Advice on Pressure Changes

[JCFlorida]

Hi All,

New member here. Currently, total 75 days on Airsense 10. Original diagnosis was OSA at AHI of 43. Mostly OSA and about 25- 30% CA's.  OSA when down to less than 1 immediately at wide open 5-20 pressures with EPR of 2. The net result after 45 days was CA's between 6-8 and I was feeling worse than before CPAP. 

Doctor said it was TECSA/complex. He lowered pressure to 8 and kept min at 5, raised EPR to 3. No difference. I turned off EPR per recommendations from what I read in forums. Definite improvement. Then last week I raised minimum pressure to 6 from 5. My CA's dropped almost in half. Last night AHI was 3.25, CA's were 2.36. I finally feel like I turned a corner. Is there any reason to continue to change the min pressure range? Any advice would be appreciated. Attached is last night's Oscar report. 

   

[Sleeprider]

I'm curious to see what your results were with EPR because that was probably going to be my first move. You have pretty steady moderate flow limits (95% at 0.06) that keep your pressure near the maximum, and I suspect those were less with EPR. The central events are well spaced over the 6:46 of this session, so it does not "look" central to me, but more like changes in sleep stage or arousal. We can verify by zooming into the events and seeing how they evolve. TESCA usually has periodic breathing, which shows as an oscillating respiratory flow, and you don't seem to have it. AHI is not too bad, and I don't see obstruction, so let's take a closer look at events. My initial suggestion is Minimum pressure 8.0, Maximum pressure 11.0, EPR 2. If you're feeling lucky, give it a try.

[JCFlorida]

I'm curious to see what your results were with EPR because that was probably going to be my first move.  You have pretty steady moderate flow limits (95% at 0.06)  that keep your pressure near the maximum, and I suspect those were less with EPR. The central events are well spaced over the 6:46 of this session, so it does not "look" central to me, but more like changes in sleep stage or arousal.  We can verify by zooming into the events and seeing how they evolve. TESCA usually has periodic breathing, which shows as an oscillating respiratory flow, and you don't seem to have it.  AHI is  not too bad, and I don't see obstruction, so let's take a closer look at events.  My initial suggestion is Minimum pressure 8.0, Maximum pressure 11.0, EPR 2.  If you're feeling lucky, give it a try.

Hi Sleeprider,

Thank you for your response. The CA's now are the lowest they have been, at least for a week. I looked at the 95% flow limits since start of therapy and it has been at 0.06 and 0.07. Before I try your suggestions, here are the EPR changes for the last few weeks and their impact. I hope you don't mind the sleephq links as they more easily allow you to look at the graphs for custom dates. Let me know if any of that changes your advice.

1/9-14: Pressure 5-8, EPR 3: https://sleephq.com/public/098581a4-e453...7c787b5f04
1/16-21: Pressure 5-8, EPR 1: https://sleephq.com/public/98ec7996-bcbb...79b34b239c
1/23-29: 6-8, EPR Off: https://sleephq.com/public/48f646ed-d1dd...e3cf315a90

[Sleeprider]

I'm not a fan of SleepHQ which is an unattributed ripoff of Oscar and that aside, these graphs still don't hit the range of pressure and EPR I'm suggesting. The trend seems to suggest lower pressure and EPR, but I'd still like to look at zoomed flow to see how the events evolve. Your efforts at 6-8, EPR off are basically fixed pressure near 8.0. Simialarly the 1/16-21 are all mostly at a pressure of 8. The efforts with EPR 3 just made the machine less responsive. i am suggesting a higher pressure range than you have tried, with an intermediate EPR. Can't say it will work out, but it is a completely different, but moderate pressure range.

[JCFlorida]

Thanks again for the advice. I apologize for the sleephq links, didn't know that history.  Here is a zoomed in version on the CA's. Let me know if you need more and I will post.

   

[JCFlorida]

Here is a 4 minute segment.

   

[JCFlorida]

I'm curious to see what your results were with EPR because that was probably going to be my first move.  You have pretty steady moderate flow limits (95% at 0.06)  that keep your pressure near the maximum, and I suspect those were less with EPR. The central events are well spaced over the 6:46 of this session, so it does not "look" central to me, but more like changes in sleep stage or arousal.  We can verify by zooming into the events and seeing how they evolve. TESCA usually has periodic breathing, which shows as an oscillating respiratory flow, and you don't seem to have it.  AHI is  not too bad, and I don't see obstruction, so let's take a closer look at events.  My initial suggestion is Minimum pressure 8.0, Maximum pressure 11.0, EPR 2.  If you're feeling lucky, give it a try.

I am going to give those changes a try tonight. Will post results soon thereafter. Thanks again.

[DancesWithCats]

Base nothing on one night, good or bad, unless perhaps if it's an outright disaster. Personally, I try to give it a week, alter one thing, and give that a week, and keep fiddling with it to see if it helps, hurts, or makes no difference. The lower part of the stats page can then be of some use (though mine is polluted with a few one night changes that went well or poorly from before I adopted this approach. )

[JCFlorida]

   

Attached is last night's report. Previous settings were min pressure 6, max 8, no epr. New settings are min pressure 8, max 11, epr 2. CA's increased from the mid 2's to over 6.  I feel definitely feel less rested and more tired.  Please advise. Thank you.

---

Thanks for the feedback. I generally try one change at a time for a few days unless as you implied, one feels worse and numbers go up.

[Sleeprider]

We needed to see if EPR would improve or worsen the CA events, so I think that question is resolved.  You are experiencing predominately open airway or central apnea, probably arising from increased ventilation using your CPAP which results in unstable CO2.  CO2 is important in respiratory drive, and when CO2 rises in your blood stream your tend to breathe deeper and faster (more urgently), and when CO2 drops your body senses its respiratory needs are being met, and your respiration rate and volume will drop resulting in the CA and H events, or a periodic breathing pattern.  This fluctuation of CO2 can occur in what is described as a "loop-gain" effect alternating between hyperventilation and hypoventilation.

Now that the technical explanation nonsense is out of the way, there are several ways to address this with CPAP.  First, this condition affects about 15% of all new CPAP users, and usually self-resolves for the majority of affected persons in several months.  So patience can be part of the solution.  We know that turning off EPR helps reduce events, so EPR at 1 or off is probably what you need. Experiment and go with the most comfortable option regardless of AHI.  Most people with treatment emergent central apnea benefit from steady pressure rather then varying pressure.  Based on your previously submitted charts, it looks like a pressure of 7.0 avoids obstructive events, and is an appropriate fixed pressure.  This can be done in CPAP mode at pressure 7.0, or in Autoset mode by setting minimum and maximum pressure to 7.0.  Finally, if this does not resolve CA events adequately, we have in our hip-pocket a tool called EERS (enhanced expiratory rebreathing space).  This is a means of reserving a fraction of the expired CO2 in the breathing tube so it is included with your CPAP fresh air. This maintains respiratory drive we discussed earlier.  I don't want to move to that immediately, but there is a Wiki on the topic if you're interested.