Concern with Central Apnea

[Bilbosax]

Hi everyone. I have been lurking here all week, but this is my first post as I am new to CPAP and have concerns about my treatment. I'm hoping you can either calm my fears or point me in the right direction. First, I have suffered from depression and anxiety for most of my life. I later found out that I have a brain lesion in my thalamus that has not grown for over 25 years, and I was able to get a surgery in 2000 that significantly helped the depression and anxiety. Sadly, I have had insomnia and sleep problems for all of these years as well, but always pointed the finger at depression as the cause, not a sleep disorder. Currently, I am on no medications at all, but my depression came back with a vengeance and I have been so exhausted from sleep depreivation that I vomit a lot and can't think or process to save my soul. I got two sleep studies recently and they show that I have both obstructive sleep apnea and central sleep apnea in about equal amounts. My AHI at the sleep study was 25 and I got about 3 hours of extremely fragmented sleep. I was placed on a Resmed Airsense 10, initially on an auto setting of 6-16, which was recently set to a static 10. Here is what my Sleepyhead report looked like after 3 days on 10cm:

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I called my doctors office and said that my AHI had gone up from 5 on the Auto setting to 12 on the 10cm setting, so he increased my pressure to 12cm to decrease the remaining obstructive events.

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As you can see, the Obstructive apneas cleared up significantly, but the Centrals became more spread out throughout the night. My AHI was 4.4 and I got a decent total amount of sleep on this day, and my depression was much improved, so I was hopeful. But the next night was a different story.

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Again, the obstructive apneas are improved, but the central apneas became much more prevalent and packed together. This was a horrible night of sleep. What you can't see is that most of the night I was not even asleep. My AHI was 8.3 and I woke up vomiting. The increased pressure is distracting and seems to cause me some type of insomnia. I lay in bed wearing the mask but just skipped across the top of sleep but never was able to fall into a deep sleep. I looked at the clock every 30 minutes. The zoomed-in picture of my central apneas looks like Cheyne-Stokes breathing to me and this all just has me concerned. I desperately need some consistent 5+ hour nights of sleep soon or I fear it may kill me. My questions are as follows:

1) Should I be concerned about the Central Events, or could they actually get worse because of the CPAP machine? Is there any possibility with continued treatment that these may improve, or do I need to contact my doctor quickly and see what the problem is?

2) The auto CPAP was nice because I would fall asleep while the pressures were low and they might climb when needed in the night. The doctor said it is best to use a static pressure because it guarantees my airway will be open all night. But the static pressure just feels so high that it is distracting and is causing insomnia on top of the sleep apnea. I just can't seem to fall asleep and get past it. Will my body adjust to these high pressures eventually if I stick with it?

3) The doctor adjusted from a pressure of 10cm to a pressure of 12cm which you can see helped the obstructive events. I don't know how big of a change jumping 2 cm of water is. Could a setting of 11 be a possibility to consider to help relieve a little of the pressure but still keep my airway open?

Thanks for any insights everyone!

[zonker]

welcome!

your screenshots aren't showing up. please use the "attachment" button at the bottom in order for them to display.

good luck!

[palerider]

And the preview button to see what your post looks like, before submitting it.

[Bilbosax]

Thanks for the heads up. I updated the original post. Thanks!

[Pugsy]

Go here and watch the videos and learn how to distinguish asleep real events from awake/semi awake events or what we often refer to as SWJ or sleep/wake/junk.
http://freecpapadvice.com/sleepyhead-free-software

Again, the obstructive apneas are improved, but the central apneas became much more prevalent and packed together. This was a horrible night of sleep. What you can't see is that most of the night I was not even asleep. My AHI was 8.3 and I woke up vomiting. The increased pressure is distracting and seems to cause me some type of insomnia. I lay in bed wearing the mask but just skipped across the top of sleep but never was able to fall into a deep sleep. I looked at the clock every 30 minutes.

It's very possible that the bulk of those centrals (and maybe some of the other stuff) aren't real and are instead SWJ flagged events.
If you weren't asleep they don't count.
If you weren't asleep other than the fact they indicate poor sleep quality, we don't worry about them.... but instead worry about how to fix the sleep quality first...get you to fall asleep and stay asleep with minimal wake ups.

[stevezoller]

Sorry to hear about your medical issues but I’m glad you’re now on CPAP therapy. Here’s some perspective.
1) You need a lot more than a night or two on a given setting. AHI scores vary a lot from day-to-day. So while I know you’re anxious about your settings, you have to give each setting a week or two so you can see the median scores you get.
2) Many of us never got to our optimal AHI scores from our doctors. We had to figure out the optimal settings on our own.
3) A small percentage of people, which includes me, are very sensitive to air pressure which causes the central apneas to skyrocket. Basically the sensors in your lungs that sense a high CO2 level which causes you to take a breath, don’t trigger because the air blowing into your lungs from the CPAP machine dilutes the CO2 concentration and voila, central apneas.
4) For me personally, the auto set with a range has always given me lower AHI scores than a single or dual pressure. The reason is it nets out in a lower pressure which results in fewer central apneas and a lower AHI score. In fact, I can drive my obstructive apneas to near zero but the centrals go through the roof. I had to find the pressure that actually allowed some obstructives in order to get the lowest possible AHI. From a health standpoint, it’s the AHI score that counts. The internal ratio of obstructives to centrals is helpful for figuring the optimal pressures but isn’t important for health.
5) As strange as it sounds, another thing that can lower AHI is your choice of mask. In general, nasal pillows reduce AHI versus a full face mask. Other things like a thinner pillow and sleeping on your side versus back may also help.
Good luck!

[palerider]

I was placed on a Resmed Airsense 10, initially on an auto setting of 6-16, which was recently set to a static 10.

Why do doctors like to screw up a relatively good thing by going backwards?

Setting your machine *back* to auto, and a setting of min 10, max 20 may make things much better... certainly better than they are now, and probably better than they were at the other settings.

[Bilbosax]

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I really appreciate the feedback everyone. Coming from veterans like you just gives you a feeling of comfort. Of course I can't get my doctor on the line, and his nurse always sounds like I'm the last person on earth she wants to be talking to.

So, I am a little relieved because I at least got a couple of small blocks of sleep last night and did not wake up vomiting and my depression is not off the charts. I'm also happy that I only had two obstructive events even after lowering the pressure one point from 12cm to 11cm last night. But the central apneas are still quite high and they alone are responsible for my higher-than-wanted AHI. I notice that they are always more dense in the early morning around 4am or 5am. I don't know if that is relevant or not. So my two big questions are:

1) Central Apneas -- Should I be alarmed about my number of central apneas? If I stick at a pressure for awhile, will my body adapt and start to bring these down on their own? Is this any indication that I need to get my heart checked out, or perhaps be on some other treatment like a BiPAP or ASV, or do I need to just relax and keep fiddling with the CPAP? This is what my centrals look like:

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2) Ranges -- Are setting a pressure range in Auto mode a good thing for people like me? My nurse told me that a single pressure is more likely to remove the obstructive events for good, but I had no idea that it could impact your centrals so much. They also said that you may miss out on a half an hours sleep at a time while your machine tries to get you to a proper pressure while you are having events. But I am tempted to try a range at some point, like 9-13, to see if I could lower my AHI and my centrals. Any thoughts on range versus a static pressure for me?

Thanks again, your feedback is invaluable!

[Pugsy]

Some people who develop Complex Sleep Apnea because of cpap therapy can find that it will go away with time as the body adjusts.
So it can happen but it doesn't always happen and typically when it does happen it's over a period of several months.
So...sometimes they can go away on their own without anybody doing anything special....and sometimes they don't.

Some people have a fine line where above so and so pressure they get centrals and below that line they don't get centrals.

Some people get centrals pop up with as little as 5 cm pressure....doesn't matter how high it is...any pressure will trigger the unstable breathing.

Some people get centrals popping up because of using exhale relief which creates a bilevel pressure situation because for some people bilevel causes the unstable breathing. It's relatively small number of people that see this as the cause of the centrals but enough that we mention it when we see centrals in larger than we want numbers and people are using exhale relief.
You are using EPR at 3...exhale relief giving you a bilevel pressure situation. At this most recent setting...11 inhale and 8 exhale.
You might be one of those people...you might not.

The centrals pop up because the breathing becomes unstable for some reason. Doesn't necessarily mean you have anything wrong with your heart. Centrals are simply the brain not sending the signal to the body to breathe because the carbon dioxide levels in the blood stream don't get high enough to cause the brain to send the signal to breathe. The airway is open but no air is moving because the brain didn't send the "breathe" signal to its human. The exchange of gases get out of whack. Sometimes its because cpap causes the body to blow off too much carbon dioxide during the respiration process and then the blood levels never get high enough to cause the brain to say "OMG carbon dioxide levels are high...need to breathe to get things back in balance".

Some parts of the night your breathing is nice and stable and no centrals are popping up and some parts of the night it's obviously unstable. Why we don't know but there are some things you can do to maybe reduce the centrals. It all depends on what is causing the unstable breathing in your situation.

AND you also have to be for sure asleep for the centrals to be real and worth worrying about. So if you weren't asleep when those centrals were flagged....all this discussion is for nothing.
I mention this because the one cluster of centrals you zoomed in on looks like the breathing pattern prior to the first CA/central flag at 6:10 AM that you weren't asleep. I can't really see enough of that respiration/flow rate before 6:10 to be sure but it sure looks like arousal breathing to me. Makes me doubt the centrals were real or not. I can't see enough respiration before that first 6:10 flag to really know for sure.

It's fairly obvious that 11 cm fixed is doing a good job dealing with the obstructive side of things...so I might try a lower fixed setting to see if there is a line between a pressure that triggers centrals (assuming you were asleep) and a pressure that doesn't trigger centrals and can still deal with the obstructive apnea stuff well enough.
I would also consider reducing or elimination EPR exhale relief to see if that is a factor or not.

Your nurse is partially correct when she says that apap mode might allow some events to happen while the machine is trying to fight off the obstructive stuff...but that is easily remedied by just using a high enough minimum pressure in the first place to prevent the bulk of the obstructive stuff from happening and then allowing the machine to increase if it needs to for the harder to deal with obstructive stuff like maybe when on your back or during REM. What she is talking about is when people set the minimum pressure too low and the machine can't get to where it needs to be fast enough. They need a better head start and people often set the minimum too low thinking the machine can go up quickly and deal with things and they just can't move that fast.
Though it won't take the 30 minutes your nurse mentioned...they will respond faster than that. I sometimes need 6 to 8 cm more pressure in REM. The machine can get there in about 10 minutes. I see if often.

Sometimes apap mode and the pressure changing around isn't the best option when it's a situation with the centrals where there is a fine line between a pressure that triggers centrals and a pressure that doesn't. The machine will still try to kill the obstructives with more pressure and if more pressure triggers centrals the machine won't do anything about it because it can't. It responds to obstructive stuff where the flow is reduced because of airway soft tissues causing a reduced air flow....that's all this type of machine can do.
Central apneas aren't a reduction in flow because of airway tissues blocking the airway...they are simply a lack of effort to breath because the brain didn't send the "breathe" signal. The airway is open but no air is moving because of lack of effort.

If I was going to use apap mode....I would use a really tight range until I figured out exactly what might be the trigger for the centrals and the first thing I would try is turning off EPR and see if the centrals reduced in number or not.
If they don't reduce then bilevel/EPR isn't the trigger.
Move on to next potential trigger and try to figure out if its the pressure itself causing the centrals and is there a line where no centrals pop up below that line and they do pop up above that line.

I wouldn't advise apap 9 to 13...you don't need the higher for the obstructives and the machine probably wouldn't go anywhere over 11 anyway...remember it only deals with obstructive stuff.
I would try either fixed at 9 cm and turn off EPR...or if I wanted apap...8 minimum and 11 maximum with EPR off.
If doing without EPR is too uncomfortable right now...just reduce it from 3 to 2. Work your way downward in terms of EPR.

I have seen some remarkable changes in centrals with just a 1 cm reduction the exhale relief. I know a woman who was using 4 cm exhale relief (different machine than yours but essentially same function) who had about 17 centrals per hour when using 4 exhale relief and when using 3 cm exhale relief maybe a random rare central pop up. Essentially her centrals all went away with just a change from 4 cm exhale relief to 3 cm exhale relief. I can't promise you that it will do the same for you but it sure isn't impossible.
Some people do have to turn exhale relief off...hopefully their pressures to deal with the obstructive stuff won't be too uncomfortably high.

I see more instance of exhale relief bilevel situations causing the centrals than I do a fine line between pressures causing the centrals which is why I suggest turning off EPR (or at least a reduction) as the first experiment to try.

[stevezoller]

I believe your two questions were already answered above. When you’re down in the 5-6 AHI range, the ratio of centrals-to-obstructives doesn’t matter from a health standpoint. And for many of us, a pressure range is much more effective than a single pressure. My doctor had me on a pressure of 18 based on my sleep study. I’ve lowered my AHI score using a pressure range of 6-4: a huge difference in comfort and a big drop in AHI. However, everyone is different so you’ll just have to work at it. Unfortunately, it takes months because as mentioned above, scores vary a lot from night-to-night so you need a lot of nights at a given setting to know what AHI a given setting really delivers over time.

[Pugsy]

And in case this was lost in my novel above....all this talk about centrals is assuming they are the real deal and not SWJ.
If we aren't asleep...they don't count and the worst thing about them if we aren't asleep is that our sleep quality is in the toilet and people need to work on worrying about why the sleep quality is crap. They aren't necessarily the cause of the crappy sleep but instead a symptom of the crappy sleep.

[Okie bipap]

My wife is one of the people that start to have central apneas when starting to use the machine. When I first looked at her initial sleepyhead reports, I thought what the heck is going on. It essentially reduced her AHI by 50%. Instead of 48, she was at 25 with most of them central apneas. After a few days, the number of CAs decreased. They made small changes to her pressure every month for four months in order to het her up the required pressure. She still has a few events (AHI of 2.5) with over half of them CAs. She is sleeping well and is no longer sleepy during the day.

[Bilbosax]

Thanks for all the comments. Truly helpful. And Pugsy, I cannot thank you enough for writing such a detailed message of things for me to try. I have had two sleep studies, got my CPAP and mask and have had adjustments made, and in all of that time, my doctor did not add as much to the discussion as you have. I saw him for 15 minutes after my first sleep study, and that is it. You are a gift to this community.

I am actually looking forward to going to bed tonight, because I actually have things to try that make sense to me. I'll keep you all posted!

[palerider]

1) Central Apneas -- Should I be alarmed about my number of central apneas? If I stick at a pressure for awhile, will my body adapt and start to bring these down on their own? Is this any indication that I need to get my heart checked out, or perhaps be on some other treatment like a BiPAP or ASV, or do I need to just relax and keep fiddling with the CPAP?

I wouldn't think that's a 'go to a cardiologist' just yet.

Now, if your night looked like this:

(that person had bad undiagnosed congestive heart failure.)

2) Ranges -- Are setting a pressure range in Auto mode a good thing for people like me? My nurse told me that a single pressure is more likely to remove the obstructive events for good, but I had no idea that it could impact your centrals so much. They also said that you may miss out on a half an hours sleep at a time while your machine tries to get you to a proper pressure while you are having events. But I am tempted to try a range at some point, like 9-13, to see if I could lower my AHI and my centrals. Any thoughts on range versus a static pressure for me?

Already stated that. Ranges work best for most people, because their sleep varies throughout the night.

Pugsy's a great example, for much of the night, she's fine with 7or so pressure, but during REM, she needs upwards of 18. if she was on straight pressure, she'd have to be at 18 all night long to get coverage for the REM exceptions.

[Bilbosax]

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Pugsy, my friend, you might be a certifiable genius! I decided not to change too many things all at once, so I left the pressure at 11 and simply dropped the EPR from 3 to 1. I practiced with it earlier in the day and 1 just felt more natural to me, less artificial. I know for certain that I got two separate 3 hour blocks of sleep, for a total of 6 hours of sleep! That is an eternity for me, double my sleep study time. In a million years, I would not have thought to alter the EPR, so I thank you for your suggestion. It still marked a fair number of centrals, but they were less clumped together, and with an AHI of 2.6, I am not going to complain!

I'm probably going to leave this set for a couple of days to make sure everything is stable, but the next thing I want to tackle is the time it takes me to fall asleep. Since I started the CPAP at a set pressure, it takes me a full hour to actually fall asleep, each time I fully wake up. I'd like to get that under 30 minutes if at all possible. Personally, I think that it is because of the higher static pressure, it feels unnatural when I lay down to fall asleep, but is helpful once I actually fall asleep. I am thinking of setting a pressure range of 8-11 as you suggested to see if the lower starting pressure of 8 would make it easier or more comfortable to fall asleep, and it could ramp up to 11 to hold back the obstructives. Let me know if anyone has any thoughts on this!