Centrals: When to move to BiPAP?

[zeleni]

Greetings,

I've been on CPAP for almost three months. My initial sleep test showed an AHI of 28 (7 of which were from centrals, and most of the rest were hypopneas - only a handful of obstructives) A few weeks ago my sleep doctor upped my prescription to try and lower my AHIs - which had been averaging just over 9. My new prescription has slightly increased my AHIs and I've been on it for over two weeks. At what point should I start looking to BiPAP (and then ASV)? Are there any other pressure adjustments I should try making? I've been noticing some mouth breathing lately, but as I understand it, that's more of a comfort issue than something affecting my AHI. I'm still feeling tired and brain fogged (although I've had a few particularly good days).

And although my AHIs average 9, they hourly events increase drastically throughout the night and will peak up to 25 or 30 before I wake up (I've also noticed I wake up in the middle of the night right after this increases).

Also, I've seen a few snores popping up on the graphs (although my wife says it's much improved). Are they likely snores or just funny noises from the mask?

I've uploaded some of my images from last night and trends in case it's useful. Thanks in advance for your help.





Thanks!

[Bons]

I was bumped to bipap after a month, and then on to ASV a month after that.

[zeleni]

What kind of AHIs were you having when they bumped you up? Thanks!

[RationalEntropy]

I had a very similar experience.

Well, here is a short history: my sleep study's PSG gave me the following results:

Diagnostic
AHI (Non REM): 21.6
AHI (REM): 27
SaO2 nadir: 90%
All Hypopneas

CPAP
AHI (Non REM): 11.84
AHI (REM): 8.47
SaO2 Nadir: 89%
Again, hypopneas

Bipap
AHI (Non REM): 0
AHI (REM): 0
SaO2 Nadir: 94%

So, that seems to be a "happily ever after ending", but a month later, with an at home AHI ranging from 7 - 11 (where 90% of these consisted of Clear Airway Events). Occasionally I would feel lucky to have 7, or less, but noticed increased brain fog. I, just as most folks, dislike brain fog... a lot. Nuvigil was not helping at this point. My doctor listened to me, and prescribed my System One Bipap ASV.

At first my AHI consisted entirely of Hypopneas with not pure obstructions or Centrals. The hypopneas were to be reduced through CPAPping. I was titrated initially to 11 was the maximal effective CPAP, but with the AHI mentioned earlier on for CPAP. CPAP was not tolerated... and then BPAP was phased in to 15/11, and the "clear airway apneas began". Now the saga of the ASV.

I was diagnosed with OSA, and when treated [using bipap] had the clear airway apneas when the hypopneas were eliminated. Now the clear airways have all but been eliminated with a few lingering hypopneas. Funny how things work.

The above were quoted from here: viewtopic/t74107/viewtopic.php?f=1&t=70 ... 79#p652579 . This page gives a brief account of my ASV which was used after receiving my unsuccessful BiPAP treatment. I did not need oxygen, but other people do. I hope this is helpful.

Note: I did not tolerate CPAP, but they will likely move you to BiPAP (given AHI > 5 with more than 50% occurring from central apneas), and if that persists on BiPAP, then it goes to BiPAP ST then ASV, but often they go from BiPAP to ASV if it gets that far.

[teknomom]

Note: I did not tolerate CPAP, but they will likely move you to BiPAP (given AHI > 5 with more than 50% occurring from central apneas), and if that persists on BiPAP, then it goes to BiPAP ST then ASV, but often they go from BiPAP to ASV if it gets that far.

I had 50% Centrals on my first sleep study and went directly to ASV. I'm not sure why they would try anything else first unless it's an insurance question. I had about 1/2 an hour on a Cpap to prove that it didn't stop my centrals (why would it?) and then on to an ASV at my titration sleep study. I don't think you have to go through all of the steps above.

[Guest]

During the study the cpap still left me with an AHI in the neighborhood of 13 or so... so I left with the bipap. That didn't work... so, after some time on that, I waited for a few weeks on insurance, and another week for it to ship to the DME, and voila, shiny new ASV. I will not sleep without it.

I think it was 30 minutes or an hour. Then titrating with the bipap, which supposedly worked during the study, but did not in the real world. Clear airway apneas (Philips-Respironics will not call them "central apneas" since no tension values are taken around the diaphragm and belly areas) were occurring in the range of 6 - 13 (if memory serves), and the mind grew cloudy again.

Whatever the case, I hope that supplying the SD card's data, keeping copies, and asking the right questions will lead zelini (or any readers) down the right path.

[JohnBFisher]

... Whatever the case, I hope that supplying the SD card's data, keeping copies, and asking the right questions will lead zelini (or any readers) down the right path. ...

The desire to help others avoid the years of torment that I suffered is one reason I try to stay active in this forum. It literally took me YEARS to get doctors to pay attention to my central sleep apneas. I know that the untreated apneas led to controlled high blood pressure that ... combined with my Ibuprofen use to help me deal with the horrible headaches I suffered every morning ... led to permanent kidney damage. Gee, THANKS! We could have avoided that problem.

I finally broke down in tears in front of my current neurologist and explained yet again that when I fall asleep I stop breathing so long that my BiPAP unit would turn itself off. It assumed I was no longer wearing it. That meant that I would stop breathing for more than a minute. And that happened over and over and over again. When I finally broke down in front of him, I was getting an hour or two of sleep per night.

When he finally "got it", he set me up for a titration on an ASV unit. The headaches disappeared almost immediately. As did my uncontrolled high blood pressure.

The process was so painful and frustrating that I've done everything I can to try to help others facing similar circumstances.

[VikingGnome]

The is a misconception that "Clear Airway" apneas ARE Central Apneas. No machine for home use can detect Central Apneas because the lack of respiratory effort cannot be detected. All the machine knows is that puff of air sent from the machine did not rebound indicating an obstruction. But lack of obstruction does not mean Central Apnea. The lack of breathing must be linked with no respiratory effort by chest/abdomen muscles to be called a Central Apnea.

This is the danger of patients seeing their CPAP data and making assumptions about what they need. None of you are sleep doctors and should be very careful about what you do about the data you see.

I personally will be sharing my data with my doctor on my 60-day check-up appointment. But I will make no determination about what it means without a medical degree and Board Certified in Sleep Disorders.

[idamtnboy]

This is the danger of patients seeing their CPAP data and making assumptions about what they need. None of you are sleep doctors and should be very careful about what you do about the data you see.

Just like I'm too dumb and uneducated to know that when my blood glucose readings are above 130 morning after morning that maybe I need to get more serious about exercise and eat fewer carbohydrates.

[FeelingBetter]

Did you guys have to go back to the sleep lab when you switched to bipap or ASV? I was recently diagnosed with secondary PAH and my AHI are in the 15-17 range and my last oximetry was >66.7% of the night with an o2 sat below 90% and I was down to 60% at times. 2 months ago only 3% of the night was below 90%. Anyway, they want me to go back to the sleep lab to either bleed in o2 or go to bipap or bipap with bled in o2. Do I really need to go back to the sleep lab for this? I really don't want the expense or the super soft bed which kills my back.
Any input will be appciated.

[JohnBFisher]

... Did you guys have to go back to the sleep lab when you switched to bipap or ASV? ...

In a word: Yes. The ASV titration is quite a bit different than CPAP or BiPAP. Ditto, BiPAP is quite a bit different than CPAP titration. Sorry.

[portiemom]

Just a ? here, I've been on cpap and autocpap for almost 7 years, good ahi 1.8 and below, but remain in the fog and terrible headaches, how would I know if bi=pap or apap would help! Is there any treatment for this fog,,,, it's neverending for me! I just got a new S9 autoset and don't want to end up with it after 60 days if I need a different type of machine.

[teknomom]

Just a ? here, I've been on cpap and autocpap for almost 7 years, good ahi 1.8 and below, but remain in the fog and terrible headaches, how would I know if bi=pap or apap would help! Is there any treatment for this fog,,,, it's neverending for me! I just got a new S9 autoset and don't want to end up with it after 60 days if I need a different type of machine.

What do your doctors say? Are you on any meds or have other conditions that could cause this? Do you check your O2 at night? Your AHI makes me think that your cpap or apap is already treating your apnea pretty well. Not everything is related to Sleep Apnea, so look for help in all directions not just one. I haven't felt much difference in my energy or concentration either but I've only been on my machine 7 weeks not 7 years. Good Luck!

[portiemom]

Yes, I do have some other conditions, but that said, they are under good control, I am off most meds that would cause this fog, I have been told by the Dr. that for some folks cpap treatment is not answer for OSA, that's when I quit him. The last Doctor had 30 hours training and was certified to be a sleep specialist! UGH
I am constantly looking for other avenues to persue to help this fog, but to no avail I run through the fog in to the brick wall.
Thank you I do appreciate your post, I'll just keep on trying to deal with all this,

[teknomom]

I'll just keep on trying to deal with all this,

It sounds very frustrating! On most routine days I'm OK, but throw in anything complicated and I'm lost. The Fog is no fun!