Just Diagnosed - Unsure About Recommended Treatment

[restoresleep]

Hi folks,

Recently diagnosed with moderate OSA and it's great to find this forum with so much useful information. Have been reading through the newbie info and with some additional Googling I'm trying to make sure I'm on the right track with the recommended treatment. I'll provide more detail below, but in short, although I've been told I have moderate OSA, the report I got notes that a significant number of events were central apneas: 36 (70%) out of 52 apneas were central. I've been told I need APAP but my reading would suggest that BiPAP is the way to go with centrals.

My Details:

• 37 years old

• Male

• Experienced day-time tiredness / fog for approximately 4 years

• Tiredness predominantly at work, leading to approximately 3 months off work

Sleep Study Details:

• Study completed one year ago

• Only got the results very recently

• Study was a home-based study

• No EEG etc.

• Funnily enough one of the best nights sleep I had was during the sleep study

• No snoring occurred during the study, however I normally snore a lot and my wife has to wear earplugs every night to sleep because of my snoring

Feedback from Clinic:

• All I've been told is "you have moderate OSA and we recommend APAP", that's it.

• I believe my results were somehow forgotten about as I telephoned the clinic who managed the sleep study and got the results immediately over the phone. The person who gave me the results made a comment that suggested they had my results for a long time but someone forgot to forward them to the hospital consultant...great start to the process!

• I am due to have a more formal feedback session but it was cancelled due to covid-19 related issues and is pushed back a month. Even though I have not had this formal feedback session I am being told to undertake APAP by the clinic who gave me the results.

I can't attach images so have linked to an image of the one page report I have received (with personal details redacted). Based on my understanding of the report:

• Link to image of report: https://ibb.co/GpKB65g

• It appears I'm just over the threshold for moderate sleep apnea.

• It's the combination of apneas and hypopneas that's pushing me into the moderate range.

• Drawing on apneas alone I'm at 6.8

• I appear to have most apneas/hypopneas while on my back

My main question:

• The note on the report that "A significant number of events were central apneas" is the main piece of info that I'm curious about and trying to understand.

• Would this suggest that I have predominant central sleep apnea and that I should instead be undertaking BiPAP treatment?

• I have read that CSA can be secondary to other health difficulties, however to the best of my knowledge I have no other health difficulties (that I know of).

• When I first began to feel tired / foggy, it all began with ocular migraines, though these have since stopped, though I continue to see flashes of blue dots (not floaters) in my vision daily. I'm not worried about tumors or anything but I have read that these can be related to tumors in the brain and that CSA can be related to this also - I wonder should I be getting an MRI to rule this out or would this be OTT?

Thank you for any help and guidance.

[LSAT]

You are not considering the hypopnias.. You had 52 Apneas and 65 Hypopnias....Total 117 events in 7.4 hours. 36 were CAs. If the CAs are deducted you have 81 events in 7+ hours. The true AHI is 10+. You need the APAP. You do not have Central Apnea. Without seeing the data, we can assume that the CAs came when you were falling asleep or when you were waking up and partially awake. We call them Sleep/Awake Junk. Apnea is a 80-100% Blockage...Hypopnea is 40-79% blockage.

[Pugsy]

You may or may not need bilevel (bipap is a Respironics marketing term for their bilevel machines). There are several bilevel models out there meant to deal with central apneas as well as other respiratory issues.

Do you take any medications that might suppress respiration? Usually this means some sort of pain medication.

Here's the deal...sometimes with a few people cpap/apap will reduce the number of centrals that they are no longer a problem.
It's normal to have a few centrals anyway and centrals aren't a big deal unless they are numerous enough to cause desats or they keep bouncing a person out of sleep.

While 70% of your apnea events might have been central you didn't have an extremely large number of them over the 9 hours as you overall AHI was just a little over 15 anyway... Borderline for a diagnosis of central apnea without the obstructive stuff. It's not like you had 25 centrals an hour kind of thing.

All that said....most insurance companies will require you to at least give cpap/apap a try and see what happens both with the centrals and obstructives before they will pay for the more expensive bilevel machine. The reason why they require this is simple...sometimes it works and the cpap/apap machines are cheaper and they just don't want to pay for a more expensive machine when cheaper fixes a problem.
There is also a chance that your centrals were related to obstructives in the sense that the obstructive stuff caused an arousal and you maybe held your breath a bit during the arousal and the machine then flags a central apnea. Since your home study didn't measure actual sleep status there is no way to know for sure if this happened or not.

My recommendation....specifically request the ResMed AirSense 10 AutoSet (or the AutoSet for her model) as your first machine.
It actually has some bilevel capabilities and is often called the poor man's bipap/bilevel. It's limited but it is bilevel and a way to sort of test bilevel on a cpap/apap machine.

You have to start somewhere...and that machine will flag central apneas if you continue to have enough of them to be a problem.
Plus by utilizing the EPR exhale relief feature we can make it function in a limited bilevel capacity.
Your results are very borderline and would need to be a lot more remarkable to get your insurance company to jump on the bilevel or something else just to treat centrals.

Start with the basics....it might just work well enough and if it doesn't it will document that it isn't doing a good job and you need something else and the insurance will be forced to get on board.

Oh...hyponeas are still a big deal. They are apnea events that just don't quite meet the criteria for an OA classifcation...technically.
OA...80 to 100% air flow reduction that lasts at least 10 seconds.
hyponea..40 to 79% air flow reduction that last at least 10 seconds.....they are still bad guys.

[restoresleep]

You are not considering the hypopnias.. You had 52 Apneas and 65 Hypopnias....Total 117 events in 7.4 hours. 36 were CAs. If the CAs are deducted you have 81 events in 7+ hours. The true AHI is 10+. You need the APAP. You do not have Central Apnea. Without seeing the data, we can assume that the CAs came when you were falling asleep or when you were waking up and partially awake. We call them Sleep/Awake Junk. Apnea is a 80-100% Blockage...Hypopnea is 40-79% blockage.

Thanks for such a rapid reply! Nice to have confirmation that APAP is the way.

Data wise, that's all I've been given. Would it only be possible to 100% confirm that the CAs occurred while falling asleep / waking up / partially awake through a polysomnogram measuring sleep stages during a sleep study? No data was gathered on this from what I can tell (nothing was attached to my head during the study).

Just to add for what it's worth, as I forgot to add this stuff:

• It's a year ago now but to the best of my memory I didn't wake up (consciously anyway) during the sleep study -if I did I was awake very briefly to turn on my side/back.

• I don't wake up during sleep and get 7+ hours of (consciously) unbroken sleep at night. I have only had 2-3 moments of waking up due to not breathing over the last 4 years.

• I was taking no medications (the occasional paracetamol but rarely) around the time of the onset of fatigue and during the sleep study (~2 year period of time). I am now taking Etoricoxib 90 mg due to an injury but only take them during flareups of pain - this medication is not taken daily and I have noticed no differences in sleep quality when taking it or not.

• I virtually don't drink alcohol. I do drink but it's rare.

[Pugsy]

There is zero way to even hazard a guess as to whether any centrals flagged were related to sleep stage transition or awake just holding your breath without EEG sleep stage data recording. Just not possible.

BUT.....when you get your machine and using OSCAR software there is a way to zoom in on flagged events and the flow rate (which is just your breathing) and get a good educated guess as to whether you were asleep or not when those machine flagged events happened.

Watch the videos here and learn how.
http://freecpapadvice.com/sleepyhead-free-software

And you can find OSCAR information here
OSCAR https://www.sleepfiles.com/OSCAR/
http://www.apneaboard.com/wiki/index.ph ... stallation
http://www.apneaboard.com/wiki/index.ph ... rpretation

Not all of them are easily distinguished but enough of them can be with a bit of time and experience and education.
My AHI routinely runs about 75% false positive arousal related vs asleep events because I don't sleep so great due to pain issues.
And while the above talks about central/Clear airway apneas....any category of event can be a false positive. It's not limited to central apneas.

A central apnea...clear airway on the OSCAR reports is nothing more than a cessation of breathing that lasts at least 10 seconds and the airway is open. Hold your breath for 10 seconds...that's essentially a 10 second central apnea. Not horribly stressful and you can manage it easily. They aren't a problem when random or rare. They are only a problem when we have a lot of them close together to the point they actually stress the body or impact sleep itself.
Anything flagged while awake...simply doesn't matter or count. You have to be asleep for anything flagged to matter.
It's called sleep apnea for a reason....not awake apnea.

[restoresleep]

Sorry I missed your first reply - thanks for all of that great info. I was replying to the previous post when yours came in.

BUT.....when you get your machine and using OSCAR software there is a way to zoom in on flagged events and the flow rate (which is just your breathing) and get a good educated guess as to whether you were asleep or not when those machine flagged events happened.

Awesome - and great to see the AirSense 10 AutoSet being recommended as it was the one I was homing in on from all my reading / video watching. The clinic linked me with a crew who only have the DreamStation but I have sourced another clinic to rent the AirSense 10 AutoSet. I have seen it mentioned a few times to get the 'for her' version - is that because of the ramp feature is easier to tolerate? I might have misread that elsewhere, so apologies if I have that completely wrong - I'm still getting my head around all the lingo.

Sorry also I forgot to add in my location as requested in the sticky - I am based in Ireland and have to pay for the rental / purchase of a machine myself. If it improves the fatigue I've been feeling for 4 years I'm more than happy to pay for it and am fortunate to be able to afford it.

[Pugsy]

The only real difference between the for Her AutoSet and the regular AutoSet is that there is a 3rd mode available to operate in and that mode itself does contain some differences. It's a lot more than just a ramp difference.

https://www.respshop.com/manuals/ResMed ... %20her.pdf

Regular AutoSet has 2 modes of operation
CPAP fixed pressure mode
Auto/APAP auto adjusting mode

The for her model has 3 modes of operation
CPAP fixed pressure mode
The regular auto/apap auto adjusting mode that the regular AutoSet has
plus the for Her auto adjusting mode which uses a different auto adjusting algorithm. This was target marketed for women but in reality the changes it has really could benefit either sex. It may or may not benefit you.

[rick blaine]

Hi restoremysleep,

Thanks for adding in your location. It's important because the situation when it comes to Eire/ the Republic of Ireland is quite unlike anywhere else when it comes to buying or renting an APAP machine.

For one thing, the VAT is at 23 per cent. And if the machine comes from a manufacturer outside the Republic, there is also customs duty.

Not only that, but the way the system is set up puts pressure on Irish patients to rent rather than buy.

I know this because I've advised other people from Eire. (I'm over in England, btw. Until recently, part of the EU.)

There's an information and support group specifically for sleep apnea patients in the Republic. They're called the Sleep Disorders Support Foundation, and they have a website. And they're on: +353 86 605 3891 (9am-5pm / Mon-Fri)

They have details of the three methods of financing your CPAP equipment in the Republic – Medical Card, Outright Purchase, and Rental Agreements (which comes under the 'Drugs Payment Scheme'.)

Personally, I think the set-up (in Eire) is nothing sort of extortion. And you should write to your TD about it, get the laws changed.

[restoresleep]

I got my ResMed AirSense 10 AutoSet (trying the non-for-her version initially) on Saturday and it's a lovely quite machine which is great not to disturb my wife's sleep!

Been watching a lot of videos and I as I breathe through my mouth in my sleep I initially went with the ResMed F30i as it appeared to be getting solid reviews - due to covid there was no option to test out different masks so had to make a choice without any testing. I've had a lot of difficulty getting a good seal with the mask without tightening the straps to the extent that I start to get facial and dental pain after wearing it for an hour, so haven't been able to tolerate it while asleep. I was sent a Medium mask even though the mask came with piece of card to help select the best fit for your nose (S, M, SW, W) - I can't find instructions for how to use that piece of card and whether the best fitting size is based on whether your nose fully covers the coloured area. My nose is big enough and I don't find that any of the four sizes seem to fit snuggly on that piece of card. I also found that the top strap sagged forward somewhat onto my forehead so likely need a smaller head strap.

The company offer 2-3 free masks to try if each mask initial mask isn't working out. I was considering trying one of the ResMed F20 full face mask. I've had no issues with feeling claustrophobic with the mask on and almost find it a little soothing so I think the full face mask shouldn't cause me any issues in that sense.

I was just curious if there is a known 'go to' full face mask that I should maybe try other than the F20 or whether the F20 would be a good first try at the full face masks? Also which of the F20 AirTouch versus the F20 AirFit might be the way to go - I've seen comments in videos noting the AirTouch fit can be better than the AirFit, but of course everyone's face is different.

Thanks again for any help.

It may or may not benefit you.

Thanks again for taking the time to reply, super helpful!

Personally, I think the set-up (in Eire) is nothing sort of extortion. And you should write to your TD about it, get the laws changed.

Cheers for the link to SDSF - had fortunately found them when trying to track down a company supplying the ResMed machines.

It has indeed been interesting to see how it's not covered by my health insurance and even though the rental cost is covered under the drugs payment scheme I won't reach the minimum amount each month to claim any expense back. I am fortunate to be financially secure to afford the €1,000+ a year to rent. The nurse I spoke with said most people rent for a year and then buy their own machine, so that will be my plan.