5). After the first night, I dialed down the maximum pressure from 15 to 12 cm H2O, but the clear airway AHI stayed roughly the same.

What am I doing wrong?

Two things to note:
(1) My prescription was for 5-10 cm H2O APAP
(2) I am taking 150mg trazodone before bed for sleep continuity (waking up 3-4 times nightly without it).

[Pugsy]

Did you have an in lab sleep study with the cpap machine being used?

Do you have copies of the sleep study results? Both the diagnostic sleep study (no cpap use) and if you had a titration with cpap being use??? If you don't have the results...get copies of the reports.

Your centrals don't appear to be tied to higher pressures all that much....we see a sizable number of them even when pressures are low. So I don't know if further limiting of the maximum will do anything to reduce the centrals or not.

Do you have a post cpap therapy follow up appointment scheduled anytime in the near future? If not, I suggest you make that appointment.

[zzrrrp]

Did you have an in lab sleep study with the cpap machine being used?

Do you have copies of the sleep study results? Both the diagnostic sleep study (no cpap use) and if you had a titration with cpap being use??? If you don't have the results...get copies of the reports.

Your centrals don't appear to be tied to higher pressures all that much....we see a sizable number of them even when pressures are low. So I don't know if further limiting of the maximum will do anything to reduce the centrals or not.

Do you have a post cpap therapy follow up appointment scheduled anytime in the near future? If not, I suggest you make that appointment.

I do have a copy of the results. No titration, but no central apneas recorded, either. I've got a followup scheduled in a few weeks. Might look into moving that earlier.

[robysue]

Did you have an in lab sleep study with the cpap machine being used?

Do you have copies of the sleep study results? Both the diagnostic sleep study (no cpap use) and if you had a titration with cpap being use??? If you don't have the results...get copies of the reports.

Your centrals don't appear to be tied to higher pressures all that much....we see a sizable number of them even when pressures are low. So I don't know if further limiting of the maximum will do anything to reduce the centrals or not.

Do you have a post cpap therapy follow up appointment scheduled anytime in the near future? If not, I suggest you make that appointment.

I do have a copy of the results. No titration, but no central apneas recorded, either. I've got a followup scheduled in a few weeks. Might look into moving that earlier.

I think moving that follow up appointment earlier is a very good idea.

[zzrrrp]

Potentially interesting: CA count had a fairly good correlation with mean (rather than e.g. 99%) pressure. The last two nights (see OP) are the outliers above the trendline.

[Pugsy]

Please confirm...the diagnostic sleep study was it done in a sleep lab setting or was it done using home sleep study and if it was a home sleep study do you know the type of device that was used?

The number of centrals and the consistent pattern throughout the night no matter what the pressure is does cause some concern.
The cpap pressure doesn't have to high to trigger the unstable breathing that goes along with Complex Sleep Apnea ...IF (big if) that is what is going on here.
People tend to think higher pressures cause it but it can happen with as little as 5 cm pressure too.

I don't know what role your sleeping aid might impact things or even if it does impact things.

I don't know to what extent you might want to experiment with things to see if you can get a night without centrals and have the obstructive stuff (and with all the pressure fluctuations seen we know the machine is wanting to fix obstructive stuff) also be well controlled.
If it were me I would back way up and start with tiny range and see what happens with the centrals and the obstructive stuff (OAs and hyponeas) but then I am a bit fearless with what I would do.
By backing way up I mean minimum of 5 and maybe maximum of 7 8...see if the centrals still are there and see how many obstructives show up.

Also...a second experiment would be to turn off EPR if I could...sometimes EPR causes centrals...not common but not impossible either.

Should you decide to experiment...I would try turning EPR off first and not change the pressure settings until I see if EPR is a factor or not. Don't make 2 changes at one time. Remember science 101...limit your variables when experimenting so that you can hopefully isolate causative factors.

If turning EPR off doesn't help and then reducing the pressure to a tiny range doesn't help the centrals...then I would for sure be keeping that follow up appointment and try to move it up to sooner if at all possible.

[palerider]

After the first night, I dialed down the maximum pressure from 15 to 12 cm H2O, .... (1) My prescription was for 5-10 cm H2O APAP .

if your rx was for 5-10, why were you up to 15? and 12? if you've got complex sleep apnea, then higher pressures often equal higher centrals.

some people report more centrals when using EPR, you've got EPR at 2, if you turn if off, and you see your centrals get lower, then you're probably one of those people. (EPR increases co2 blowoff, which can depress respiratory drive)

[zzrrrp]

After the first night, I dialed down the maximum pressure from 15 to 12 cm H2O, .... (1) My prescription was for 5-10 cm H2O APAP .

if your rx was for 5-10, why were you up to 15? and 12? if you've got complex sleep apnea, then higher pressures often equal higher centrals.

some people report more centrals when using EPR, you've got EPR at 2, if you turn if off, and you see your centrals get lower, then you're probably one of those people. (EPR increases co2 blowoff, which can depress respiratory drive)

I had a few nights where I was at 10 cmH2O for hours and having lots of hypopneas. Bumping up to 12 seemed to help the OA index. I'll definitely try reducing the EPR.

[zzrrrp]

Please confirm...the diagnostic sleep study was it done in a sleep lab setting or was it done using home sleep study and if it was a home sleep study do you know the type of device that was used?

The number of centrals and the consistent pattern throughout the night no matter what the pressure is does cause some concern.
The cpap pressure doesn't have to high to trigger the unstable breathing that goes along with Complex Sleep Apnea ...IF (big if) that is what is going on here.
People tend to think higher pressures cause it but it can happen with as little as 5 cm pressure too.

I don't know what role your sleeping aid might impact things or even if it does impact things.

I don't know to what extent you might want to experiment with things to see if you can get a night without centrals and have the obstructive stuff (and with all the pressure fluctuations seen we know the machine is wanting to fix obstructive stuff) also be well controlled.
If it were me I would back way up and start with tiny range and see what happens with the centrals and the obstructive stuff (OAs and hyponeas) but then I am a bit fearless with what I would do.
By backing way up I mean minimum of 5 and maybe maximum of 7 8...see if the centrals still are there and see how many obstructives show up.

Also...a second experiment would be to turn off EPR if I could...sometimes EPR causes centrals...not common but not impossible either.

Should you decide to experiment...I would try turning EPR off first and not change the pressure settings until I see if EPR is a factor or not. Don't make 2 changes at one time. Remember science 101...limit your variables when experimenting so that you can hopefully isolate causative factors.

If turning EPR off doesn't help and then reducing the pressure to a tiny range doesn't help the centrals...then I would for sure be keeping that follow up appointment and try to move it up to sooner if at all possible.

Sleep study was overnight in a lab setting. Diagnosis was mild/moderate OSA (study suggested untreated AHI of 10-11). Going to try reducing EPR first and subsequently reducing the pressure spread. Thanks for your detailed advice!

[palerider]

I had a few nights where I was at 10 cmH2O for hours and having lots of hypopneas. Bumping up to 12 seemed to help the OA index. I'll definitely try reducing the EPR.

fair enough... raising max pressure in that case is the right thing to do, as long as it doesn't cause other problems, which, in this case, it looks like it might.

hopefully, the EPR removal will help.

[zzrrrp]

Results of zero EPR below. AHI still high. Seems like I should raise both the max and min pressure tonight.

[robysue]

Results of zero EPR below. AHI still high. Seems like I should raise both the max and min pressure tonight.

The AHI is still high because the central apnea index is 3.8, which is 62% of the events scored. And increasing the pressure is NOT going to reduce the CAI at all. And increasing the pressure settings may increase the number of CAs. So I would NOT advise you to increase both the min and max pressure settings at this time.

That said, reducing EPR from 2 to 0, does seem to have reduced the number of CAs somewhat. On the two nights you posted data from with EPR = 2, the CAI was 5.37 and 4.97. So getting the CAI down to 3.8 is progress---provided that this reduction in CAI is really caused by the reduction in EPR instead of just normal night-to-night variability in your sleep.

Personally, I think you need to proceed with a great deal of caution and also go very slowly. You've had only one night with EPR = 0. If you slept OK subjectively, I'd encourage you to leave the settings where they are (including EPR = 0) for at least 3 or 4 more nights. (I'd actually suggest leaving them alone for a whole week.) That's the only way you're going to be able to figure out whether EPR = 0 is really helping or not when it comes to reducing the number of CAs.

[tedburnsIII]

zzrrp- please provide us with updated information re this thread topic.