Should I get a bilevel or ASV?

I've been struggling with really fragmented and unrestful sleep for years and CPAP seems to have failed me so I'm trying to move beyond that. I probably have a very strong UARS component to my moderate OSA. On the CPAP, I seem to have much less rattiness in my flowrate and less fatigue when I turn EPR up to 3, but even without EPR at 3, I already get anywhere from 2-5 central index every night. However I also needed more pressure support.

So with the advice from some good people online, I managed to trial a bilevel for a week and well the centrals are even higher as to be expected, yet I've had one good night sleeping for over 6h30 without waking. I don't have full data for that night unfortunately. I also got lucky and got to trial a heavily used S9 VPAP Adapt and well so far I've been feeling painfully fatigued with it after a little over a week of use. I did have one OK night with it. There's a dusty odor coming from the ASV blower. I'm not sure if it's just dust build-up or if it's coming from a part that's worn out so I'm back on the CPAP for now. Maybe it should be obvious to me, but I'm still trying to figure out if I am a threshold case of complex apnea so that I should go ahead now and spring for the ASV and brave the necessary nights to make it work. My centrals last 30ish seconds at the most and most happen after recovery breaths.



CPAP night



These ratty clusters I mentioned which gets even worse with less or no EPR. Does anyone have any idea what could cause this? Mouth breathing?



Bi-level night



Bi-level night #2



Bi-level night #2 - An idea of how long the centrals last. Less than half of them follow after recovery breaths.



Bi-level night with the same settings as that one decent night I mentioned. Only woke up once this night.



Centrals for that night



ASV example night at 5 EPAP 5-12 PS



Short night with the ASV at 5 EPAP, 6-12 PS



Flow rate from the night above


I'm feeling like a squeaky wheel at the other place where I mainly post. I'll be so, so grateful for any input. Thanks.

How did you sleep with the ASV? If you are able to get more restful sleep with it, then it might be worth the added expense to get the ASV. If the quality of your sleep was no better with it, then the added expense would probably not be justified.

YOu will need a prescription....It depends on what your doctor thinks.

love2sleep69 wrote: ↑

Wed Jul 04, 2018 1:51 am

My centrals last 30ish seconds at the most and most happen after recovery breaths.

I'll deal with this one first... Any centrals that happen *after* a recovery breath are most likely something that should be disregarded, just you holding your breath because you turned over or something.

love2sleep69 wrote: ↑

Wed Jul 04, 2018 1:51 am

I already get anywhere from 2-5 central index every night. However I also needed more pressure support.

I wouldn't worry about a central index that low. Centrals generally don't disturb your sleep, and holding your breath (which is what they are) a few times an hour isn't going to impact your oxygenation in any significant fashion. It's when you start having lots of them, in clusters, that your O2 starts dropping.

Many thanks for all the replies.

So far I've only used the ASV for a little over a week so it's inconclusive if I feel better on it. I've only had one semi-decent day with it despite several brief awakenings. All other days, I've had terrible fatigue but I was only starting to get used to it before I discontinued due to being squeamish to the dusty odor coming from the blower and feeling sick for two days. Also due to the smell, my insomnia is even worsened psychologically. I guess I'll just have to find some way to open up the machine to clean it or just tough it out.

There's no way I can get access to either machine through the proper channels of going to my current sleep doctor. He simply doesn't care beyond looking at the AHI and compliance hours so I'm on my own here.

palerider wrote: ↑

Wed Jul 04, 2018 6:59 pm

love2sleep69 wrote: ↑

Wed Jul 04, 2018 1:51 am

My centrals last 30ish seconds at the most and most happen after recovery breaths.

I'll deal with this one first... Any centrals that happen *after* a recovery breath are most likely something that should be disregarded, just you holding your breath because you turned over or something.

love2sleep69 wrote: ↑

Wed Jul 04, 2018 1:51 am

I already get anywhere from 2-5 central index every night. However I also needed more pressure support.

I wouldn't worry about a central index that low. Centrals generally don't disturb your sleep, and holding your breath (which is what they are) a few times an hour isn't going to impact your oxygenation in any significant fashion. It's when you start having lots of them, in clusters, that your O2 starts dropping.

Of those breaths that follow recovery breaths, they happen a few (2-4) breaths after the recovery breaths. Could those be disregarded as well?



I just feel like an outlier because I mostly see either people with proper centrals in clusters or people with hardly any. I just haven't seen anyone with the same pattern of centrals as me. Is there like a spectrum of complex apnea of which I appear on the lower end? If my central index is considered low with CPAP, you don't see any indication that I could be prone to developing any complications with bilevel therapy since I hear those machines are notorious for worsening centrals? I felt I had one decent night with the bilevel. What would you do if you were me?

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

Of those breaths that follow recovery breaths, they happen a few (2-4) breaths after the recovery breaths. Could those be disregarded as well?

To be clear, recovery breaths happen *after* an event.

Your disturbed breaths, happening before a central aren't what I'd call 'recovery' since you're not recoverying from anything.

But yes, when you've got a breathing disturbance followed by a central, then most of the time, that would be something that wouldn't be counted in a lab.

eg: https://www.youtube.com/watch?v=xallwxPCg84

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

I just feel like an outlier because I mostly see either people with proper centrals in clusters or people with hardly any. I just haven't seen anyone with the same pattern of centrals as me

What I'm seeing aren't centrals... they're evidence of disturbed sleep.

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

Is there like a spectrum of complex apnea of which I appear on the lower end?

again.

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

If my central index is considered low with CPAP,

I have no idea what your real CAI is.

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

you don't see any indication that I could be prone to developing any complications with

I see no evidence one way or the other from what you've shown.

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

bilevel therapy since I hear those machines are notorious for worsening centrals? I felt I had one decent night with the bilevel.

Where are you getting your information? Bilevels aren't 'notorious' for anything. somewhere between 6 and 15% (depending on what study you look at) people have complex SA, and develop true CA when they start using CPAP, some at low pressures, some at higher pressures. It varies.

A further subset of people are sensitive to the lower CO2 that the extra ventilation higher levels of PS cause, some people are even so sensitive that EPR (which is just limited PS). But those are *true* centrals, not preceded by disturbed breaths.

Maybe you have some legit centrals, but you said:

love2sleep69 wrote: ↑

Wed Jul 04, 2018 1:51 am

My centrals last 30ish seconds at the most and most happen after recovery breaths.

Also, please fix your charts in the future.

either pressure, or mask pressure, but not both, they're redundant.

the tidal volume chart doesn't help, but snore and flow limitations do.

Events.
Flow.
Pressure
Leaks
Flow Limitations
Snore.

that's all,, just those six.

love2sleep69 wrote: ↑

Thu Jul 05, 2018 1:34 am

I guess I'll just have to find some way to open up the machine to clean it or just tough it out.

https://imgur.com/a/S0ojG

Or, clean the filters and let it blow for a bit to clear it out?

Thanks for clearing things up.
Distinguishing between recovery breaths vs. disturbed breaths – Fair enough. I guess trying to figure out what’s what and what’s behind each arousal episode is the name of the game. I was ignorantly using a catch-all term for large swings in the flowrate. My bad.

Well, I just found something interesting though about my first sleep study and my CPAP titration study:

FWIW, I slept for a little over 2 hours and 5 hours correspondingly, but I had 22 spontaneous + 26 respiratory arousals without CPAP vs. 57 spontaneous arousals + 16 respiratory arousals with CPAP. PLMI without CPAP was 7.1 vs 0 with CPAP. However the sleep lab doesn’t seem to diagnose for UARS. I also found that I woke up less with an MAD, but slept worse sometimes with it. What to take away from that if any?

Are some people just unable to stay asleep with PAP therapy no matter how many years they’ve tried despite how compliant they’ve been?

“Centrals” – Noted. I’ll look at the video later, thanks. It turns out my sleep study of 2 hours of sleep reported 0 centrals.

I guess what I mean then is I don’t think I’ve come across another person’s chart in SH with a similar pattern as me of little purple sticks sometimes lasting 30s following numerous spikes/sleep disruption in the flow rate throughout the night.

Bilevel, “notorious” – Well, people on forums told me. Don’t the pressure EPAP/IPAP differentials potentially create even more centrals than a CPAP could? I did see consistently higher # of centrals when I tried it.
What would stand as evidence that I could provide outside of a lab that bilevel may create problems with central for me?

I posted some graphs with my adventures with bilevel starting here, I don’t know if you want to skim some of the graphs. It’d be extremely cool of you to. I know it's an unbearably long thread:
http://www.apneaboard.com/forums/Thread ... ate?page=8

According to that thread, bilevel cleaned up my breathing pretty well, and ASV charts look quite good as well. But so far I haven’t noticed any improvements on the ASV.
So centrals don’t seem to be a problem for me even with bilevel but I haven't tried either ASV or the bilevel long enough to see how each would perform. I'm trying to extrapolate from limited data. I guess what I’m trying to say is I have no capacity for independent thought on what to do next because my mind has been broken down so much from years of dogshit fragmented sleep.

There's more than one filter? Thanks for those tear-down shots/guide. I'll fix my charts, thank you.