Transitional apnea making CPAP impossible?

Diagnosed OSA, ~25 AHI during REM, ~4 AHI during non-REM. First time I tried CPAP I had difficulties with anxiety/claustrophobia. Saw a cognitive behavioral therapist to address, which was surprisingly successful. I am now returning to CPAP for a second attempt. On to the issue:

When using CPAP, the moment I fall asleep, I stop breathing. As far as I can tell, this isn't obstructive - I actually stop trying to breathe. These show up as CA events in Oscar. After a period of time, I wake up gasping for breath. The period of time varies. At first, it's 15-30 seconds. Then the process repeats - I start falling asleep and the moment I do, I stop breathing. After a few cycles, the period gets up to 50-60 seconds (again, according to Oscar). At that point, I am sufficiently freaked out that I rip the mask off and fall asleep without it. Oscar examples below, the first with a 50 second CA and the second with 62 and 63 second CAs.

I wear a pulse oximeter (similar to the Oura ring) that shows my blood oxygen level drops to 75-78% during the longer episodes. This is a much lower level than what I see from obstructive sleep apnea - typically the lowest I see from OSA is 88-89% .

My pulmonologist changed the pressure from 5 to 6. No effect (unsurprising, if the issue is not obstructive). He also said I should ignore what OSCAR shows and keep trying. But that's easier said than done.

Is this transitional/sleep onset apnea? Is there anything I can do to address? If I can't get past it, I can't use CPAP.

fwiw, I *think* I'm having these episodes even when I don't use CPAP, but to a much lesser extent - much shorter periods, and I can push through to sleep. Advice/thoughts would be greatly appreciated!

The brain can remain sensitive and react to small changes in airway stability at initiation of sleep. And for some of us, the time when we most need effective pressure is right at the start as we fall asleep. Not true for all; but true for some, such as those experiencing what you describe.

One way to deal with that is to make sure your PAP pressure is therapeutically effective from the start, to keep the airway stable immediately upon your donning the mask, instead of your using the ramp feature, or your starting therapy with too low of an initial pressure.

It is natural for a pause in breathing to occur as you fall asleep. If PAP pressure is too low for you when that happens, then that natural pause can easily morph into the start of an obstruction, or into the start of a partial obstruction, which in turn, can jar you awake because of special sensitivity to airway instability.

Find the pressure that is comfortable enough and yet effective enough for you to fall asleep smoothly while wearing the mask. That balance can usually be found with a little experimentation.

I wish you all the best with making your therapy as effective as possible.

You're using EPR. = Exhale Pressure Relief
See what happens if you disable it entirely.

Normal inhalation is triggered by CO2 accumulated in your blood.
It is only when your brain gets the message that there's too much CO2 in your blood that it initiates and inhalation.
Central apneas i.e. delayed resumption of inhalation, and can happen when you're blowing off to much CO2.

EPR- drops the pressure each time you breathe out, making breathing out - and blowing off CO2 that much easier.
If all you have is garden variety OSA, and no other pulmonary issues, I don't see why you need EPR, and I do see why it can be causing your central apneas.

On an AS10, You have to get into the clinician's menu to turn EPR off.

As for you doctor telling you to ignore OSCAR: you can't convince you doctor something is wrong based on OSCAR. You have to convince her/him by describing your symptoms. If cancelling EPR wont' work, ask you doctor for an all night pulse monitor to use while you're on CPAP. A type of monitor the doctor trusts.

Hi Wired!
I’m sorry to hear that you have difficulties with your PAP machine. I’ve had many patients in the past who struggle with their masks and end up failing compliance because of it. Regarding your claustrophobia, I would recommend trying a nasal pillow mask or a nasal mask if you have not already. It’s smaller than the full face mask and many of my patients prefer it. If you’re still around 25-30 AHI with the CPAP on, I would recommend to have your physician prescribe a BIPAP on your 90 day follow up after receiving your CPAP. Your oxygen levels are also a bit concerning. To put into perspective, patients qualify for oxygen if their SATS are 88 or below. It looks like to me that you would need oxygen bled into BIPAP. This will all be determined with a polysomnogram. I would like to emphasize that I am not a doctor. I merely work in the industry and deal with DME patients daily. Make sure to keep close communications with your doctor and definitely include the fact that your SATS drop to the 70’s while you sleep. Thank you.

Also a follow up to my previous comment,
It is normal for OSA patients to have lower oxygen levels. A PAP will usually treat this along with your sleep apnea. That being said, PAP machines are not a direct treatment to low oxygen levels. If you’re still experiencing low oxygen levels while on a PAP machine, consult your doctor as you may need oxygen bled into your PAP.

I hope that turning off EPR, per Ozij, will help you get over this hurdle. Give it a few nights to see how it goes.

If it doesn't make any difference, then some key information for your doctor will be how many minutes per night you spend below 90% for your O2 sats and how many below 80%, according to your device. Then, as Ozij says, you should request that your doctor give you, or prescribe you, an O2 monitor to take home and use. That way you can give the doctor data that he will regard as trustworthy.

A couple of quick questions. What did your sleep study show about CAs? And what medications, if any, are you taking?

Thanks all! A few responses and clarifications:

- My O2 is only 75%-78% during the periods where I am not breathing for 50-60 seconds, and that only happens 2-3 times at the start of the night when I am trying to fall asleep with CPAP.
- Otherwise (i.e. without CPAP), the lowest my O2 typically gets is 88%-89%. The sleep study shows total time < 90% as less than a minute.

Miss Emerita wrote: ↑

Tue Aug 22, 2023 2:40 pm

A couple of quick questions. What did your sleep study show about CAs? And what medications, if any, are you taking?

Sleep study said "no significant central apneic events." This was of course without CPAP. When I had a BIPAP titration, "severe treatment-emergent central apneic events were observed." The titration was, overall, a disaster.

And a mild/moderate statin, but no other medications.

wired1 wrote: ↑

Tue Aug 22, 2023 5:29 pm

The Sleep study said "no significant central apneic events." This was of course without CPAP. When I had a BIPAP titration, "severe treatment-emergent central apneic events were observed." The titration was, overall, a disaster.

Can you elaborate on what you mean by "a disaster"?
Because, based on what you've said, the titration was, also, overall informative.
Normally, titrations start with CPAP, and only then do they switch to Bi-Level machines. Did that happen in your case?

Did your doctor discuss the treatment emergent central apneas with you?
Can you hide all personal data and upload your sleep study?

Sometime, treatment emergent cental apneas are a result of CO2 imbalance, and seometimes go away when a persons body gets used to sleeping with CPAP.
There's a third modality of PAP therapy called ASV, used when a person does not get used to Fixed or Bi-Level pressures. These machines are very expensive, and frequently, insurance will not pay for them unless there's proof you've failed the other modalities.

Did your doctor discuss the treatment emergent central apneas with you? Treatment emergent central apneas are not transitional apnea. They happen when you're asleep, on PAP therapy. Did he tell you for how long he wants you to try the present machine and its settings?
When is your titration from? Is that pre-the CBT for anxiety etc. or is it a recent, post CBT titration?
Is your pulmonologist certified in sleep medicine?

Edited to correct a typo

The following by Lazarus looks just like the information you need.
Interesting-discussion-of-CSA-as-it-relates-to-OSA--

Thanks for the thoughtful response. A few responses:

ozij wrote: ↑

Tue Aug 22, 2023 7:07 pm

Can you elaborate on what you mean by "a disaster"?
Because, based on what you've said, the titration was, also, overall informative.
Normally, titrations start with CPAP, and only then do they switch to Bi-Level machines. Did that happen in your case?

Did your doctor discuss the treatment emergent central apneas with you?
Can you hide all personal data and upload your sleep study?

The BIPAP titration was post CBT, which is the only way I was able to keep the mask on all night. I slept for, at most, 60 minutes during the BIPAP titration. The report from the titration does not reflect that - it indicates 300 minutes of sleep, which is just not accurate. So I'm not sure how much to take away from it other than I was not able to tolerate BIPAP?

ozij wrote: ↑

Tue Aug 22, 2023 7:07 pm

Did your doctor discuss the treatment emergent central apneas with you? Treatment emergent central apneas are not transitional apnea. They happen when you're asleep, on PAP therapy. Did he tell you for how long he wants you to try the present machine and its settings?
When is your titration from? Is that pre-the CBT for anxiety etc. or is it a recent, post CBT titration?
Is your pulmonologist certified in sleep medicine?

My pulmonologist is sleep medicine certified and part of a sleep practice. We did not talk about the treatment emergent apnea at length. I am supposed to be trying CPAP at current settings for ~6 weeks, but I just have not been able to do it every night. Every time I have this experience of trying to fall asleep with CPAP and stopping breathing for 50-60 seconds (and then ripping the mask off and sleeping without CPAP), my sleep is far worse than on a typical night. I suspect it's the rush of adrenaline waking up gasping for air.

Call your doctor ASAP and explain that the 6 week trial isn't going well because you can't stay asleep.
I know that the standard practice is to at least try with cpap first but sometimes people just can't do the standard practice.

Pugsy wrote: ↑

Wed Aug 23, 2023 12:29 pm

Call your doctor ASAP and explain that the 6 week trial isn't going well because you can't stay asleep.
I know that the standard practice is to at least try with cpap first but sometimes people just can't do the standard practice.

Do that.
Don't try to convince your doctor the sleep study wasn't valid.
The definition of "sleep" in sleep studies is based on your brainwaves (EEG) - arguing against it will get you nowhere. We do at times misjudge the amount we slept, especially when our sleep is disrupted, as yours was by severe apneas.
Sleep studies distinguish time in bed from to total time asleep, and sometimes have many terms and abbreviations we're not familar with when we start this journey.

You did not respond to my comment about the EPR. Perhaps you don't want to go into the medical reasons for using it, and that's OK.

But in case you just happened to forget to respond, I'll repeat:
EPR may be destabilizing you breathing and causing you to stop breathing.
You may be able to breathe more smoothly and stably without it.
Try the present pressure settings without it.
If you don't want to make that change on your own, ask the doctor to have it done.

ozij wrote: ↑

Wed Aug 23, 2023 8:38 pm

You did not respond to my comment about the EPR. Perhaps you don't want to go into the medical reasons for using it, and that's OK.

But in case you just happened to forget to respond, I'll repeat:
EPR may be destabilizing you breathing and causing you to stop breathing.
You may be able to breathe more smoothly and stably without it.
Try the present pressure settings without it.
If you don't want to make that change on your own, ask the doctor to have it done.

I apologize, I did forget to respond. EPR appears to be controlled by my doctor. I will ask. I also appreciate the practical advice re interacting with my doctor.

If the issue is related to blowing off too much CO2, but I continue to experience the issue even after disabling EPR, are there other ways of addressing short of ASV?

wired1 wrote: ↑

Thu Aug 24, 2023 5:37 pm

I apologize, I did forget to respond. EPR appears to be controlled by my doctor. I will ask. I also appreciate the practical advice re interacting with my doctor.

Most of us go into the clinician's menu and change our own settings. If people can make changes in the amount of insulin they inject get from their insulin pumps, based on self monitoring, they can certainly be trusted to do that with their APAP machines.
And, as a matter of fact, in the Airsense 11 it's been moved to the patients menu.

If the issue is related to blowing off too much CO2, but I continue to experience the issue even after disabling EPR, are there other ways of addressing short of ASV?

Not that I know of. But I'm just a patient like you - though definitely more experienced and at this point probably better read...