New User Looking for Some Help

A huge thanks to everyone on this forum - the posts on here I've browsed through have been very helpful! I recently started with a CPAP a few weeks ago after being diagnosed with severe apnea - 40 AHI (mostly OSA, but a central component as well). I was given a ResMed 10 AutoSet with P10 nasal pillows. So far I find the equipment pretty comfortable, but seem to be subconsciously taking the mask off in the middle of the night. The OSA seems to be mostly taken care of with the CPAP, but I can't seem to get the CA and Hypo apneas under control. I also live at altitude (about 5400 feet) which may contribute to the CA. I'm really concerned about the super high AHI early on in the night. I just recently turned off EPR last night. Attached is my OSCAR report from last night. I appreciate everything in advance!

Welcome, and congratulations on starting PAP therapy! As you say, the CAs may at least in part reflect your body's response to living at a high altitude. Do you know what your CA index was during your sleep study? Was the study done at the same altitude as your home? And did your doctor discuss the CA component of your AHI with you?

You were right to turn off EPR, at least for now. For some people, EPR can contribute to CAs.

CAs often come about in this way. The level of CO2 in your blood must rise to a certain level in order to launch the neurochemical process that ends with a "breathe now" signal to your brain. If it takes more than 10 seconds for the CO2 level to reach that point, then your machine will flag a CA.

The pressure provided by PAP machines can wash out a bit of the CO2 that would otherwise be building up. This can make you more prone to having CAs.

One thing that can further slow down the build-up of CO2 is deep breathing, which will often occur when you're aroused from sleep or from one stage of sleep to another. In that case, the arousal is probably the real problem, rather than the CA.

Also, one CA can set off a period of unstable breathing, where your recovery breaths after the CA wash out some CO2, leading to another CA, etc. This may be what's causing those CA clusters.

Happily, to the extent that any of this is what's going on, your body will probably adjust over time. In addition, if arousals are playing a role, you'll have fewer of them as you get more accustomed to the machine.

It's great that you're using Oscar already. Try zooming in on the start of a cluster of CAs to see whether you can spot arousal breathing. It will be deeper than what came before (with a flow-rate trace that goes higher and lower than the breathing that preceded it), and it may appear to be ratty-looking, with little irregularities top and/or bottom. The curve of both inhalation and exhalation may also look different from your regular asleep breathing.

But you may always experience a baseline of CAs due to your elevation. That's why I'm curious what the story was with your sleep study.

When you post your next chart, could you swap out the mask pressure graph for the pressure graph?

Thank you so much for the warm welcome and super helpful info already, I really appreciate that! What you said definitely makes sense about the altitude - I was recently visiting family at sea level and had a lower AHI (including lower CA) and could tell the difference.

My CA during my sleep study was around 16 if I'm reading it right and was done at home in altitude - They stated I had primarily OSA, with a strong central component. Their recommendation was to start with an Auto PAP and possibly do a titration study.

This recent screenshot shows minimum pressure at 6 and ramp off - but I didn't make these changes until this morning. So this data really reflects minimum pressure at 5 and the ramp on. I will have my first night with minimum pressure at 6 and the ramp off tonight. This screenshot also shows the first night without wearing my dental mouth guard I use for grinding which I absolutely threw away yesterday. Whoops! I'm interested to see how that may change things.

I would also like to do a better job of keeping the mask on - as you can see I seem to be taking it off subconsciously in the middle of the night.

I am wondering if I should be raising the minimum pressure more than 6 and if turning off the ramp will help reduce CA?

Thank you so very much!

Do you know whether the "16" was the total number of CAs during your sleep period, or the CA index, which would be the total number of CAs divided by the number of hours your sleep period lasted?

Definitely *don't* raise your pressure. That would make sense if you were having obstructive events and needed more help keeping your airway open, but your airway is open during CAs. (And in fact higher pressure can lead to an increase in CA events.) Let's see how you do for a few nights with a minimum of 6.

Your pressure is rising and falling mostly in response to your flow limitations. Down the road, you may want to lower your maximum pressure, but one change at a time. Otherwise it's hard to tell what is causing what.

That mask problem is pretty common. One trick people use is to put a strip of medical-type tape over one of the straps, anchoring on both sides to the skin on your face. That way the tug will wake you up before you can get the mask off. After a time, I bet your subconscious will learn its lesson. A different trick is to put socks on your hands so you'll lack the dexterity to get the mask off, at least in theory.

My dentist keeps bugging me to start using a night guard again, but honestly there's only so much gear I can stand to load onto my head. So yeah, whoops!

Miss Emerita wrote: ↑

Sat Jun 17, 2023 3:58 pm

My dentist keeps bugging me to start using a night guard again, but honestly there's only so much gear I can stand to load onto my head. So yeah, whoops!

man, do i ever envy those cpap users who just put on their mask and don't have to worry about all those extra "accouterments"!

Amen, Zonker. And you are well and truly laden!

Miss Emerita wrote: ↑

Sat Jun 17, 2023 5:44 pm

Amen, Zonker. And you are well and truly laden!

i bet you say that to all the boys!

Ooooh!

Miss Emerita wrote: ↑

Sat Jun 17, 2023 3:58 pm

Do you know whether the "16" was the total number of CAs during your sleep period, or the CA index, which would be the total number of CAs divided by the number of hours your sleep period lasted?

Definitely *don't* raise your pressure. That would make sense if you were having obstructive events and needed more help keeping your airway open, but your airway is open during CAs. (And in fact higher pressure can lead to an increase in CA events.) Let's see how you do for a few nights with a minimum of 6.

Your pressure is rising and falling mostly in response to your flow limitations. Down the road, you may want to lower your maximum pressure, but one change at a time. Otherwise it's hard to tell what is causing what.

That mask problem is pretty common. One trick people use is to put a strip of medical-type tape over one of the straps, anchoring on both sides to the skin on your face. That way the tug will wake you up before you can get the mask off. After a time, I bet your subconscious will learn its lesson. A different trick is to put socks on your hands so you'll lack the dexterity to get the mask off, at least in theory.

My dentist keeps bugging me to start using a night guard again, but honestly there's only so much gear I can stand to load onto my head. So yeah, whoops!

I'm not sure how to fully calculate the CA index based on the info provided in the sleep study, but I did attach a screenshot of it.

The good news is I was able to keep the mask on for almost the whole night which was great, but the bad news is the centrals went way up. Also I noticed the Hypopneas went up - any info on what causes this?

This was the first night with a minimum at 6 and the ramp off. Crazy to see the huge jumps and drops in pressure.

Thanks for posting the sleep study summary. What we can see is that your CA index was 16.1. That means that over the course of your sleep period, you averaged 16.1 CA events per hour. We can also see that your CA index was considerably higher than your OA index. (So I don't know why your doctor said you had predominantly obstructive apnea.) Hypopneas can be either central (airway open) or obstructive (airway partially closed), and the summary indicates that the kind of test you had couldn't tell which type of H you were experiencing.

You're getting better results than that by using the machine, but CAs and Hs continue to outweigh OAs in your index data for the night. Your flow limitations continue to be a strong driver of your pressure.

Your CA index jumps around, and as I mentioned in an earlier post, it's hard to know how much reflects your high altitude and how much reflects, say, arousals. (Did you try zooming in to take a look?) That cluster of CAs before your second, shorter period on the machine probably happened while you were awake or possibly falling asleep. (There's also a phenomenon called sleep-transition central apnea, where the hand-off of breathing control from waking systems to sleeping systems doesn't go as smoothly as it might. Possibly you're seeing a bit of that.)

All of that is a long-winded way of saying you're having a lot of centrals and it's hard to be sure exactly what is contributing to that.

If you're up for an experiment, you might try setting your min = max = 6. It's possibly that a lower and steady pressure will give you a bit more stability during the night.

It will be helpful to know how you feel during the day after each night for which you post a chart.

One last thing. For people with stubborn central apnea, a different kind of machine might be advisable. It's called an adaptive servo-ventilation machine (ASV). They have the ability to "force" a breath when you aren't breathing spontaneously. ASVs are more expensive than regular PAP machines, and so patients with central apnea are often started on regular machines to see whether the cheaper option can do the trick. (And occasionally they can.) I hope you can get on a good track with your PAP machine, but if time goes by and you continue to experience central apnea, you may need to go back to your doctor to ask about getting an ASV.

Thanks so much for another excellent response and information. I hope to not need an ASV, but willing to try whatever works.

Just to confirm, your idea was to try setting the minimum and maximum pressure at 6? I think that may be a good idea to see if the drastic pressure changes are creating the CA. This is what you’re referencing when you describe flow limitation right?

How good or bad I feel really is all dependent on my ahi from the previous night and how long I’ve wore the mask the night before. Not surprisingly, the best I’ve felt through this process was visiting family at sea level and averaging around 5 ahi and 5-6 hours of mask time.

Yes, in APAP mode, set both the min and the max at 6.

Flow limitations are restrictions in your airway, and when your machine senses them, it increases pressure to head off OAs that may be developing. (Similar story for snores.)

Some people are sensitive to pressure changes, even fairly small ones, and they may experience arousals when pressures change. There’s no particular reason to think that’s true of you, but it’s an hypothesis worth testing, if you’re game.

Miss Emerita wrote: ↑

Sun Jun 18, 2023 6:36 pm

Yes, in APAP mode, set both the min and the max at 6.

Flow limitations are restrictions in your airway, and when your machine senses them, it increases pressure to head off OAs that may be developing. (Similar story for snores.)

Some people are sensitive to pressure changes, even fairly small ones, and they may experience arousals when pressures change. There’s no particular reason to think that’s true of you, but it’s an hypothesis worth testing, if you’re game.

Thank you again and great idea! I was a bit hesitant to reduce the pressure all the way to 6 and 6, but I certainly did take your advice into consideration as I adjusted the minimum to 5 and maximum to 9. I feel like the results of this were good as my AHI numbers lowered slightly, I had vivid dreams, and feel fairly (more) rested. It is interesting to see the pressure raise all the way to the maximum of 9 early on. I am wondering - if my OA is at 0 as it is, should I continue to lower the pressure? I am thinking of going to minimum 5 and maximum 7 tonight.

Also, I never put this together until now, but I have felt and looked very bloated since starting CPAP. I never connected it to CPAP until last night. Anything I can do to remedy this? I heard turning on EPR to 3 would help, but I fear that would raise CA more.

I'm glad to hear you felt a bit better today. If you could clock 8 hours of sleep I bet you'd feel better still!

I'm curious why you want to maintain a pressure range. Although your flow-limitation graph didn't make it into your chart image, I'm willing to bet that FLs are what's driving your pressures up and then letting them go back down. If you were willing to try a straight pressure, we could see whether eliminating pressure changes helped you sleep more soundly. If you feel that 6 would be uncomfortable for you, maybe you could try 7? Keeping the pressure as low as possible might help with the CAs.

FLs do bother some people; they don't bother others. The best way to address them is by using EPR, but you're right to avoid that, at least for now. So all those pressure changes may not be doing much of anything for you.

Do you think your bloat is from air in your digestive tract?

Miss Emerita wrote: ↑

Mon Jun 19, 2023 11:25 am

I'm glad to hear you felt a bit better today. If you could clock 8 hours of sleep I bet you'd feel better still!

I'm curious why you want to maintain a pressure range. Although your flow-limitation graph didn't make it into your chart image, I'm willing to bet that FLs are what's driving your pressures up and then letting them go back down. If you were willing to try a straight pressure, we could see whether eliminating pressure changes helped you sleep more soundly. If you feel that 6 would be uncomfortable for you, maybe you could try 7? Keeping the pressure as low as possible might help with the CAs.

FLs do bother some people; they don't bother others. The best way to address them is by using EPR, but you're right to avoid that, at least for now. So all those pressure changes may not be doing much of anything for you.

Do you think your bloat is from air in your digestive tract?

You’re right - I’ll be trying for a full 8 hours tonight. I think the reason I was hesitant to get away from a range is I didn’t want to limit the pressure in a sense. Should I be concerned the pressure was at a max of 9 at the beginning?

In regards to the flow limit, I did post it in this image. Does anything change after looking at the FL here?

But overall I agree with your points and will be trying a fixed pressure tonight. I’m thinking of doing the minimum and maximum at 6 as you suggested.

I think the bloating is from maybe too much pressure? Maybe when the pressure was getting too high it was adding excess air. I'm hoping with a reduction in pressure this will subside maybe? I may get some Gas X in the short term to relieve some of this.

Thank you for everything!!!