Newbie Seeking Expert

Sleep Central · Post by **Sleep Central** » Sun Sep 13, 2020 7:46 pm

I’m a newbie and would like to hear the overall wisdom from the forum about how to best optimize my CPAP settings. In addition, I would like to hear insight about my Central Apneas and Mixed Apneas and whether an AirCurve would be more appropriate for me.

I was diagnosed with Severe Apnea (AHI 65.61) on July 28 and have been on ResMed AirSense 10 AutoSet every night/all night since I started on August 11. I haven’t slept this well in years, and yet I feel there’s significantly more room for improvement. I currently use ResMed AirTouch F20 Full Face Mask. (Note: I tried a Soft Cervical Collar one night but it did not reduce my obstructive apneas or other events.)

With respect to the Central Apneas, they aren’t caused by alcohol, drugs, high altitude or any known neurological disorder.

My in lab sleep study shows:
Central Apnea Index: 11.79
Mixed Apnea Index: 22.06
Obstructive Apnea Index: 21.11
Apnea Index: 54.96
Hypopnea Index: 10.65
AHI: 65.61
AHI supine: 81.42
AHI lateral: 15.79
Lowest O2 Sat: 72%

Per OSCAR, my last 7 days stats show:
AHI: 7.57
Obstructive Index: 2.09
Hypopnea Index: 0.54
Clear Airway Index: 4.92
RERA Index: 0.09
Average Leak Rate: 0.72
95% Leak Rate: 4.80
Average Pressure: 12.43

Been reading the forum for a couple of weeks, but first-time caller. I’ll hang up now and listen to your reply.

Pugsy · Post by **Pugsy** » Sun Sep 13, 2020 8:24 pm

Welcome to the forum.

Let's try simple and easy first and see if we get lucky.

Turn EPR off. If you feel you need it to fall asleep there is a setting in the machine setup menu to have EPR on only during ramp.
Then make use of the ramp feature and set it for a little bit longer than it normally takes you to fall asleep.
If you use the ramp....set it for a starting point of 7 instead of the usual 4. This can also be done in the setup menu area.
You won't like 4 cm after using what you have been using and EPR won't kick in either at 4 cm because the machine can't go lower than 4 cm.

If you don't know how to get to the clinical setup menu area...the manual explains how. It's just a matter of button pushing in combination.
https://www.respshop.com/manuals/ResMed ... %20her.pdf

Sleep Central · Post by **Sleep Central** » Mon Sep 14, 2020 8:05 am

Thank you for the suggestion Pugsy. I turned EPR off last night. (I did not use Ramp). So far, no luck decreasing Central Apnea events. Here are last night's stats:
AHI: 7.98
Clear Airway: 5.74
Obstructive: 0.75
Hypopnea: 1.50
RERA: 0.50

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 8:37 am

Okay....How many times did you wake up during the night? Very many or do you think you slept soundly.

Before we worry about the centrals we have to first try to figure out if they are real asleep centrals or awake/arousal breathing related.

Go here and watch the videos and you will get an idea what I am talking about.
http://freecpapadvice.com/sleepyhead-free-software

Oh....at what altitude do you live and are you on any medications, if so, what?

Sleep Central · Post by **Sleep Central** » Mon Sep 14, 2020 9:02 am

My in lab sleep study shows the centrals are real and pre-existed the CPAP. (The sleep study did not offer a titration due to Covid concerns). I also had reviewed Jason's videos before posting as I saw you had suggested that to others in the forum. My zoomed-in, self-analysis indicates that the vast majority of the centrals are real. I woke up a few times last night, but nothing excessive.

I live at sea level. I have not had any alcohol the past week. I do not take any narcotics. I take a statin each night for high cholesterol (Atorvastatin). I am not aware of any neurological disorders.

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 9:18 am

Something weird going on with your attachment. Might be on my end but it is flashing through and I can't stop it and read each page..

Your are borderline (at least on the machine software reports) where doctors worry about central apneas to the point that a different kind of machine should be considered.
Your centrals happen at low pressures and the higher pressures needed to treat the obstructive stuff so obviously not a situation where the higher pressure make the centrals worse.

Obviously cpap/apap can't treat centrals but sometimes the centrals will fade to manageable numbers with cpap/apap therapy.
That's why docs will sometimes start cpap/apap and "give it time" because sometimes "give it time" works.
That and most insurance companies will require proof that giving it time on the cheap cpap/apap machine has failed before they will pay for the kind of machine that will deal with both obstructive apnea stuff and the central apnea stuff....those ASV machines.

You technically had complex sleep apnea prior to beginning cpap therapy.
Central apnea index of 11.9 on your diagnostic study.....anything over 5 per hour qualifies as central sleep apnea.
Complex sleep apnea is when we have both central sleep apnea and obstructive sleep apnea

Do you have a follow up visit scheduled with your doctor or sleep doctor anytime soon? If not...make one.
Are you using insurance to pay for stuff or are you self pay?

Sleep Central · Post by **Sleep Central** » Mon Sep 14, 2020 10:25 am

My next doctor appointment currently scheduled for end of September, but am on the waitlist for earlier opening if one becomes available. I use Blue Cross Blue Shield insurance which so far has paid for sleep study and all equipment. AirSense 10 is currently rented (rented for 90-days and then purchased assuming compliance).

I attach first three pages of sleep study.

Sleep Central · Post by **Sleep Central** » Mon Sep 14, 2020 10:26 am

I attach last three pages of sleep study.

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 10:44 am

Your OSA is worse in REM and when on your back. Very common. You probably didn't get into REM soon enough and stay there long enough to meet criteria for the titration that would normally have been done. They said they ran out of time...same thing happened to me.

You still have a high enough central index to warrant the additional central sleep apnea diagnosis per the diagnostic sleep study and borderline for while using cpap.

The machine is dealing with the obstructive side of your sleep apnea quite nicely. Obviously not able to do anything with the centrals.
There are really no tweaks that I can think of to help you reduce the central apneas. The only real hope we had was if EPR elimination was a factor and that was a remote chance since obviously EPR didn't cause your centrals. You had too many centrals even before you were ever put on cpap.

I suspect that you need one of those ASV machines that can auto adjust for the obstructive stuff and kick in with high PS only for the centrals and it forces you to breathe. Since your centrals are more sporadic during the night and not constant I wouldn't want a machine doing the high PS with every breathe...those machines don't do well for treating obstructive stuff and it's not real comfortable using high PS (pressure support) with every breath and you don't need it with every breath anyway....but some docs will use the ST machine for complex sleep apnea and won't consider ASV. If it were me...I wouldn't accept anything but the ASV.

You really don't have much of anything you can do until you see the doctor. I am sorry but your situation is complicated. Sometimes with time the centrals will fade to an acceptable number but if they haven't done it after this length of time on the machine...I honestly don't see that miracle has much chance of happening.
ASV machines are expensive but insurance will pay for them as long as proof of need is documented.

My personal opinion....you need ASV.
Something like this is what I would want if I were in your shoes.
https://www.resmed.com/us/en/healthcare ... 0-asv.html

Miss Emerita · Post by **Miss Emerita** » Mon Sep 14, 2020 10:56 am

If you google "Understanding ASV Therapy" using quotation marks, your top hit should be a slide deck prepared by a neurologist/sleep doc that explains a lot about central and mixed apnea and ASV treatment.

Your doctor may want to steer you to a bi-level machine like the ResMed VAuto Aircurve. This will do you no good at all. So don't agree to trial an SV machine (per Pugsy) or a bi-level machine -- unless you have to try them for insurance purposes before you move on to an ASV machine.

Sleep Central · Post by **Sleep Central** » Mon Sep 14, 2020 5:00 pm

I just returned from an appointment with my sleep doctor/neurologist as she had a last minute cancellation. She is aghast at my suggestion that I might need an ASV. She says that only extremely sick patients need an ASV. She said she wouldn't like to see an otherwise very health patient without any heart problems or known neurological disorders use an ASV. She said an ASV is somewhat akin to a respirator and should not be used by a patient like me.

Her solution: she wants to increase my pressure to 13-20 for two weeks and see what happens. Her goal is to get me to an AHI of 5 or less. She says if she can get me to an AHI of 5 (or less) then she has done her job and I am within the range of normal and no further work is needed. She feels highly confident that turning up the dial will decrease my AHI, and if it doesn't work, she wants me to do an in lab sleep titration. (They weren't offering titration when I had my sleep study in July due to concerns about COVID--my sleep study incorrectly used default language stating that the titration wasn't offered because I didn't display enough apnea the first half of the study, but that wasn't the case).

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 5:18 pm

Oh well.

You were fed a load of bullshit but you can't get anything done without trying what she says she can accomplish if you want insurance to pay for anything.

Watch your numbers...if after a week they don't do what she promised....start looking for a second opinion.

Pugsy · Post by **Pugsy** » Mon Sep 14, 2020 5:36 pm

Oh...and yes ASV does work like a ventilator at time when it breathes for you when you have a central apnea and aren't breathing.
When you aren't having centrals it functions just like any other auto adjusting cpap machine.

And not all doctors think the same about everything. Opinions vary widely even among those with fancy letters after their names.
We have a sleep doctor here who is a member and cpap user and he thinks everyone should get an ASV machine since it is so versatile.

Sleep Central · Post by **Sleep Central** » Tue Sep 15, 2020 9:14 am

The first night of data at the doctor's recommended settings of 13-20. I slept soundly the first 4 hours 40 minutes. But once I awoke, I felt amped up and couldn't fall back asleep for a long while. I took the mask off for a bit to read and then put it back on and fell asleep right away for another hour. On the one hand, the sleep I had seemed good. On the other hand, I'm very tired right now given the short duration of sleep and the disruption.

Pugsy · Post by **Pugsy** » Tue Sep 15, 2020 9:29 am

Short hours of sleep is going to be pretty much a recipe for feeling not so great no matter what the AHI might be.
Been there, done that and have the Tshirt myself.
The fragmented sleep is also a killer. We don't get the needed sleep stages in cycles where we get the needed amount of sleep in each sleep stage.

The very slight reduction in the centrals might simply be you didn't get to the point the unstable breathing happens which manifests itself as centrals.

It's going to take a few nights for your body to adjust to the new settings so that you sleep more soundly in general and can then evaluate if the big change in pressure is actually helping with the central numbers or not.

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