Advice on this CA event, it fully wakes me up

[Phil487]

Can someone look at this CA and tell me what I can do. This thing tends to fully wake me up. Last night it woke me up, I think I fumbled around with the pressure settings and then went back to sleep. It usually happens around 3AM. 

Any advice is appreciated. 

       

[Sleepy Quixote]

@Phil487,

Hey Phil, are you absolutely certain it was only that singular CA event that woke you up? On the zoomed out view, when I scan down the charts I see multitudes of things that would wake you up. The high pressure would certainly wake me up, those leaks in there, though not bad, if leaking in the right direction or noisily enough would be a source of disturbance enough to wake one up. Those Flow Limits would be enough to wake a sleeping zombie.

Again the question is, are you certain? Or did you wake up around that time, note the time, then in the morning check the carts and zero in on the CA and come to the conclusion that it was the only thing it could be, then obsessed over the idea it was a Central Apnea?

Just asking because I get centrals of many stripes fairly frequently, and early on in my treatment became obsessed with managing them over all else because they are so "dangerous"...
That preoccupation with managing the Central over all else caused me to make decisions concerning my treatment settings that were detrimental to my over all treatment and sleep quality. I still haven't figured out how to eliminate ALL central apnea events, but have definitely improved the overall quality of sleep and therapy by following the standard board mantra of managing the Flow Limits first, monitor the CA and observe trends over time.

Good Luck! Keep on keepin after it, better sleep ahead for us all!

[Phil487]

Hello Sleepy Q!

Yeah, I'm pretty sure it was due to that CA. I woke up with my heart about to bust out of my chest, and felt like someone was trying to drown me, it was so bad my heart burn caught on fire and I had to take another H2 pill, even though I always take one before bed. 

That's what I was going to write, then I remembered that I took another famotidine, but it looks like I never got out of bed according to the flow chart. I keep my pills in the bathroom. You're right! 

Here is where I woke up with rapid heart beat, and very breathless and got up to take my H2 pill (enclosed).
So what is happening here in the red box? And can you explain the flow limits and how I can fix that? I am currently using a FF mask that seems to leak a lot, it's actually irritating my eyes, but I'm a total mouth breather. BTW, I do fully sleep on my back, have to as I have low back issues. 

   

[Sleepy Quixote]

@Phil487

Hey Phil,


"Here is where I woke up with rapid heart beat, and very breathless and got up to take my H2 pill (enclosed) So what is happening here in the red box?." I have no idea what's going on there but, am absolutely certain that would wake me up too! hopefully someone in the community has similar things going on and can give some insight. 

 "And can you explain the flow limits and how I can fix that?" I can give a rudimentary explanation of how Flow limits affect sleep quality and tell you what helped me, an in-depth study of Flow limit causes and effects will need to come from the more knowledgeable folks around these boards that I learned from. Basically high Flow Limits (above .05 [my opinion]) degrade overall quality of sleep in many ways. Flow Limits stem from restrictions in the airway of various causes, airway obstruction, expiratory flow rate and body posture are the main culprits I believe. We manage Flow Limits by using the EPR setting on our Respironics devices, (Airsense 10 and 11 are the only ones I am familiar with), avoiding chin tucking and running high enough pressure to manage OA. That being said you do have some instances of severe Central Apnea events that can be exasperated by high EPR, but don't throw the baby out with the bath water and paint EPR as all bad for CA, in some cases it helps. Even an EPR of 1 could help manage some Flow Limits without causing additional CA problems, its a tight rope those of us with true CA events need to balance to improve overall sleep quality. One of the problems with EPR and CA is that it only becomes active after the pressure rises above 7, so any time spent below that isn't contributing to Flow Limit mitigation. I am guessing your very low starting pressure is due to higher pressures instigating excess CA events. True chronic CA should probably be treated with a Bipap or ASV machine. I don't know the severity or frequency of your CA events but it may be the case that you need to convince the powers that be that for proper treatment you need a different device. The EPR function of the Resmed AS 10 and 11 is basically mini bipap, but I really don't know what the ideal settings for you particular CA would be. Sleeprider would be a good one to get advice from. For me I have been able to get the most out of my machine with the settings of auto, min 7, max 9.6, EPR 3 full time, no ramp of any kind. My centrals are fairly mild and were treatment onset. Did have one official during the original study. My current settings are more effective than when I used the outside this board internet suggested recommendations for managing CA. Again it is very possible you situation is entirely different and need a different mode of treatment.

"I am currently using a FF mask that seems to leak a lot, it's actually irritating my eyes, but I'm a total mouth breather. BTW, I do fully sleep on my back, have to as I have low back issues." As much as that mask leaks I assume you've done everything in you power to reduce it (read the wiki on ff masks etc..), its time to try some different masks. There are plenty out there for mouth breathers. Sleeping on the back is a major cause of airway compromise, but when we have to, by gosh we have to. I'm an all over sleeper and in some cases cant sleep in any other position. Being a dedicated back sleeper, are you doing the things necessary to reduce compromising your airway? like proper neck support, angled support with a gentle slope to prevent tucking your chin into your chest? Look up proper support for back sleepers. If you are a FF mask user its possible that your mouth is dropping open when you sleep compromising the seal of your mask, if your jaw is dropping open wide, its possible there isn't a mask made that wouldn't leak, in that case a Respironics chin strap may be just the ticket, keeps your mouth closed enough that you don't break the mask seal but can still breath through your mouth into the mask. Final note, resolving mask leaks is a very important part of improving overall quality of therapy. For those of us prone to CA events a leaking mask can washout too much co2 actually causing some CA events. The info is out there. Not only that an excessively leaking mask reduces the overall efficacy of the device in all areas including Flow Limit mitigation, not to mention the leaks simply wake us up further degrading sleep quality and quantity. 

Good luck! Keep at it, just gets better as we get better at it.

[Phil487]

@Phil487

Hey Phil,


"Here is where I woke up with rapid heart beat, and very breathless and got up to take my H2 pill (enclosed) So what is happening here in the red box?." I have no idea what's going on there but, am absolutely certain that would wake me up too! hopefully someone in the community has similar things going on and can give some insight. 

 "And can you explain the flow limits and how I can fix that?" I can give a rudimentary explanation of how Flow limits affect sleep quality and tell you what helped me, an in-depth study of Flow limit causes and effects will need to come from the more knowledgeable folks around these boards that I learned from. Basically high Flow Limits (above .05 [my opinion]) degrade overall quality of sleep in many ways. Flow Limits stem from restrictions in the airway of various causes, airway obstruction, expiratory flow rate and body posture are the main culprits I believe. We manage Flow Limits by using the EPR setting on our Respironics devices, (Airsense 10 and 11 are the only ones I am familiar with), avoiding chin tucking and running high enough pressure to manage OA. That being said you do have some instances of severe Central Apnea events that can be exasperated by high EPR, but don't throw the baby out with the bath water and paint EPR as all bad for CA, in some cases it helps. Even an EPR of 1 could help manage some Flow Limits without causing additional CA problems, its a tight rope those of us with true CA events need to balance to improve overall sleep quality. One of the problems with EPR and CA is that it only becomes active after the pressure rises above 7, so any time spent below that isn't contributing to Flow Limit mitigation. I am guessing your very low starting pressure is due to higher pressures instigating excess CA events. True chronic CA should probably be treated with a Bipap or ASV machine. I don't know the severity or frequency of your CA events but it may be the case that you need to convince the powers that be that for proper treatment you need a different device. The EPR function of the Resmed AS 10 and 11 is basically mini bipap, but I really don't know what the ideal settings for you particular CA would be. Sleeprider would be a good one to get advice from. For me I have been able to get the most out of my machine with the settings of auto, min 7, max 9.6, EPR 3 full time, no ramp of any kind. My centrals are fairly mild and were treatment onset. Did have one official during the original study. My current settings are more effective than when I used the outside this board internet suggested recommendations for managing CA. Again it is very possible you situation is entirely different and need a different mode of treatment.

"I am currently using a FF mask that seems to leak a lot, it's actually irritating my eyes, but I'm a total mouth breather. BTW, I do fully sleep on my back, have to as I have low back issues." As much as that mask leaks I assume you've done everything in you power to reduce it (read the wiki on ff masks etc..), its time to try some different masks. There are plenty out there for mouth breathers. Sleeping on the back is a major cause of airway compromise, but when we have to, by gosh we have to. I'm an all over sleeper and in some cases cant sleep in any other position. Being a dedicated back sleeper, are you doing the things necessary to reduce compromising your airway? like proper neck support, angled support with a gentle slope to prevent tucking your chin into your chest? Look up proper support for back sleepers. If you are a FF mask user its possible that your mouth is dropping open when you sleep compromising the seal of your mask, if your jaw is dropping open wide, its possible there isn't a mask made that wouldn't leak, in that case a Respironics chin strap may be just the ticket, keeps your mouth closed enough that you don't break the mask seal but can still breath through your mouth into the mask. Final note, resolving mask leaks is a very important part of improving overall quality of therapy. For those of us prone to CA events a leaking mask can washout too much co2 actually causing some CA events. The info is out there. Not only that an excessively leaking mask reduces the overall efficacy of the device in all areas including Flow Limit mitigation, not to mention the leaks simply wake us up further degrading sleep quality and quantity. 

Good luck! Keep at it, just gets better as we get better at it.

Just wanted to say a belated thank you for your reply. 
I've been using an Amora Silicon Face Mask Medium, which is too small for my big ugly face, but when I bought the CPAP machine off of Craigslist the guy only had medium, it was sealed but that's all I got to chose from. It's been causing a lot of leaks, which wakes me up and then I tend to take off my mask and fall back to sleep. I end up catching myself doing that so eventually I put my mask back on. Overall some nights it's off for a hour or two.

I ordered a Amora Gel Cushion Large on Amazon, and it came today. It was sealed, I washed it and it seems like a much better fit, so we'll see how it goes. I put one of our security cameras in our bedroom, put it on continuous recording with night vision and pointed it at me. I tend to move around a lot, but I remain on my back, which is good otherwise I get low back pain. We have a fancy Sleep Number bed with the incline frame, so I do adjust it. Most of what I can see from the video is uneventful but with the CPAP hanging off my face and a game ready Ice machine attached to my hip at night, I look rather freakish. But anything for a good nights sleep. My wife sleeps in the other room since I make too much noise at night, so our cat has taken her spot on the bed.

So far, most nights my AHI is under .5, flow limits are usually under 6%, but sometimes higher, which I noticed I might be a little tired the next day when it's like that. I tend to get a large hypopnea once a night like this: 

   
I'm hoping with the new mask it will help with that.

When I get several sessions in I will post Oscar data.

[Sleepy Quixote]

@Phil487

Sounds good!

[Sleeprider]

Phil, the flow chart you posted contains a classic RERA which is an increasing flow limitation, in this case nearly obstructive apnea, leading to arousal where the hypopnea is noted. This is fully an obstructive event and most often it is positional, resulting from an airway obstructed by bending, chin-tucking or other blockage related to the sleeper's position. It is by definition a respiratory event related arousal, so arousal or wakening is frequently a consequence.

[Phil487]

Phil, the flow chart you posted contains a classic RERA which is an increasing flow limitation, in this case nearly obstructive apnea, leading to arousal where the hypopnea is noted.  This is fully an obstructive event and most often it is positional, resulting from an airway obstructed by bending, chin-tucking or other blockage related to the sleeper's position.  It is by definition a respiratory event related arousal, so arousal or wakening is frequently a consequence.

Sleeprider, looks like you are 100% correct, here is a larger print screen:

I don't have a video of that night, so I don't know what I was doing, probably turning my head which I noticed I do a lot.

   

[Phil487]

How do I deal with the RE events?? I got another one last night, this is after a new mask and pushing the pressure up. I don't want to increase the pressure anymore because it already leaks enough and wakes me. Why do these things always seem to happen around 3AM? I watched myself on video and I didn't see any chin tucking, nothing strange, but I do turn my head, so I sleep on the side of my face. Maybe from that? But I tend to do that throughout the night. Is my airway closing up or is the hose kinking somehow? 



   

[Sleeprider]

RERA is a function of flow limitation. It is caused by increasing resistance to flow as inspiration progresses, and shows up as flattening of the inspiration peak. This causes a "respiratory effort related arousal". Our first and best tool to treat this is pressure support or EPR. Both result in an increasing pressure as inspiration progresses which offsets respiratory effort and results in a smoother, easier airflow. Your solution is simple. Increase minimum pressure to 7.0 and turn on EPR Full Time at Setting 3. This will start your pressure at 7.0/4.0 (inhale/exhale) and allow you to increase to 9.0/6.0. This pressure support will solve the problem.