CPAP journey starts but still high Central Events

Hello everyone,

I'm very new to sleep apnea and CPAP treatment (about a month in) and would kindly request your feedback and interpretation my charts. Here are the details:

* 45M, home sleep study showed AHI: 17.1, OA: 3.1, CA: 7.7, Unclassified: 1.8

* Analysis included: There was evidence of clinically significant central sleep apnea, hypoventilation or upper airway resistance syndrome. The mean SpO2 was 93% with a nadir of 85%. Heart rate varied between 46-89 ... HSAT can underestimate severity and it is not validated for central sleep apnea ... If there is no improvement of symptoms with CPAP, consider organizing polysomnography and referral to sleep specialist. Initial titration pressure to be set at 6-12 cmH2O.

I was given a ResMed AirSense 11 CPAP machine. We started with the 6-12 Auto CPAP and P30i mask. I did not tolerate the mask well and switched to N20, which works better for me in terms of sleeping with it. Initial AHI was high the first week and the clinic was tweaking settings without much improvement. All OSAs were gone but the CSAs were still there and lots of them. Eventually they settled down on Fixed PAP: 11, Ramp of 5 with EPR during Ramp only of 2. This combination dropped AHI to about 12. At this point I decided to take over, educate myself and try some titration to see how I respond to the pressure alone. I decided to go down to the minimal pressure of 4 and to keep increasing by 1cm every night until I get back to 11 as they recommended. I got an SDCard, O2Ring (later) and started recording. I am currently at level 8 where I got some improvement. Please find my SleepHQ data below:

* August 2nd (first day of data on the card): Pressure: 10.0cm, AHI: 11.81, OA: 0.10, H: 1.04, CA: 10.67 - https://sleephq.com/public/d9755abc-61e ... 90be04b60e

--- Start of my titration ---

* August 3rd: Pressure: 4.0cm, AHI: 6.99, OA: 0.44, H: 0.87, RERA: 0.29, CA: 5.68 - https://sleephq.com/public/4773719d-042 ... 49b194617a

* August 4th: Pressure: 5.0cm, AHI: 7.94, OA: 0.13, H: 2.21, RERA: 0.00, CA: 5.60 - https://sleephq.com/public/b2c53812-ec4 ... abc3c82409

* August 5th: Pressure: 6.0cm, AHI: 7.31, OA: 0.00, H: 1.13, RERA: 0.25, CA: 6.18 - https://sleephq.com/public/7394e254-e5b ... 5f3056ae56

* August 6th: Pressure: 7.0cm, AHI: 8.57, OA: 0.00, H: 1.54, RERA: 0.26, CA: 7.04 - https://sleephq.com/public/cb272b9e-b88 ... 0dc4c85295

--- Up to this point It seemed like the higher the pressure the higher the AHI and especially CAs! But something happened on the next day

* August 7th: Pressure: 8.0cm, AHI: 3.64, OA: 0.24, H: 0.49, RERA: 0.00, CA: 2.79 - https://sleephq.com/public/3a0f2e2f-db3 ... 1200870dda

--- I did tighten up the mask a bit more on the night before this reading. I also don't notice the cluster of CAs right before waking up. Are those Sleep Wake Junk (SWJs) and that day it simply didn't get detected and thus the CAs dropped? I decided to repeat this a few more days

* August 8th: Pressure: 8.0cm, AHI: 6.89, OA: 0.32, H: 0.65, RERA: 0.32, CA: 5.92 - https://sleephq.com/public/e303e1ca-bb6 ... d7362e28b3

--- I added data from an O2Ring (SpO2), Pulse and Movement are now available in the charts

* August 9th: Pressure: 8.0cm, AHI: 6.68, OA: 0.00, H: 0.42, RERA: 0.14, CA: 6.26 - https://sleephq.com/public/b27fb2fa-4b2 ... 3c939d557b

* August 10th: Pressure: 8.0cm, AHI: 5.42, OA: 0.39, H: 0.58, RERA: 0.19, CA: 4.45 - https://sleephq.com/public/447ecd1c-4e2 ... c3d8d68aa0

* August 11th: Pressure: 8.0cm, AHI: 6.27, OA: 0.27, H: 1.36, RERA: 0.00, CA: 4.64 - https://sleephq.com/public/486b259c-640 ... a5ccd37f16

That's all the data I have at this point. Tonight I will increase to 9 and so on. So far what it seems to me is that the OSA is more or less solved by the CPAP but the centrals are not. Is that your interpretation too? Or are there a lot of SWJ that are muddying the picture? Since this is a CPAP machine, will we ever get to a combination of settings where the Central Events are corrected or do I need an ASV machine based on this data?

Thank you in advance

I didn't have time to look at all those reports but I did scroll through the Monday Aug 11the report.
How was your sleep quality? I saw LOTS of awake breathing flagged events so lots of post arousal flagged events along with lots of SWJ flagging.
IMHO probably 90% of that AHI you weren't sound asleep when the flags happened.

Do you take any medications of any kind? If so, what?

Hi and thank you for taking a look. Appreciated!

How was your sleep quality?

More or less the usual. I feel tired as I normally do. FWIW, since the start of the therapy I haven't felt any different either.

I saw LOTS of awake breathing flagged events so lots of post arousal flagged events along with lots of SWJ flagging.
IMHO probably 90% of that AHI you weren't sound asleep when the flags happened.

I don't remember being awake. Not sure what that means. Perhaps if you could compare with some of the previous nights and share some more thoughts on what this means.

Do you take any medications of any kind? If so, what?

I only take Zoloft (75mg) in the morning for OCD. I've been on it for 14 years. No other medications

johncray wrote: ↑

Tue Aug 12, 2025 12:12 pm

Perhaps if you could compare with some of the previous nights and share some more thoughts on what this means.

Sorry....no time right now. But I would expect more of the same.

But you might learn something here

viewtopic.php?f=1&t=187767&p=1451526#p1451526

Just because you don't remember a wake up or arousal doesn't mean it didn't happen.

You might want to do some deep research on the Zoloft and what it can do to sleep.
It's a SSRI type of meds....google SSRIs and sleep. Doesn't do you any favors and it is well known to affect sleep quality as well as how we feel during the day.

I DON'T (at least at this time) see any reason to be talking a different machine like the ASV.

It's a SSRI type of meds....google SSRIs and sleep. Doesn't do you any favors and it is well known to affect sleep quality as well as how we feel during the day.

Hmm, I did some research on this topic and as far as I could tell no proven link has been established between quality of sleep and Sertraline (Zoloft). That doesn't mean it isn't in my case. I could try to stop it for a night or two, but after that I will start feeling withdrawal symptoms and the awful brain zaps. Not sure if two nights would show any difference but worth a shot. Sadly, I am not sure if I can stop it completely at this time after 14 years. I'll do more research.

So, if I follow your reasoning so far - you're leaning towards those centrals being really detected as such because I don't have a sound sleep, which might be caused by the SSRI. Is that so?

SSRIs, SNRIs or really any mood medication can mess with sleep quality. It's part of the baggage that comes with taking those types of meds. Now don't get me wrong...I am NOT suggesting discontinuing it at all. You are taking it for a valid reason and it comes with some nasty withdrawal side effects if you try to go cold turkey. DO NOT try going without it without a discussion with your doctor.

What I am suggesting is that your meds may be playing a bigger part in how you sleep and feel than you might think.

And there is most definitely "proof" of what SSRIs and SNRIs mess with sleep. Lots of studies done about this issue. Dig deeper. The data is there.

And you don't need ASV machine for arousal or post arousal central apneas. An occasional central apnea (that is for sure a real asleep central) is really normal but what I saw of yours about 90% you weren't sound asleep. There are sleep onset centrals or sleep transition centrals...real and no big deal when in low numbers.

johncray wrote: ↑

Tue Aug 12, 2025 12:53 pm

So, if I follow your reasoning so far - you're leaning towards those centrals being really detected as such because I don't have a sound sleep, which might be caused by the SSRI. Is that so?

Huh? Did you mean to put a "not" in there? As in "centrals NOT being really detected".

Your meds might be impacting your sleep quality....how much I have no way of knowing but it wouldn't surprise me at all.
Your sleep quality is crap and you aren't going to see much of an improvement in how you feel is your sleep quality is less than needed for restorative sleep.

Just remember....just because you don't remember an arousal doesn't mean it didn't happen

I scrolled through Aug 9 report. I saw maybe 2 sleep onset centrals and that's all that I could spot that might be real and a sleep tech friend of mine would probably say they aren't real (he did that to one of my own centrals that I thought was real but had a teeny tiny blip in the breathing so that disqualified it from being real)....all the other Centrals flagged were so blatantly arousal or post arousal that a blind man could see it.
If you aren't asleep....anything flagged isn't real....think false positives for lack of a better term.

Hi again,

Thanks for sticking with me and shedding some more light. This is all very very new to me and I am trying to make some sense of it all. Lots of conflicting information too.

Pugsy wrote: ↑

Tue Aug 12, 2025 1:18 pm

SSRIs, SNRIs or really any mood medication can mess with sleep quality. It's part of the baggage that comes with taking those types of meds. Now don't get me wrong...I am NOT suggesting discontinuing it at all. You are taking it for a valid reason and it comes with some nasty withdrawal side effects if you try to go cold turkey. DO NOT try going without it without a discussion with your doctor.

What I am suggesting is that your meds may be playing a bigger part in how you sleep and feel than you might think.

And there is most definitely "proof" of what SSRIs and SNRIs mess with sleep. Lots of studies done about this issue. Dig deeper. The data is there.

I hear you. It makes sense. I'll do some more research. I've gone cold turkey before and I know the terrible side effects. Last summer I tried reducing the dose from 75mg to 50mg over a period of 3 months but eventually had to go back up to 75 because I don't think 50 was enough. So, I can go for a day or two without feeling the side-effects, just as a test, but doubt that anything will change for such a short period.

Your meds might be impacting your sleep quality....how much I have no way of knowing but it wouldn't surprise me at all.
Your sleep quality is crap and you aren't going to see much of an improvement in how you feel is your sleep quality is less than needed for restorative sleep.

Do you think a proper in-lab polysomnography would be useful in my case? How would it help?

I scrolled through Aug 9 report. I saw maybe 2 sleep onset centrals and that's all that I could spot that might be real ....all the other Centrals flagged were so blatantly arousal or post arousal that a blind man could see it. If you aren't asleep....anything flagged isn't real....think false positives for lack of a better term.

I'm this blind man
How can you tell that I am not sound asleep from those charts? Would you be able, when you have the time, to highlight a section of my charts that tell you this with high degree of confidence and perhaps explain the pattern you saw? Maybe compare to another section which is good? I want to know what I am looking at.
Also, how come the doctor/technician who has read my home sleep study not pointed that out at all? If my sleep quality is so bad, does it even make sense to try CPAP treatment?

Once again thank you very much for taking the time to analyze those charts. Appreciated

Cheers

johncray wrote: ↑

Tue Aug 12, 2025 2:18 pm

How can you tell that I am not sound asleep from those charts?

Because asleep breathing doesn't look anything like arousal/awake breathing. I learned to spot the difference. Sometimes it's kinda iffy but most of the time it's fairly clear.

Here I have circled the asleep breathing....


and same time but zoomed out so you can get an overall picture of things


Anything flagged or shown that isn't inside the red circle....not sound asleep so "false positives"/SWJ or arousal or plain old awake breathing.

johncray wrote: ↑

Tue Aug 12, 2025 2:18 pm

Do you think a proper in-lab polysomnography would be useful in my case? How would it help?

I have my doubts but they would at least be able to tell if you are really asleep or not when anything got flagged.
What lab studies can't do is tell for sure what might have caused the arousal. There are two kinds of arousals....spontaneous and airway related. Spontaneous means "we don't know what caused the arousal".....CPAP does absolutely nothing for spontaneous arousals. If a problem isn't related to the airway then CPAP is useless. A medication side effect or just crappy sleep isn't something cpap can fix unless the airway is in play.

The meds.....

Zoloft will stay in your system for up to a week.

How long does it take Zoloft to wear off?
Zoloft® is an antidepressant used to treat depression and other mood and anxiety disorders. The average half-life of Zoloft® is 24-26 hours, and it can stay in your system for 5-7 days. Zoloft® can be detected using a urine, blood, saliva, or hair sample test.

johncray wrote: ↑

Tue Aug 12, 2025 2:18 pm

Would you be able, when you have the time, to highlight a section of my charts that tell you this with high degree of confidence and perhaps explain the pattern you saw? Maybe compare to another section which is good? I want to know what I am looking at.

Very well. Give me a bit of time. I have some chores to do that I have put off too long. It's a steep learning curve for some.

Oh....one question I forgot to ask.....are you having any nasal congestion at night? This is rather important to know.
If you are NOT experiencing much nasal (or any) nasal congestion try increasing your EPR setting from 2 to 3 and lets see what happens to that Flow Limitation graph with the increase to 9 cm minimum tonight.

johncray wrote: ↑

Tue Aug 12, 2025 12:12 pm

I only take Zoloft (75mg) in the morning for OCD. I've been on it for 14 years.

In my book, an in-lab polysomnograph is imperative before prescribing any "psych" drug. I've talked to too many cases where it was only discovered years later that the emotional problems stemmed from undiagnosed/untreated sleep apnea. In some of these cases, they were able to taper off the drugs once a good CPAP therapy was being practiced.

There is one of the members who tried three different antidepressant drugs and three months of mental health counseling. None of it worked, so he quit. About a year later, a smarter doctor sent him for a sleep study. He started using CPAP and his "depression" was gone. In a private message, he told me by PM that he called his counselor to tell him about his sleep apnea. The counselor said, "Well, if I sent all my patients for a sleep study, more than half would fail." Then why the hell don't you send them!

Think about when you were diagnosed with OCD, and then more recently when you tried reducing the dosage. This was when you had untreated sleep apnea. Sleep deprivation has been used in warfare to "break" enemy soldiers.

Good luck whatever you do.

Aug 11 report.

Here's a partial breakdown.

When you see evidence of arousal/awake breathing right before the flagged event....not really sound asleep.

You weren't ever asleep in this time frame.



You were maybe asleep a little after the flagged event but it wasn't good sound sleep.



Here's one where you took a big gulp of air and then there is a pause in breathing that got flagged.
I zoomed in a little more to see each breath a little clearer.

We don't take big gulps of air when sleeping. So that would mean this central is a post arousal central. There was a rather quick arousal (maybe turned over in bed and held your breath briefly) right after the gulp but looks like nice asleep breathing after that.

With this I think you were asleep from that 1:47 to around 1:51 and after that I don't see asleep breathing on this segment.


Might work better for you if you did the scrolling and zooming and posted the ones you needed clarification on.

FWIW....I have crappy sleep issues myself and I know I have lots of arousals but it's not sleep apnea related. I might remember half a dozen awakenings but when I stroll through the report I might see evidence of 20 or 30 arousals that I don't remember.
I spent a couple of years with my flow rate (breathing) under the microscope to get comfortable with this type of analysis.
I still am not always 100% certain what I am seeing but I get close.

Pugsy wrote: ↑

Tue Aug 12, 2025 3:10 pm

Because asleep breathing doesn't look anything like arousal/awake breathing. I learned to spot the difference. Sometimes it's kinda iffy but most of the time it's fairly clear.

Here I have circled the asleep breathing....


and same time but zoomed out so you can get an overall picture of things


Anything flagged or shown that isn't inside the red circle....not sound asleep so "false positives"/SWJ or arousal or plain old awake breathing.

I think I follow now. You're looking for low amplitude, monotonic pattern where each breath is almost the same as the previous one. That is what sound asleep looks like. Anything else outside of that is not. As a consequence you say that if we are NOT in the sound asleep pattern then any event flagged by the machine is to be considered false and a consequence of the unsound sleep rather than the reason for it. Did I get that right?

I have a few questions:
1. How much of the total sleep should look like sound sleep pattern?
2. What about dreams? Don't they change the breathing pattern?
3. Did you recognize those patterns yourself or is there literature that describe them?

I saw the Glasgow Index at https://www.fortaspen.com/sleep/Intro.html and uploaded a bunch of samples. My scores are consistently around 2.5. Which is bad. I think that's in line with what you're saying.

Oh....one question I forgot to ask.....are you having any nasal congestion at night? This is rather important to know.
If you are NOT experiencing much nasal (or any) nasal congestion try increasing your EPR setting from 2 to 3 and lets see what happens to that Flow Limitation graph with the increase to 9 cm minimum tonight.

I do have a condition in my nose where my turbinates have some hypertrophy and as a result I do get trouble breathing sometimes. I go to an ENT specialist every few years where he applies radio frequency (RF) turbinate reduction procedures (burning of the turbinates) and that buys me a few more years because the body absorbs the damage and shrinks them. Eventually I need to go under the knife and have him cut some. I also have a deviated septum which he will address as part of it. Concretely, these days I am not suffering too much. I started using sinus rinse before bed, then I use a moisturizing spray (saline + aloe vera, etc) which helps and I use Breathe Right strips under the mask. I also use Ryaltris nasal spray (corticosteroid + antihistamine) if/when my nose gets too blocked. I've used it twice with the CPAP machine without any changes in sleep or patterns. My EPR is currently set to only be active during Ramp from the clinic and I left it like this. I will try with 8 again tonight and enable it full time on 3 to see what happens.

You weren't ever asleep in this time frame.

For sure I was not. I got out of bed to go to the washroom, then went back to sleep at 11:20 and couldn't get back to sleep. So here I am 100% sure I wasn't sleeping. That helps establish what non-sleep breathing looks like! Then between 11:28 and 11:30 I took the mask off for a little bit (although not sure if it was for a full 2 minutes) and then I put it back on and went back to sleep (or did I). The pattern between 11:30 and 12:00 (before the event) does not look like sound sleep if I understood it properly.

Here's one where you took a big gulp of air and then there is a pause in breathing that got flagged.
I zoomed in a little more to see each breath a little clearer.

We don't take big gulps of air when sleeping. So that would mean this central is a post arousal central. There was a rather quick arousal (maybe turned over in bed and held your breath briefly) right after the gulp but looks like nice asleep breathing after that.

I don't think I have turned over in bed because I don't see a corresponding change in the "Movement" chart around 12:51:10 or a change in Pulse rate (from the O2Ring data). Could this be really the bad effects of the Zoloft?

Might work better for you if you did the scrolling and zooming and posted the ones you needed clarification on.

Now that I'm looking for this pattern in my chart I am hard pressed to find a good stretch actually.
Is the stretch between the events at 2:22 and 2:40 to be considered sound sleep breathing? Doesn't look great to me. What do you think?



What would you do if you were me as next steps?

Thank you so much for the valuable information!

Let's see how that FL graph looks after changing EPR to 3 and full time.

johncray wrote: ↑

Tue Aug 12, 2025 5:19 pm

I have a few questions:
1. How much of the total sleep should look like sound sleep pattern?
2. What about dreams? Don't they change the breathing pattern?
3. Did you recognize those patterns yourself or is there literature that describe them?

1.....I don't know for sure because I don't remember a specific percentage but around 80% or higher would be good.
Below 50% and we start talking TWS (train wreck sleep). From a quick glance...yours looks like 50 to 60 %.
I think that is call a sleep efficiency number.

2.....not really able to tell REM stage from the other stages...some educated guesses maybe but not with any level of certainty IMHO

3.....Actually there is some literature and explanation out there but all I have handy is a quick guide to what the different shapes of breath mean.
Plus I have a couple of friends who worked as sleep techs and I would pick their brain often

johncray wrote: ↑

Tue Aug 12, 2025 5:19 pm

As a consequence you say that if we are NOT in the sound asleep pattern then any event flagged by the machine is to be considered false and a consequence of the unsound sleep rather than the reason for it. Did I get that right?

That's about right. Your AHI is primarily elevated because of the crappy sleep caused by whatever is causing the crappy sleep.
If we were to discount those "false positives" and just worry about the "real asleep" stuff....your AHI would be quite low

BUT

then you would be here saying what I hear so often...."my AHI is great(below 1.0) and I still feel like crap"...
And I would be having the same discussion about medication side effects potential to screw with how we feel or sleep.

Sometimes when it comes to meds it's a damned if you do and damned if you don't kind of thing. Been down that road myself.

Let me go see if I can find some info on sleep efficiency.
I found this

What is a good sleep score for sleep efficiency?
80–99 stand for good sleep, 50–79 for moderate and 0–49 for poor sleep. Sleep score is a combination of two variables, amount and quality of sleep. Thus, you can achieve the same score in many ways, by sleeping longer or sleeping better.

Found some good common sense at the Nyquil website.

https://www.zzzquil.com/en-us/article/h ... ell-rested

johncray wrote: ↑

Tue Aug 12, 2025 5:53 pm

Now that I'm looking for this pattern in my chart I am hard pressed to find a good stretch actually.
Is the stretch between the events at 2:22 and 2:40 to be considered sound sleep breathing? Doesn't look great to me. What do you think?

Hard to say. You haven't zoomed in quite enough to see each breath clearly.

Go back and look at my examples where I circled the asleep breathing in red....one is zoomed in perfectly but the other isn't zoomed in enough to see each breath clearly.

There's something a bit "off" on this report you shared but I can't put of finger on it right now. It's not horrible though.
It is only 18 minutes though....I saw more SWJ stuff on your report than I saw asleep stuff and the asleep stuff was a bit "ragged" at times.

johncray wrote: ↑

Tue Aug 12, 2025 5:53 pm

What would you do if you were me as next steps?

Make the EPR change to 3 and full time to start with. Your FL graph isn't horrible but it is a bit active and FLs can disturb sleep as well. Can't say for sure if it will help or not but something worth trying that is painless and cheap.

A boring FL graph looks like this.

Pugsy wrote: ↑

Tue Aug 12, 2025 6:23 pm

Make the EPR change to 3 and full time to start with. Your FL graph isn't horrible but it is a bit active and FLs can disturb sleep as well. Can't say for sure if it will help or not but something worth trying that is painless and cheap.

A boring FL graph looks like this.

Roger that. Changes made. Pressure: 8.0, EPR: 3 Full time, Ramp auto with pressure 5.0. Ready for another data point. I'll report back here tomorrow.

Thank you for all the help and information Pugsy.

Good night to both of us!