Help Request for new CPAP user: Beautifully Broken Sleep

Hi,

A few months ago I had a polysomnogram and was diagnosed with Obstructive and Central sleep apneas (sleep was very poor and fragmented). 76 respiratory events of which 38 were apneas (8 obstructive, 1 mixed, 29 central). Non-supine 26 AHI/hr. Supine 36 AHI/hr.

Then I went back for a second night to do the titration test. The results were at 9 cmH2O they said I was nearly completed resolved of my apnea. And they said I only had obstructive sleep apnea. I believe this is not correct based on my AirSense 11 data (my sleep was very poor and fragmented and I only got a couple hours of sleep in which much of it was in REM).

So I now have an AirSense 11 and I've tried many different settings and nothing has worked. In fact, my sleep is the same or worse than it was before I got the CPAP. My Airsense typically says I get 0-0.2 OSAs per hour and about 20-40 Central Events (CAs) per hour (although I spend many hours awake with the mask on so I think the AHIs/hr is actually about 40-50).

I've tried humidity, temperature, pressure (9-11cm), EPR, mask types, etc changes but nothing works. Except when I set EPR to 3 (9cm/6cm) I actually slept for 4 hours straight but woke up with a headache and AHIs/hr in the 40s. So it kind of helps?

Below are links to my OSCAR data for one night (but this data is typical for all my nights). The second image that is zoomed in of 2 minutes of data shows exactly what 99% of my sleep apneas look like. My Airsense 11 marks them as Central Sleep Apneas.

Given how consistent and recurring these apnea events are I'd say it almost looks beautiful.

I'm still trying to get a hold of my doctor and maybe I'll be able to talk to the sleep doc who interpreted my results but this process of talking to an expert is very cumbersome. That's why I'm hoping someone here might be able to help.

I think I need a BPAP or ASV at this point, but I don't know!?!?

Any insight anyone could provide would be welcome. Thanks in advance.

Edit: Over a year ago I moved to ~6000 ft altitude.

Overview Image:
https://imgur.com/OjrO6nj

Zoom in of 2 minutes of what seem to constitute 99% of my apnea events:
https://imgur.com/ACGmpVi

Assuming you were actually asleep when all those centrals got flagged....I vote for ASV.

CPAP_Newb wrote: ↑

Fri Jan 05, 2024 11:25 am

Except when I set EPR to 3 (9cm/6cm) I actually slept for 4 hours straight but woke up with a headache and AHIs/hr in the 40s. So it kind of helps?

No...with an AHI in the 40s it didn't help at all and in fact was worsened and most likely EPR use was a factor in making it worse. EPR creates a bilevel situation and for some people using bilevel actually can cause centrals and/or make them worse.
Assuming that is the case....a regular Bipap (bilevel) machine won't help with centrals either and might make it worse.
ASV is a bilevel device but it isn't/doesn't work like a regular bilevel works.

Where do you live? At what altitude? And do you take any medications that might suppress respiration like some sort of pain medication?

What happens if you use a fixed cpap pressure of 9 instead of the 11 your shared report shows????
Are the centrals reduced at all with the pressure of 9????

As a follow-up to Pugsy's post: At what altitude were you for your sleep study and your titration study?

I appreciate the reply Pugsy. I'd quote your reply but I don't know how yet

I've been a "lowlander" all my life but moved to 6000 ft altitude a year and a half ago (and had both of my seep tests at 6000 ft altitude). Soon after moving here my blood pressure which used to be in the 130s/high 80s, rose to the point I got put on 10mg Lisinopril. My SpO2 levels used to be 97-99% but after moving here to 6000ft dropped to 92-94% while laying down or resting and dropping into the low 80s occasionally while I sleep. Which is what drove me to see my doc for a sleep study.

I didn't think EPR helped either based on this youtube video:
https://www.youtube.com/watch?v=GaXA0ZIWj1Y
But I thought if I needed a BPAP then I figured EPR could be used as a "poor man's BPAP". But yeah I agree with you.

if I use 9cm I get the same Central Apnea events. The below link is for 9cm and it shows CAs identical to what I saw at 11cm.

https://imgur.com/oJ0Dl7o

Thanks again for your insight. I'll look more into how ASVs work.

No need to quote me each time unless you have a specific response to a specific question of mine.
Waste of forum air space IMHO to make gigantic quotes when the post is readily available to read just up line a little.

Was your titration sleep study done (the one that said 9 cm fixed everything) at your current 6K plus elevation or much lower????

Any chance you can go to a lower elevation short term and see if that helps reduce the centrals or not?

Altitude is a known factor in causing central apneas. Quite common in fact.

For now....if you were a family member of mine I would be pushing ASV. It will fix not only the central apnea problem but also easily fix the obstructive apnea problem.
Unfortunately it isn't always so easy to get an ASV machine due to some doctors being idiots and some insurance companies putting up hurdles because they don't want to pay for the high dollar machine.

Do you have an overnight recording pulse oximeter on hand to check your oxygen levels now when using cpap and getting all those centrals?

Pugsy,

My titration test was in Denver (5280 ft) while I live in Colorado Springs (6035 ft) so my test was at a little lower altitude.

I should be able to spend a few days at a lower altitude within the next couple weeks. In fact, my plan is to move permanently to a lower altitude in about 6 months, for a few reasons but in part because I felt my sleep and blood pressure got worse once I moved here to Colorado. I thought I'd adapt to the altitude but I don't think I am.

Since getting my CPAP machine I haven't used the pulse oximeter. I realize I should have and tonight I'll use it (it records the data and email me a report).

I don't look forward to going into my doc with my own reports and analysis based on watching youtube videos and forum discussions, convincing him of what I think I need. And I don't trust a general practitioner to know himself. Fun times...

While I don't know for sure if going to a lower altitude will fix your problem or not....it might...so well worth at least giving it a try especially if you are wanting to move lower in the near future.
People get centrals at sea level too.... so it's not set in stone that going to a lower altitude will fix your problem.
It all depends on what is causing them.

If your doctor won't listen to a well informed patient .....he's not much of a doctor and I would be doctor shopping (but I know that is easier said than done).
Remember HE WORKS FOR YOU and not the other way around.

I can't explain why the titration study at 9 cm fixed all your problems. It simply doesn't compute based on your original non cpap diagnostic sleep study where you had a bunch of centrals.....unless you haven't been asleep at all when all these centrals got flagged. While it's not impossible to have centrals go away with fixed cpap....most of the time fixed cpap doesn't work well with centrals and most people end up on ASV when the centrals are present in excess of 5 per hour average and yours is well above that number.

Dig out the recording pulse ox and lets see if you are still having desats or not with current settings.

Pugsy,

I'll see with the doc and what I can do. Below is the original polysomnogram in which my original central sleep apnea diagnosis was removed and they said I was effectively cured at 9cm. As you can see I wasn't sleeping much. Maybe the extra 800 ft altitude I live at compared to where I was tested makes the difference? Weird.

Edit: So to sum up the way to phrase it to the doc is:
When I was tested at 5200 ft, the OSAs were eliminated at 9cm. The residual CSAs of about 5/hr were low and so the sleep doc said I was effectively cured. At 6000 ft where I sleep, the OSAs are still cured (based on Airsense11 data) but my CSAs have significantly increase (based on Airsense 11 data). And so a follow-up sleep study shouldn't be done in Denver because then the vast majority of my CSAs would go away again. Therefore, likely an ASV that can provide adaptive inhalation/exhalation pressures based on my breathing cycle should be used.

Polysomnogram:
https://imgur.com/u270wyk

Well.....I don't think that small of a difference in altitude would make that much difference but I suppose it wouldn't be impossible.
More likely the fact that you didn't sleep well meant you didn't get much sleep to have the centrals form...they don't happen when we are awake. So maybe the lack of centrals was simply lack of much sleep giving the centrals a chance to happen.

I would be trying a much lower altitude sooner than later though....that might give you the clear cut answer you need ...or it might not.

Pugsy, I hear what you're saying. I had poor sleep during the polysomnogram, but I'm getting poor sleep now (at 6000 ft) with all the CSAs. Maybe not quite as poor sleep compared to when I took the polysomnogram so the CSAs are showing up?

Thank you for walking me through this. It's helped me understand the variables. Whether altitude induced or not, I think the ASV may be the way to go right now.

Pugsy wrote: ↑

Fri Jan 05, 2024 1:10 pm

Dig out the recording pulse ox and lets see if you are still having desats or not with current settings.

Here are my O2 levels from before getting the CPAP, and then with the CPAP from last night. ODIs dropped but that could be due to the fact it took 2+ hours to fall asleep last night and so I had 2+ hours of a lower ODI rate. This is different from the past - in the past, I've fallen asleep very easily due to tiredness but then had terrible sleep all night.

I think this means my CAs are driving my O2 desaturations and not my OAs, because my OAs have effectively gone away with the CPAP. Also, my heart rate seems to fall faster without the CPAP than with it. Maybe that's an artifact of the delayed onset of sleep with the CPAP...

On another note, the altitude data I provided earlier was wrong (I said I sleep at 6000 ft, tested at 5280 ft). I was using what the cities reported as their altitude. Instead if I use altitude data from weather stations located nearby, I'm actually sleeping at 7100 ft, while my test was at 5900 ft.

https://imgur.com/sZEyBnv

A bit of an update to keep this saga going.

In April I'll be <1000ft altitude for several weeks so that may be my best chance to see how altitude is affecting me. I don't know how long it takes to adapt once at a lower altitude so I'm not sure how helpful only a couple days would be.

Also the paper linked below looks at the effect of altitude on those developing CSAs who have moderate and severe OSA. I tested at Site 2's altitude (5900 ft) and live at Site 3's altitude (7100 ft).

"Mean number of central apneas/h developing on treatment with PAP varied from:
4.8/h at 4600 ft
9.8/h at 5900 ft
19.2/h at 7100 ft"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227706/

I like having a quantitative answer to what correlation altitude has to CSAs. 7100ft is an extra 19 CSA's/hr!

I also reduced CPAP pressure and started wearing a nose strip (where have nose strips been all my life!?!) and I've had some success compared to the garbage I was getting before. But I don't think a sweet spot is possible with AHIs<5/hr unless the rest of my CSAs are CPAP usage emergent and go away with CPAP adaptation, which I read can take 8+ weeks. I'm at 3 weeks of usage right now.

I'm still getting clusters of CSAs. When I don't get CSAs I get periodic breathing proceeding CSA onset.

I'm out of new ideas. Lower altitude and ASV seem to be the long-term solution for me.

(I though embedding images takes [img ] and [/img ] tags but they don't seem to work...)

6.6cm (terrible night)
https://imgur.com/QaGLR4u

7cm (1 hr of CSA cluster)
https://imgur.com/a/W2EFFGs

8cm (30 min bad cluster, short night on mask)
https://imgur.com/79x1UT8

9cm was a complete sh!tshow of 40+ CSAs/hr.