Still trying to tame centrals

[startanew]

Started APAP last December – initially numbers looked good and overall I am doing better than I was last year.. but the adjustment has not been easy and I am still struggling with finding the right combination of mask, pressure, equipment, and behavior to get really restful sleep.

Generally getting 3-5 nights of reasonable numbers followed 1-4 nights with a AHIs 8 -20 which usually involve clusters of centrals running for 15 minutes to an hour. One those days I wake up groggy, fuzzy headed, and headachy.



A couple months ago I posted on an increase in Central/Clear Airways that seemed to coincide with stopping use of chinstrap in late February (see chinstraps and centrals). In early April – I started using the chin-strap again and you can see that the AHI especially CAs has not gone back down.


I’m beginning to think it has more to do with finally getting to REM…since most of the clusters are when I am asleep and 3-4 hours in. The smaller late morning stuff is prob Sleep Wake Junk.



Talked to sleep team/RT shared my data a month or so ago about the high readings and my ongoing issues with getting and staying asleep with APAP. Suggested trying a new mask, more work on sleep hygiene (which is pretty decent) and perhaps just seeing if the issue would resolve.

Talked to my primary care doc 2-3 weeks ago – who suggested trying a low dose of trazadone (50 mg) – started the last week of May. While has helped in the sleep consolidation department – but CA’s are still up. Thinking about tapering back off.....o

Will be trying Airfit P10 starting this weekend to see if that makes a difference. Haven’t been able to isolate other behavior that seems to be triggering the CA Clusters, looked at things like OTC meds, late exercise, eating out (MSG) etc .

Leaks seem to be under control. Some of the clusters but not all seem be triggered by pressure. So I’m thinking it may be time to wingding (smile) as current pressure settings now set at 5 – 20 CM the low end which has felt close Suggestions on a better range to start with welcome.



Any other thoughts on how to tame this?

Other pertinent details 57 yrs, 6 ft, 215 lbs, non drinker (recovery 25 yrs) non- smoker, 30-90 minutes of exercise daily, 3-6 cups coffee before 11 AM (need to reduce), limited dairy, gluten and sugar. Trazadone – but no other meds

Thanks again to all the folks here both conventional and unconventional.

[araris]

No advice but I will be following you closely. I'm in a similar situation except my pressure setting is not as bad as your.

[Todzo]

Started APAP last December – initially numbers looked good and overall I am doing better than I was last year.. but the adjustment has not been easy and I am still struggling with finding the right combination of mask, pressure, equipment, and behavior to get really restful sleep.

Generally getting 3-5 nights of reasonable numbers followed 1-4 nights with a AHIs 8 -20 which usually involve clusters of centrals running for 15 minutes to an hour. One those days I wake up groggy, fuzzy headed, and headachy.

Does kinda look like emergent central apnea.

A couple months ago I posted on an increase in Central/Clear Airways that seemed to coincide with stopping use of chinstrap in late February (see chinstraps and centrals). In early April – I started using the chin-strap again and you can see that the AHI especially CAs has not gone back down.

I’m beginning to think it has more to do with finally getting to REM…since most of the clusters are when I am asleep and 3-4 hours in. The smaller late morning stuff is prob Sleep Wake Junk.

Talked to sleep team/RT shared my data a month or so ago about the high readings and my ongoing issues with getting and staying asleep with APAP. Suggested trying a new mask, more work on sleep hygiene (which is pretty decent) and perhaps just seeing if the issue would resolve.

Talked to my primary care doc 2-3 weeks ago – who suggested trying a low dose of trazadone (50 mg) – started the last week of May. While has helped in the sleep consolidation department – but CA’s are still up. Thinking about tapering back off.....o

Will be trying Airfit P10 starting this weekend to see if that makes a difference. Haven’t been able to isolate other behavior that seems to be triggering the CA Clusters, looked at things like OTC meds, late exercise, eating out (MSG) etc .

Leaks seem to be under control. Some of the clusters but not all seem be triggered by pressure. So I’m thinking it may be time to wingding (smile) as current pressure settings now set at 5 – 20 CM the low end which has felt close Suggestions on a better range to start with welcome.

Any other thoughts on how to tame this?

Other pertinent details 57 yrs, 6 ft, 215 lbs, non drinker (recovery 25 yrs) non- smoker, 30-90 minutes of exercise daily, 3-6 cups coffee before 11 AM (need to reduce), limited dairy, gluten and sugar. Trazadone – but no other meds

Thanks again to all the folks here both conventional and unconventional.

So you get a CPAP machine, and it works!! So what happens inside your body? Are things likely to change?

I used to think that a tracheostomy was indeed “the ultimate cure” for sleep apnea. But as they related in a recent commentary in SLEEP[1] that is not the case:

“...central apnea following tracheostomy is well described in severe OSA patients, perhaps suggesting that the mechanism underlying baseline OSA may be a critical variable.[10,11]”
So perhaps CPAP has “un-masked” the real problem (that was kinda fun).

Most people think of sleep apnea only as obstructive sleep apnea. However there is a much broader spectrum of causes of apnea. As well the point at which arousal occurs with an event may well change. They are beginning to sort it out[2,3].

When you breath more than you should you also wash out more carbon dioxide (CO2) than you should. In the context of hyopcapnic (hypo=low capnic=CO2) central apnea as the CO2 level decreases it goes beyond the “apneic threshold” and so a hypocapnic central apnea is caused to occur.

Often CPAP tends to exacerbate central apnea as the pressure tends to cause you to use a bit more air and so tends to cause CPAP emergent central apnea often known as Complex Sleep Apnea (CompSAS).

I am suspicious that this results from two of the nonanatomic causes of sleep apnea[2,3] ganging up on you as you use CPAP. High respiratory control system gain working with low arousal threshold could mean that the times of more breathing brought forth by the respiratory gain issues would cause respiratory effort above your low arousal threshold and fracture your sleep with excessive arousals. In a recent comparison study looking at how CompSAS responds to treatment by ASV vs CPAP[6] they found that at the end of 90 days both arms were essentially equal in the number of arousals with over twenty per hour still in play. Both arms had excessive daytime sleepiness affected only a little by treatment. ASV however did well to severely reduce the hypocapnic central events so probably does better protect the brain.

The most helpful thing I have found with this is to reduce the stress in my life. Stress for me definitely raises my respiratory control system gain!

When dealing with unstable breathing with CPAP I have found it very helpful to spend some quality time with the machine during the daytime. Some in bed learning to breath quietly (at rest in bed, little real air need). Some with mild distraction such as a book, music, or lite TV.

I and others[5] have found moving vitamin D3 into its active range helpful.

And during my journey away from sleep apnea I have found that I did not know how to eat well or move well. Oh I thought I did. If you would have asked me I would have told you I did. But I learned that I did not! My three years with a dietitian helped start me on my continuing life long journey to eat well. I still strive toward the basic goal of 10,000 steps a day (about 4.5 miles for me - running about 90% at this time) and do intend to use more personal trainer time as I pursue an active lifestyle. Lately I have been thinking that running, which is known to help with brain development, might well be worth the risks to my knees at my advanced age. By eating well and moving well I hope to promote whole body metabolic health and I can say it does appear to help with my tendency to have centrals emerge as I use CPAP.

In terms of an unconventional suggestion – well how about buddhist meditation mindfulness of breathing applied as you use CPAP. I have been meaning to try this.

Also I have found EERS[4] helpful to deal with this issue.

hth


[1] Orr J, Javaheri S, Malhotra A. Comparative effectiveness research in complex sleep apnea. SLEEP 2014;37(5):833-834

[2] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman "Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets", American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004. doi: 10.1164/rccm.201303-0448OC

[3] Sairam Parthasarathy M.D., Emergence of Obstructive Sleep Apnea Phenotyping. From Weak to Strong! American Journal of Respitory and Critical Care Medicine VOL 188 2013
-- critical closing pressure [Pcrit] - Arousal Threshold - ventilatory control Loop gain - and genioglossal Muscle responsiveness. Pcrit, Loop, Arousal, Muscle (PALM)--

[4]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[5]: Those who are working with the D3 hormone (A.K.A. Vitamin D3) (e.g. Dr. Stasha Gominak, Michael F. Holick, Ph.D., M.D., Vitamin D Council) seem to be finding that the very low side of the “normal” range of 30-100 ng/L produces a range of symptoms including OSA, pain, and infection. All believe that a level lower than 50 ng/mL is not good and Dr. Stasha Gominak recommends 60-80 ng/mL for good health. It would probably be wise to check your vitamin D3 levels. See “The Vitamin D Council” for assay details.

[6] Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. SLEEP 2014;37(5):927-934 Related article (commentary):833

[10] Fletcher EC, author. Recurrence of sleep apnea syndrome following tracheostomy. A shift from obstructive to central apnea. Chest. 1989;96:206-9

[11] Guilleminault C, Simmons FB, Motta J, et al., authors. Obstructive sleep apnea syndrome and tracheostomy. Long term follow-up experience. Arch Intern Med. 1981;141:985-8

[Todzo]

Started APAP last December – initially numbers looked good and overall I am doing better than I was last year.. but the adjustment has not been easy and I am still struggling with finding the right combination of mask, pressure, equipment, and behavior to get really restful sleep.

Generally getting 3-5 nights of reasonable numbers followed 1-4 nights with a AHIs 8 -20 which usually involve clusters of centrals running for 15 minutes to an hour. One those days I wake up groggy, fuzzy headed, and headachy.

Does kinda look like emergent central apnea.

A couple months ago I posted on an increase in Central/Clear Airways that seemed to coincide with stopping use of chinstrap in late February (see chinstraps and centrals). In early April – I started using the chin-strap again and you can see that the AHI especially CAs has not gone back down.

I’m beginning to think it has more to do with finally getting to REM…since most of the clusters are when I am asleep and 3-4 hours in. The smaller late morning stuff is prob Sleep Wake Junk.

Talked to sleep team/RT shared my data a month or so ago about the high readings and my ongoing issues with getting and staying asleep with APAP. Suggested trying a new mask, more work on sleep hygiene (which is pretty decent) and perhaps just seeing if the issue would resolve.

Talked to my primary care doc 2-3 weeks ago – who suggested trying a low dose of trazadone (50 mg) – started the last week of May. While has helped in the sleep consolidation department – but CA’s are still up. Thinking about tapering back off.....o

Will be trying Airfit P10 starting this weekend to see if that makes a difference. Haven’t been able to isolate other behavior that seems to be triggering the CA Clusters, looked at things like OTC meds, late exercise, eating out (MSG) etc .

Leaks seem to be under control. Some of the clusters but not all seem be triggered by pressure. So I’m thinking it may be time to wingding (smile) as current pressure settings now set at 5 – 20 CM the low end which has felt close Suggestions on a better range to start with welcome.

Any other thoughts on how to tame this?

Other pertinent details 57 yrs, 6 ft, 215 lbs, non drinker (recovery 25 yrs) non- smoker, 30-90 minutes of exercise daily, 3-6 cups coffee before 11 AM (need to reduce), limited dairy, gluten and sugar. Trazadone – but no other meds

Thanks again to all the folks here both conventional and unconventional.

So you get a CPAP machine, and it works!! So what happens inside your body? Are things likely to change?

I used to think that a tracheostomy was indeed “the ultimate cure” for sleep apnea. But as they related in a recent commentary in SLEEP[1] that is not the case:

“...central apnea following tracheostomy is well described in severe OSA patients, perhaps suggesting that the mechanism underlying baseline OSA may be a critical variable.[10,11]”
So perhaps CPAP has “un-masked” the real problem (that was kinda fun).

Most people think of sleep apnea only as obstructive sleep apnea. However there is a much broader spectrum of causes of apnea. As well the point at which arousal occurs with an event may well change. They are beginning to sort it out[2,3].

When you breath more than you should you also wash out more carbon dioxide (CO2) than you should. In the context of hyopcapnic (hypo=low capnic=CO2) central apnea as the CO2 level decreases it goes beyond the “apneic threshold” and so a hypocapnic central apnea is caused to occur.

Often CPAP tends to exacerbate central apnea as the pressure tends to cause you to use a bit more air and so tends to cause CPAP emergent central apnea often known as Complex Sleep Apnea (CompSAS).

I am suspicious that this results from two of the nonanatomic causes of sleep apnea[2,3] ganging up on you as you use CPAP. High respiratory control system gain working with low arousal threshold could mean that the times of more breathing brought forth by the respiratory gain issues would cause respiratory effort above your low arousal threshold and fracture your sleep with excessive arousals. In a recent comparison study looking at how CompSAS responds to treatment by ASV vs CPAP[6] they found that at the end of 90 days both arms were essentially equal in the number of arousals with over twenty per hour still in play. Both arms had excessive daytime sleepiness affected only a little by treatment. ASV however did well to severely reduce the hypocapnic central events so probably does better protect the brain.

The most helpful thing I have found with this is to reduce the stress in my life. Stress for me definitely raises my respiratory control system gain!

When dealing with unstable breathing with CPAP I have found it very helpful to spend some quality time with the machine during the daytime. Some in bed learning to breath quietly (at rest in bed, little real air need). Some with mild distraction such as a book, music, or lite TV.

I and others[5] have found moving vitamin D3 into its active range helpful.

And during my journey away from sleep apnea I have found that I did not know how to eat well or move well. Oh I thought I did. If you would have asked me I would have told you I did. But I learned that I did not! My three years with a dietitian helped start me on my continuing life long journey to eat well. I still strive toward the basic goal of 10,000 steps a day (about 4.5 miles for me - running about 90% at this time) and do intend to use more personal trainer time as I pursue an active lifestyle. Lately I have been thinking that running, which is known to help with brain development, might well be worth the risks to my knees at my advanced age. By eating well and moving well I hope to promote whole body metabolic health and I can say it does appear to help with my tendency to have centrals emerge as I use CPAP.

In terms of an unconventional suggestion – well how about buddhist meditation mindfulness of breathing applied as you use CPAP. I have been meaning to try this.

Also I have found EERS[4] helpful to deal with this issue.

hth


[1] Orr J, Javaheri S, Malhotra A. Comparative effectiveness research in complex sleep apnea. SLEEP 2014;37(5):833-834

[2] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman "Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets", American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004. doi: 10.1164/rccm.201303-0448OC

[3] Sairam Parthasarathy M.D., Emergence of Obstructive Sleep Apnea Phenotyping. From Weak to Strong! American Journal of Respitory and Critical Care Medicine VOL 188 2013
-- critical closing pressure [Pcrit] - Arousal Threshold - ventilatory control Loop gain - and genioglossal Muscle responsiveness. Pcrit, Loop, Arousal, Muscle (PALM)--

[4]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[5]: Those who are working with the D3 hormone (A.K.A. Vitamin D3) (e.g. Dr. Stasha Gominak, Michael F. Holick, Ph.D., M.D., Vitamin D Council) seem to be finding that the very low side of the “normal” range of 30-100 ng/L produces a range of symptoms including OSA, pain, and infection. All believe that a level lower than 50 ng/mL is not good and Dr. Stasha Gominak recommends 60-80 ng/mL for good health. It would probably be wise to check your vitamin D3 levels. See “The Vitamin D Council” for assay details.

[6] Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. SLEEP 2014;37(5):927-934 Related article (commentary):833

[10] Fletcher EC, author. Recurrence of sleep apnea syndrome following tracheostomy. A shift from obstructive to central apnea. Chest. 1989;96:206-9

[11] Guilleminault C, Simmons FB, Motta J, et al., authors. Obstructive sleep apnea syndrome and tracheostomy. Long term follow-up experience. Arch Intern Med. 1981;141:985-8

[robysue]

The pattern of breathing in the close up of the data makes this look like a long chain of centrals. More pressure is NOT going to fix those centrals. And, quite frankly, I don't see how a change of mask would fix them if they're not SWJ.

You've been dealing with a pattern of very high centrals on several nights each week now for several months. In my opinion, it's time to talk to the sleep doc and not just the RT. You need to share the data with him---bring in printouts showing those clusters and also showing a close up of what the clusters look like.

If you are dealing with emergent central apneas (possibly caused by the positive air pressure), you're probably not going to be able to dial wing the problem away. And that's why you really need to speak with the sleep doctor about what's going on.

[Sclark08]

I think a lot of it is the nature of the machine and our natural human reaction to it. Ever since I started Vpap similar to Apap I have started with Centrals. In my investigative work I have come to learn that what the machine records as a central may not entirely BE a central.
Sometimes when I first go to bed at night I find myself breathing harder that I might if I didnt have to wear a cpap mask just to make sure the machine starts(I have auto start turned on)

I know I feel 1000 times better than I ever have and I use that as my primary indicator. I leave the numbers for the Dr because my pressure ahi and leaks are well controlled now. But it took me 2 yerars to get hear with 3 different machines 500 different masks switching from cpap to vpap. I also have copd which causes me to breathe harder than someone who doesnt have cpap.
You are on the right track because you check your data and ask questions. That is all us mear mortals can do. Best of luck!

[startanew]

Been away for most of the weekend - thanks for the replies

No advice but I will be following you closely. I'm in a similar situation except my pressure setting is not as bad as your.

I figure sharing my experience, data, steps and misteps is the best way to pay back what has been shared on the forum...

Todzo

The lifestyle changes (diet, exercise, meditation,sleep hygiene) have been an important adjunct to getting better on my journey. Not the cure but vital supplements.

In terms of an unconventional suggestion – well how about buddhist meditation mindfulness of breathing applied as you use CPAP. I have been meaning to try this.

I've looked into this Breathing exercises/meditations don't line up with "machine breathing" of the APAP and since I have a low arousal threshold -- my challenge is being too aware of my breathing and how the APAP changes it -- so white noise and tools like autogenics relaxation exercises which help me think less about breathing seem to help more in getting to sleep. I do some meditation while awake and find it helpful.

The pattern of breathing in the close up of the data makes this look like a long chain of centrals. More pressure is NOT going to fix those centrals. And, quite frankly, I don't see how a change of mask would fix them if they're not SWJ.

You've been dealing with a pattern of very high centrals on several nights each week now for several months. In my opinion, it's time to talk to the sleep doc and not just the RT. You need to share the data with him---bring in printouts showing those clusters and also showing a close up of what the clusters look like.

If you are dealing with emergent central apneas (possibly caused by the positive air pressure), you're probably not going to be able to dial wing the problem away. And that's why you really need to speak with the sleep doctor about what's going on.

I was thinking more about narrowing the range from 5-20 to something like 6-9. I still feel at 5 I am not quite getting enough air and think a little more pressure would help me get to sleep easier (and help clear out occasional sinus congestion). Some of my biggest chains of centrals are associated with big pressure increases (up to 11-12) from chasing a few events which may actually be centrals. I do agree that a narrower range and the new masks will probably not resolve centrals -- but would like to rule it out

Unfortunately I am in managed care organization - and the path to the sleep doc is through the RT's ... I tried the direct approach earlier in the year and got a bit a grief for it.. will take another run at it .. Also may try to get a referral from my Primary Care Provider for a different sleep doc -- as my current referral is a pulmonologist who might not be the best at sorting my stuff out. The managed care provider has been great for the past 20 years -- but they do don't well for cases that don't fit the common paths -- may look at leaving for a more flexible plan in the fall -- but need to work in the system for now.... Been pretty frustrated that I have been able to get access to a provider who has time and smarts to address my case.

I think a lot of it is the nature of the machine and our natural human reaction to it. Ever since I started Vpap similar to Apap I have started with Centrals. In my investigative work I have come to learn that what the machine records as a central may not entirely BE a central.
Sometimes when I first go to bed at night I find myself breathing harder that I might if I didnt have to wear a cpap mask just to make sure the machine starts(I have auto start turned on)

I know I feel 1000 times better than I ever have and I use that as my primary indicator. I leave the numbers for the Dr because my pressure ahi and leaks are well controlled now. But it took me 2 yerars to get hear with 3 different machines 500 different masks switching from cpap to vpap. I also have copd which causes me to breathe harder than someone who doesnt have cpap.
You are on the right track because you check your data and ask questions. That is all us mear mortals can do. Best of luck!

Thanks for the encouraging words .... I do hold on to idea that I do feel better than I did a year ago -- and I am on the right path. I am only six months a few layers of the onion in.

For me I find the idea of CAs to be more scary than OAs -- because with CA's we are talking about brain wiring which is much harder to address and there doesn't seem to be clear cut solutions.

[robysue]

I've looked into this Breathing exercises/meditations don't line up with "machine breathing" of the APAP and since I have a low arousal threshold -- my challenge is being too aware of my breathing and how the APAP changes it -- so white noise and tools like autogenics relaxation exercises which help me think less about breathing seem to help more in getting to sleep. I do some meditation while awake and find it helpful.

I understand what you are talking about. I have to have Georgian chant music playing all night long so that when I wake up, I can turn my machine OFF and back ON (to reset the pressures back to 6/4) and NOT start focusing so much on my breathing that I can't get back to sleep.

I was thinking more about narrowing the range from 5-20 to something like 6-9. I still feel at 5 I am not quite getting enough air and think a little more pressure would help me get to sleep easier (and help clear out occasional sinus congestion). Some of my biggest chains of centrals are associated with big pressure increases (up to 11-12) from chasing a few events which may actually be centrals. I do agree that a narrower range and the new masks will probably not resolve centrals -- but would like to rule it out

If you are going to dial wing, then narrowing the pressure at the top end is certainly the way to go. I'd also say that if you're not comfortable at 5, then bumping up the min to 6 is probably going to make you more comfortable, and that will help with getting to sleep, which may help minimize any sleep onset centrals that your machine is recording.

Unfortunately I am in managed care organization - and the path to the sleep doc is through the RT's ... I tried the direct approach earlier in the year and got a bit a grief for it.. will take another run at it ..

Have you tried simply handing the RT a hard copy of the data and mustering up all the meekness you can while asking: What do you think about all these central apneas that are being scored and that funny breathing pattern that keeps repeating all through the cluster?

For me I find the idea of CAs to be more scary than OAs -- because with CA's we are talking about brain wiring which is much harder to address and there doesn't seem to be clear cut solutions.

It's really not so much about the brain's wiring as a problem with maintaining an appropriate level of CO2 in your blood. The CO2 concentration in the blood is the trigger for respiration, and if the CO2 levels get messed up, that "tricks" the brain into forgetting to breathe on time. Essentially what happens in those long chains of central apneas is the development of a CO2 overshoot/undershoot cycle: For whatever reason you wind up blowing off too much CO2 (hyperventilation) and this reduces the "urge to breathe". And the breathing slows down and at the nadir of the cycle, the brain forgets to send the signal to breathe and a central apnea is scored. While the breathing becomes very shallow and during the apnea, the CO2 builds up (the undershoot part of the cycle), and once the apnea is over, you start hyperventilating again and the cycle starts over.

For some people, the problem with centrals emerges after starting PAP therapy. The idea is that the continuous positive air pressure can cause too much CO2 to be washed out with exhalations. Folks with this problem often have a "threshold pressure": If the CPAP pressure is kept below the threshold, the number of CAs is very low and they don't start forming long chains. But if the pressure goes above the person's threshold, the CAs start to happen, and it can take a long time before the breathing once again stabilizes. So you get a long chain of centrals.

If you can prevent that CO2 overshoot/undershoot cycle from developing, the central apneas go away. For some people with pressure emergent centrals, the problem will resolve itself in a few weeks to a couple of months as the body gets used to the continuous air pressure and sorts out how to keep the CO2 levels in check. For some people with pressure emergent centrals, the problem can be managed if a therapeutic pressure can be found that is high enough to properly treat the obstructive events and is low enough to not trigger the centrals. For a unlucky few new PAPers, the emergent centrals continue to play havoc with their sleep for more than a few weeks AND the minimum pressure needed to fix the obstructive events is high enough to trigger the centrals. Many of these unlucky people eventually need to be moved to an ASV machine, which is designed to treat central apneas by breaking the CO2 overshoot/undershoot cycle from developing in the first place.

The usual process for someone who might have emergent pressure induced centrals is a combination of close monitoring with a goal to finding a therapeutic pressure for the OSA stuff that is low enough to not cause too many centrals. But if that can't be found, then the next step is usually a change of machine. Some insurance companies and HMOs will first insist on having the patient try a plain old bi-level to see if that resolves the problem. And if it doesn't, then the patient will be moved to an ASV machine.

[igdoc]

Startanew
As usual everything Robysue says is spot on. The central episodes of periodic breathing are all about the CO2 levels specifically the CO2 apnea threshold and the recurring cycle of hyperventilation and apnea.

There are only 2 things that can be done with CPAP/APAP to reduce these central episodes before resorting to an ASV machine. One, (as Robysue says) is to reduce the pressure to just above the level where obstructive episodes occur which will reduce the tendency to hyperventilation. This is a bit of a balancing act. Two, is to reduce the CFLEX/AFLEX/EPR setting which also reduces the tendency to hyperventilate.

The first of these can be done by limiting the maximum pressure on the APAP or better still by changing to CPAP mode. Modern APAP machines are much better at distinguishing between central and obstructive events but from your Sleepyhead graph your machine continued to up the pressure during your central periodic breathing as just a few of the events were misinterpreted as obstructive when they were not.

With regards to the second point, I note your AFLEX setting is only 1. Turning off the AFLEX may help a little as long as it is not too uncomfortable.

Hope this helps
Ian

[palerider]

] Modern APAP machines are much better at distinguishing between central and obstructive events but from your Sleepyhead graph your machine continued to up the pressure during your central periodic breathing as just a few of the events were misinterpreted as obstructive when they were not.

there's no indication that the machine was mininterpreting centrals as obstructive, his pressure was very low the whole night, most of the centrals occured at a pressure of 6, and there were snore, hypop or oa indications when pressure when up, but pressure didn't go up when there were centrals.

[igdoc]

Palerider
I was referring to the cluster of central events on the night of 10th June between 2.20 and 2.35 am when the pressure went up from 6 to around 10 during the period. APAP machines are not 100% accurate in their distinction between central and obstructive events. When central periodic breathing occurs, as shown from 3.40 on the 11th, an increase in pressure is counterproductive.
Ian

[startanew]

Thanks for the very clear articulation of options and paths forward.

Quick question -- how do you turn A-Flex off... do you need to access the clinical menu.. Looked the other day and couldn't find options other than 1-3

Have bit of balancing act with managed care provider.. RT's are available by phone..and by text only e-mail. You either send them the SD card or have the DME (Apria) download and send. My particular RT -- is about 90 minutes away. Similarly need to go to the DME which is in town to have settings changed. I can of course make the changes myself --- but am holding off going that route -- since I want to keep them on my side - should I need to go to ASV.

The good news is that I expect there is enough data "history" to establish that my issues with centrals are more than just transient events

[palerider]

Palerider
I was referring to the cluster of central events on the night of 10th June between 2.20 and 2.35 am when the pressure went up from 6 to around 10 during the period. APAP machines are not 100% accurate in their distinction between central and obstructive events. When central periodic breathing occurs, as shown from 3.40 on the 11th, an increase in pressure is counterproductive.
Ian

well, you say that, but without detailed analysis, you're just gessing that the latest model machine screwing up and not reacting to real OAs that it's scoring. looking closer at the flow wave could give an indication whether they were central or OA, but, we don't have that.

[Kennerly]

Startanew I had similar issues with CompSA. My centrals are under much better control nowadays, and three changes appear to have made the difference:

- Switched to an auto BIPAP (vpap Auto)
- Doc put me on hypnotic (Lunesta in my case)
- Gradually calibrated to a relatively narrow range of pressures. (Thanks to the pros on here who helped with #3!)

It's difficult to tease out the specific impact from switching to the bilevel as that was early on when I wasn't paying such close attention. The Lunesta did clearly help, as did optimizing the pressures.

I still see CAs on most nights, but generally its only a small number of isolated ones in the 10-12 second range, and not the clusters Iike I used to have.

FWIW during one appointment with my sleep doc (very good) he mentioned that he didn't generally like to prescribe Trazadone, and it sounded like his go to hypnotic is Ambien. I ended up on Lunesta because I also have issues with insomnia late into the night.

(Edited post because it was incomplete when first sent.)

[jillianwi]

Maybe it is the trazodone? I'm a newbie, but when I asked my MD about my centrals, he told me they were likely from the Ambien or alprazolam I was using to try to adjust to the CPAP... and using SleepyHead, it does seem to correlate. He said any sleeping med would make CAs increase.