From APAP to CPAP and back to APAP. Advice needed.

Hi all,

I've currently got my S9 set at 9cm in CPAP mode. Ramp from 7-9 in 20 minutes. Full time EPR set at 1. My AHI is generally under 5. However, most of that is usually comprised of CA's. In an effort to lower my CA's, what
would you suggest I try? Go back to APAP with a 7-10cm setting? 6-9? 7-9? Lose the EPR? I had it originally set from 9-12 in APAP, with an EPR of 3 and a ramp from 5 to 9, but that didn't yield the results I'm looking for. Incidentally, I'm currently using an Aloha pillow mask, that I love... I get some leaks, but it really hasn't seemed to effect my AHI THAT much...

Thanks for any help,

Z

We don't normally treat centrals with pressure. Especially we don't increase and we don't use APAP with a range that allows much movement IF the centrals are pressure triggered.

If you think that the centrals are triggered by pressure...and your obstructive events are minimal (sounds like they are) I would reduce the pressure either by the setting or simply increase EPR and let the machine work sort of like a bilevel machine.

If your obstructive events are well treated at 9 cm cpap...I would reduce that overall setting and see how much wiggle room you have before the obstructive events start rising.

So..several choices...increase EPR...decrease set cpap pressure by 1 or 2...keep EPR at 1..
go to auto mode....small range.. maximum maybe 8...minimum maybe 6. EPR still at 1.

If the centrals are pressure related they may drop a bit....as long as the obstructives don't increase to unacceptable levels you might get what you desire. If your centrals are more sleep stage related or transitional...changing the pressure may not help but as long as your obstructive component of your AHI is still acceptable...it sure doesn't hurt anything to give it a trial.

So just bear in mind that the centrals you see may or may not be pressure related if not pressure related they may not reduce like you think they should.

Thanks P! That's some solid advice right there.

I think I'll take baby steps first... ie, simply raise the EPR to 3, leave all else. I like the notion of creating a faux bilevel experiment. Will see where I'm at in a day or so unless something dramatic happens

overnight for better or worse (increase in obstructive events).

If my CA's ARE sleep stage/transitional related, is the only solution sleep hygiene/CBT?

-Z

Zzzzzzzzzzz... wrote: If my CA's ARE sleep stage/transitional related, is the only solution sleep hygiene/CBT?

Very possibly. They also might dissipate on their own with some time as the body gets adjusted to things. I don't know how bad your sleep hygiene is to know just how stringent you would need to change things but...we all can usually benefit from better hygiene anyway. Myself included

If it were me...the increase in EPR would be what I would try to start with. Keep it simple and who knows you might really like that rhythm anyway. I experimented with EPR on my VPAP auto by using straight cpap mode and EPR of 3....it came real close to being just as comfortable as bilevel mode with pressure support of 4 cm difference in inhale and exhale.

Disclaimer: I don't do centrals. I don't know much about them, so I don't feel comfortable advising anyone what to do about them.

That said, I'm confused as to why one would want to create a bilevel situation with centrals. See this article by way of evidence that bilevel worsens centrals:

http://chestjournal.chestpubs.org/conte ... /2141.full

I was going to PM that same study to Pugsy related to an altogether different discussion. It's true that BiLevel can cause iatrogenic central apneas in some patients. Yet BiLevel is also used to successfully treat iatrogenic central apneas in other patients. Both treatment and iatrogenic triggers can be a matter of individual makeup/response.

In optimization scenarios like Z's, I don't think it's a bad idea to isolate each treatment variable--- to find out which methodical changes hinder treatment and which help.

-SWS wrote:I don't think it's a bad idea to isolate each treatment variable, to find out which methodical changes hinder treatment and which help.

OK, I agree but what's the goal here? What is the outcome variable? Last I heard Z had a subclinical AHI, including centrals.

Also, Z, maybe you should post some representative data now, before you start any experimentation, including AHI, events, and leaks.

Most of mine are CA's of short duration 10 to 15 seconds and when I look at the time frame I know I was awake and tossing and turning and when I toss and turn I have a bad habit of holding my breath, and if it's longer that 10 seconds it shows as a CA. I have bad shoulders so it takes me a few seconds to get situated when I turn, can't stay on one shoulder but for so long and I've got to change. ZZZZZZ do you toss and turn during your sleep, if you do maybe your holding your breath.

Lowering central AI seems to be the goal:

Z wrote:In an effort to lower my CA's, what would you suggest I try?

I think people most often optimize hoping to see if it results in improved daytime symptoms... What did you have in mind, Z?

I'd focus on obstructive apneas first and foremost. In my experience, setting my machine at a single pressure or a very small range keeps those darned OAs in check. When I use APAP, I just keep chasing the pressure. So I use APAP to get a general idea and then set at a single pressure.

Mindy

OP was talking about an AHI less than 5 for the most part (already considered acceptable) with the bulk of the AHI being central in nature. Most doctors probably wouldn't do a whole lot or even think it was worth messing with. For all we know the central component here might not even be flagged as a central if these occurred during a PSG. Are they evenly dispersed throughout the night or are the clustered around some possible sleep stage transitions or even awake or semi awake periods? I can have a truckload of "centrals" get flagged during my last hour of sleep when I know full well I was in and out of sleep. It messes with the overall AHI but it is easily seen that the bulk of the night there wasn't anything exciting going on.

I suppose if we wanted to get really technical we should probably look at several of the reports and see if there is a pattern to things.
Given that the AHI is probably acceptable anyway and EPR is a minor change and certainly considered something that a patient is freely allowed to change....I see no harm in trying a change in EPR to see if the "centrals" reduce. That's why I didn't go into along drawn out thing with this OP. It's a minor tweak that he was wondering about doing. Should he have reported AHI of 10 and all being "centrals" and no obstructives to mention we go into a different mode of thinking and go into the whole nine yards about were there any centrals in either of the sleep studies, etc.

I felt like this was a minor tweaking thing..no need to go into panic mode. Try something simple first.
We tell people all the time to play with EPR and see how they like it.

I did read the article and tried my best to understand the mechanics. Bilevel has long been the next step up often for people with "centrals" that aren't so horrible that they go to ASV immediately. Insurance requirements may play into that little thing more than what is best for the patient but it is what it is.
The sleep apnea world is continually changing and the changes are starting to come about faster and faster. It wasn't until we had machines that gave us "centrals" that we even started this sort of tweaking and everyone goes into panic mode when they see a few centrals.

So....changing EPR from 1 to 3....is not me telling OP to go to bilevel..only an experiment to see if a minor change in a freely available comfort feature offers any change.

Pugsy wrote: So....changing EPR from 1 to 3....is not me telling OP to go to bilevel..only an experiment to see if a minor change in a freely available comfort feature offers any change.

I appreciate all the feedback, and can understand where you're all coming from. However, I'm with Pugsy and -SWS on this one. I'm merely experimenting with ways to bring my CA's down, as they seem to comprise almost all of my AHI. With an occasional Hypopnea thrown in for good measure. I rarely see any apneas recently. For me I'm looking at my daytime symptoms (out of it, sleepy, spacey, etc) and wondering if they're directly related to the CA's when they comprise so much of my lower AHIs. It's important to note that yes, I DO toss and turn/roll over often while I'm sleeping, and I'm willing to bet I do indeed hold my breath, I actually catch myself doing that as I'm falling asleep and definitely when I'm in that "almost awake" state of consciousness just before finally deciding to get my butt out of bed. Hell, I do it when I'm awake and not paying attention... on the computer (now) watching tv, reading etc. When I look back at the data, it indicates a small cropping of CA's when I'm falling asleep (during ramp) a few later in the night and then a cluster while I'm laying there somewhat awake just before I get out of bed... so I think I might be onto something. It's interesting, I've found myself REALLY awake at around 5am or so, sometimes I get up and feel refreshed and energized. While other times, I'll think to myself, "It's WAY too early to get up" and stay in bed longer- THIS is when I'll start having more CA's, and the result is staying in bed a bit too long and waking up consequently with that groggy feeling. When if I had JUST gotten up at 5, I'd be peachy keen. You know? I'll have to keep a better mental note of this over the next few days and see what happens... for now, I'm staying the course with the exception of the EPR increase.

Thanks all!

-Z

Zzzzzzzzzzz... wrote: However, I'm with Pugsy and -SWS on this one....I'm merely experimenting with ways to bring my CA's down, as they seem to comprise almost all of my AHI... For me I'm looking at my daytime symptoms (out of it, sleepy, spacey, etc) and wondering if they're directly related to the CA's when they comprise so much of my lower AHIs....I'll have to keep a better mental note of this over the next few days and see what happens...

As noted, I don't know anything about centrals and have no opinion about whether you should or should not use EPR.

I do, however, have a strong opinion that going into this experiment, you should have an outcome variable in mind. So, what is the outcome variable? Is it your CA index, which would be measurable and easy to track but is reportedly subclinical already? Or is it your report of your daytime symptoms, which on Friday was "refreshed" and today is "out of it, sleepy, spacey", about which you intend to make a "mental note"? In my experience, this whole business is consistently inconsistent, so if your outcome variable is EDS, if I were you, I would do more than make a mental note. I would log your settings and write down your subjective experience of your daytime symptoms, at each setting, which I would not change more frequently than once a week (unless it's clearly a disaster right away). Sit on your hands, if you must.

And that's my two cents.

SleepingUgly wrote:

Zzzzzzzzzzz... wrote: However, I'm with Pugsy and -SWS on this one....I'm merely experimenting with ways to bring my CA's down, as they seem to comprise almost all of my AHI... For me I'm looking at my daytime symptoms (out of it, sleepy, spacey, etc) and wondering if they're directly related to the CA's when they comprise so much of my lower AHIs....I'll have to keep a better mental note of this over the next few days and see what happens...

As noted, I don't know anything about centrals and have no opinion about whether you should or should not use EPR.

I do, however, have a strong opinion that going into this experiment, you should have an outcome variable in mind. So, what is the outcome variable? Is it your CA index, which would be measurable and easy to track but is reportedly subclinical already? Or is it your report of your daytime symptoms, which on Friday was "refreshed" and today is "out of it, sleepy, spacey", about which you intend to make a "mental note"? In my experience, this whole business is consistently inconsistent, so if your outcome variable is EDS, if I were you, I would do more than make a mental note. I would log your settings and write down your subjective experience of your daytime symptoms, at each setting, which I would not change more frequently than once a week (unless it's clearly a disaster right away). Sit on your hands, if you must.

And that's my two cents.

Noted. With a pencil.