Pressure induced Centrals: Need advice please. ASV next?

I'm going in for a 2nd titration (will be my 3rd sleep study since the first in late Feb) due to pressure induced centrals on my last titration study (my first was untreated) where unfortunately, the tech failed to titrate me at the time on a bipap/asv machine as recommended. Rather she scored the CA's improperly and deduced that a pressure of 10cm was adequate. I tried 10cm the next night and for a week after until I met with my PA. The pressures spiked my AHI as well as my CA's. When I met with the PA, she read the chart and saw that my Centrals were pressure related, and not simply sleep transitional. And there were MANY. More than 50% were CA's. We agreed that in the time before my 3rd sleep study (on a Bipap/ASV) I'd try lower pressures with my S9 and see what happens. I tried 5cm, but that was WAY too low. I tried 7 and that worked REALLY well for about 4 or 5 days. AHI's were around 3 or below. BOY WAS I HAPPY!!!! I attached a sample night for you. Then,
without making any changes, my AHI and CA scores started going up... as evidenced in the second chart. And they've increased since... less than 10, but I'm puzzled as to why. At any rate, I'd really like to know what to do between now and my next study... which is next Tuesday. I've tried 7 with an EPR of 2. No decrease in AHI. What should I do?

I'm assuming I've not got CSA rather than OSA... incidentally, my Hypopneas and Apneas are typically treated pretty successfully... it's just the introduction of CA's that have me concerned. Hoping a Bipap will fix the issue, but something tells me I'm due for an ASV.... oh, and I'm 48, in really good health overall, with no heart or neurological issues (okay, I don't get along with my Mom, but I digress)... Nothing abnormal showed up on either study thus far to indicate otherwise either...







Thanks for any advice.

Z

Zzzzzzzzzzz... wrote: Hoping a Bipap will fix the issue, but something tells me I'm due for an ASV....

BiLevel can yield good treatment in some cases, but it can also worsen central apneas in other cases. So I think it's a good idea that your titration plan includes switching over to ASV if BiLevel doesn't pan out.

Can you spot a "hard" pattern whether EPR of 3 worsens/improves your central tendency? If it worsens your central tendency, then ordinary BiLevel may do the same. Some patients for whom BiLevel worsens central apneas, might actually fare better with the Respironcs rather than Resmed ASV implementation. Why? The Respironics ASV can be configured to run with either CPAP or BiLevel as base modality---with servo ventilation occasionally kicking in as-needed. By contrast the Resmed ASV can only be configured with BiLevel as base modality.

Here is a recent thread discussing that:
viewtopic.php?f=1&t=77572&p=706600&#p706600

Good luck with that titration!

If they properly run your titration with bilevel and ASV that may give some answers. Unfortunatley one night in the sleep lab only gives a snapshot of your SDB. As you have seen things change and sometimes rather quickly. I think the ASV is being prescribed more often as it can treat you and pretty much do do no harm. I also suggest a good talk with the tech before your test to be sure you're on the same page as to how she's supposed to test you so you don't have the mixup as before.
Good luck.

-SWS wrote:

Zzzzzzzzzzz... wrote: Hoping a Bipap will fix the issue, but something tells me I'm due for an ASV....

BiLevel can yield good treatment in some cases, but it can also worsen central apneas in other cases. So I think it's a good idea that your titration plan includes switching over to ASV if BiLevel doesn't pan out.

Can you spot a "hard" pattern whether EPR of 3 worsens/improves your central tendency? If it worsens your central tendency, then ordinary BiLevel may do the same. Some patients for whom BiLevel worsens central apneas, might actually fare better with the Respironcs rather than Resmed ASV implementation. Why? The Respironics ASV can be configured to run with either CPAP or BiLevel as base modality---with servo ventilation occasionally kicking in as-needed. By contrast the Resmed ASV can only be configured with BiLevel as base modality.

Here is a recent thread discussing that:
viewtopic.php?f=1&t=77572&p=706600&#p706600

Good luck with that titration!

Thanks. I've never tried an EPR of 3 with a setting of 7cm. Might try that tonight. Also, for some reason Sleephead is showing an EPR of 1 in both those charts, when in reality, I had it off altogether those nights. I agree though, if I'm "simulating" a BiPap scenario with no positive effect, it will probably indicate BiPap won't be too successful for me.

Good to know about the differences in machines. I'll make sure to note that if/when they prescribe an ASV... which as I've read/heard is really the gold standard overall, but just a bit difficult to adjust to.

Z

Mary Z wrote:If they properly run your titration with bilevel and ASV that may give some answers. Unfortunatley one night in the sleep lab only gives a snapshot of your SDB. As you have seen things change and sometimes rather quickly. I think the ASV is being prescribed more often as it can treat you and pretty much do do no harm. I also suggest a good talk with the tech before your test to be sure you're on the same page as to how she's supposed to test you so you don't have the mixup as before.
Good luck.

Agreed. In fact, I've asked for a different tech for this next session. I had a feeling the last one wasn't well versed in CA's to begin with, as I had a brief chat with her while being "connected" and she could barely explain to me any difference between sleep onset and true CA's. Far too many of these techs I fear are simple note takers and by the book pressure adjusters. It takes REAL attention to detail and focus to sort our individual needs out. Furthermore, It SHOCKED her how much I knew about my treatment and apnea overall. Which in turn shocked ME that most people come in blindly and leave with even less understanding than they had before. I think the folks on this forum are definitely in the minority compared to the SA world at large.

Thanks,

Z

Zzzzzzzzzzz... wrote: Good to know about the differences in machines. I'll make sure to note that if/when they prescribe an ASV... which as I've read/heard is really the gold standard overall, but just a bit difficult to adjust to.

Well, if they titrate you on a Resmed ASV and you receive spectacular results, then consider sticking with that proven ASV algorithm.

You will find some old posts on this message board referring to ASV as if it were a fine wine, good cigar, or SDB panacea. I have yet to see proof that ASV is anything other than a specific treatment for specific problems. I hope ASV turns out to be your specific fix.

-SWS wrote:

Zzzzzzzzzzz... wrote: Good to know about the differences in machines. I'll make sure to note that if/when they prescribe an ASV... which as I've read/heard is really the gold standard overall, but just a bit difficult to adjust to.

Well, if they titrate you on a Resmed ASV and you receive spectacular results, then consider sticking with that proven ASV algorithm.

You will find some old posts on this message board referring to ASV as if it were a fine wine, good cigar, or SDB panacea. I have yet to see proof that ASV is anything other than a specific treatment for specific problems. I hope ASV turns out to be your specific fix.

Fine wine or the worlds's stinkiest, tastiest cheese... if it works, I'll eat it to my heart's content. Pun intended.

Oh, and this clinic doesn't use Resmed machines. They prefer the "easier to read" data that the PR machines spit out.

So I'm already dealing with the "choice" machine in this case... I hope anyway.

Z

Greetings! Glad you are going to have another titration study with a BiLevel and/or an ASV unit.

First, let me answer your question about CSA vs. OSA. You have what is now understood as a subset of Central Sleep Apnea. Even a couple years ago there was doubt in the medical community whether pressure induced central apneas was a "real" problem or not. It's now accepted as a problem in it's own right and treated as such. Unfortunately, not everyone (your first sleep tech as an example) got the message. But in general the industry is moving toward this overall consensus of opinion that Complex Sleep Apnea (pressure induced central apneas) is a subset of Central Sleep Apnea.

You might want to watch the following short YouTube article. You might be wondering "Just what is Complex Sleep Apnea?". I found the following YouTube video that does a great job of explaining Complex Sleep Apnea:

http://youtu.be/CU-XTcfg3M8

Though written by Resmed, it is not product specific. Also, though it is written as if it is for a medical practice, it uses layman's terminology, so most anyone can watch and learn.

And here's how it is recognized during a polysomnograph (PSG) [Sleep Study]:

http://youtu.be/0WpZka7wYow

Additionally, since you are trying to get those central sleep apneas under control, you might want to do some background reading. Rested Gal put together a post to which we've added over the years. It provides lots of links to articles and material about Central Sleep Apnea, which includes Complex Sleep Apnea:

viewtopic.php?t=3025

As -SWS noted, some people find that BiLevel therapy is sufficient to reduce the impact of the pressure induced central apneas. In those cases, it is wise to go with BiLevel therapy. It is less expensive and easier to adjust to it. But if the central apneas remain even with BiLevel therapy, then ASV can be used to address the central apneas. And, it is a bit harder to adjust to it, but you will be surprised to find out you can adjust even to ASV .. if it means a good night of sleep.

Here's hoping your continuation on your journey to good sleep will finally reach an effective therapy for you. And do keep us posted.

Zzzzzzzzzzz... wrote: Fine wine or the worlds's stinkiest, tastiest cheese... if it works, I'll eat it to my heart's content. Pun intended.

Good analogy... That "will succeed" attitude ain't exactly shabby either.

Agreed .. about a good positive attitude.

Z, you also mentioned that your sleep tech was so surprised that you knew so much about your own situation .. Unfortunately, your assumption that many people just don't want to be bothered about understanding their situation is quite accurate. And there is clear statistical evidence from apnea patients and other chronic disorders (such as diabetes) that clearly show the most successful patients are those that are involved in their own therapy.

So, don't let someone discourage you. If a doctor asks why you would want to monitor your therapy, ask them if they would want a diabetic to monitor their blood glucose levels. If they say "No", then run away. It's time to get a doctor who was trained in the past 50 years or so.

Of course, doctors want to have a diabetic patient monitor their own blood glucose levels. They need that involvement on a daily basis to be certain the patient does what is right for themselves. As my endocrinologist answered me when I asked if he wanted to see my blood glucose levels: "No. YOU need to see them. Your body used to automatically adjust your blood glucose levels. It no longer does. YOU *NEED* to manage that now."

As so it is with sleep apnea. Imagine if your xPAP therapy effectiveness is reduced by something as simple as a large leak. You get more and more tired. You become a danger on the road and it adversely impacts your health. Why on earth should you NOT monitor your own therapy? You have a vested interest in it. Just as with blood glucose levels, you can no longer depend on automatic adjustments by your body. YOU *NEED* to manage your sleep, since your body no longer automatically does what is right.

Just my thoughts on this .. but it provides one analogy that most medical professionals can understand and embrace.

JohnBFisher wrote:Greetings! Glad you are going to have another titration study with a BiLevel and/or an ASV unit.

First, let me answer your question about CSA vs. OSA. You have what is now understood as a subset of Central Sleep Apnea. Even a couple years ago there was doubt in the medical community whether pressure induced central apneas was a "real" problem or not. It's now accepted as a problem in it's own right and treated as such. Unfortunately, not everyone (your first sleep tech as an example) got the message. But in general the industry is moving toward this overall consensus of opinion that Complex Sleep Apnea (pressure induced central apneas) is a subset of Central Sleep Apnea.

You might want to watch the following short YouTube article. You might be wondering "Just what is Complex Sleep Apnea?". I found the following YouTube video that does a great job of explaining Complex Sleep Apnea:

http://youtu.be/CU-XTcfg3M8

Though written by Resmed, it is not product specific. Also, though it is written as if it is for a medical practice, it uses layman's terminology, so most anyone can watch and learn.

And here's how it is recognized during a polysomnograph (PSG) [Sleep Study]:

http://youtu.be/0WpZka7wYow

Additionally, since you are trying to get those central sleep apneas under control, you might want to do some background reading. Rested Gal put together a post to which we've added over the years. It provides lots of links to articles and material about Central Sleep Apnea, which includes Complex Sleep Apnea:

viewtopic.php?t=3025

As -SWS noted, some people find that BiLevel therapy is sufficient to reduce the impact of the pressure induced central apneas. In those cases, it is wise to go with BiLevel therapy. It is less expensive and easier to adjust to it. But if the central apneas remain even with BiLevel therapy, then ASV can be used to address the central apneas. And, it is a bit harder to adjust to it, but you will be surprised to find out you can adjust even to ASV .. if it means a good night of sleep.

Here's hoping your continuation on your journey to good sleep will finally reach an effective therapy for you. And do keep us posted.

Thanks so much for posting John. I've read many of your threads on this topic in the past and find your advice and support most helpful and encouraging. I'll look forward to reading up on the topic and will certainly post my results as soon as I have something concrete to go on. In the meantime, what would YOU suggest I do with my S9 settings between now and next Tuesday? Throwing the whole thing out the window is kinda not an option. Though it MIGHT be for sale soon.

Z

Zzzzzzzzzzz... wrote:... what would YOU suggest I do with my S9 settings between now and next Tuesday? ...

I like the idea from -SWS about using EPR at 3 (even if SleepyHead does not report the results correctly). This will give you a feel of how well BiLevel therapy will help. And hey! If BiLevel does the trick, it's definitely an easier path (and cheaper) to take.

Zzzzzzzzzzz... wrote:... Throwing the whole thing out the window is kinda not an option. ...

Darn! Though I used to be a problem solvers problem solver in a major computer company, I definitely love to rail against our technical overlords. There's nothing like "the tyranny of the inanimate" to get the blood boiling! Thinking about performing mayhem on an xPAP device has often been a thought as I've fought with a mask or cold or ... It would be SO satisfying .. until I tried to go to sleep afterwards!

JohnBFisher wrote: Darn! Though I used to be a problem solvers problem solver in a major computer company, I definitely love to rail against our technical overlords. There's nothing like "the tyranny of the inanimate" to get the blood boiling! Thinking about performing mayhem on an xPAP device has often been a thought as I've fought with a mask or cold or ... It would be SO satisfying .. until I tried to go to sleep afterwards!

Okay, maybe just the humidifier as I can only get $40 for that sucker anyway!!!!

As for the settings... 7cm with an EPR of 3?

Thanks!

Z

What's EPR?

Interesting comments above regarding the technician's skill/knowledge level. My experience: My doctor told me during the office visit after the first titration that "... the administering tech's experience wasn't sufficient to correctly interpret the CPAP portion of the test results." He ordered another study for a week later that proved BEYOND A DOUBT that ASV was the most beneficial treatment for my case. I don't fault the tech; I fault the doctor for not ensuring that his staff were properly trained and/or supervised. With the information I have gleaned from this board (and the links the kind folks here have added) even I could interpret the results to the same conclusion. I discussed my disapointment with the doctor and he said that the tech wouldn't be disciplined per se, but would be mentored and provided additional instruction. If it weren't for this board (and my anal tendencies) I would have accepted any solution offered by the doctor. Thank goodness he was honest with me. And I am actually pretty happy with him; he owned his mistake and "ate" the cost of the second study - my insurance wouldn't pay for a second test so soon.

To the OP - I hope you find a solution that works for you; whether it's Bi-Level, ASV or something "completely different".