Advice wanted for CPAP settings & central apneas

[EnigmaticToad]

Hello all.

I started using a ResMed AirSense 10 at the end of last year after an at-home sleep test indicated an AHI of 22.8; 13.7 UAI, 7.4 OAI, 1.7 CAI.

Initially the sleep clinic started me on auto mode with a min pressure of 5 and a max pressure of 20. During this time, I still experienced ~9 AHI per night on average, but it was highly variable (lowest I can recall was a little over 5, and highest I can recall was a little over 17). Most of this seemed to be caused by central apneas.

In response, the sleep clinic told me to do a titration. The outcome of that was increasing the pressure on the machine to a fixed 16 about a week ago. Overall, it resulted in no meaningful changes to AHI; slightly reduced obstructive apneas and slightly increased central apneas. Then they reduced it down to 14 and then up to 15, where it now remains.

As a result of the changes, the machine has become more uncomfortable for me to use, as I now need to strap my mask very tight to prevent air from blowing in my face. I also immediately started to experience symptoms of aerophagia after the changes (constant burping all throughout the day, and chest discomfort for a couple hours after waking up).

I've decided to discontinue working with this sleep clinic for a large number of reasons.

I'm hoping someone here can suggest changes to settings to improve the results that I'm getting. I've attached data from OSCAR for the past two nights, and also overall statistics. If there is anything else you'd like to see or know, please ask.

Specific issues I need help with are as follows, in no particular order. (Though, I honestly don't have much hope for any of them except #2.)

1) Reduced AHI to the extent possible with this machine.
2) Reduced aerophagia symptoms as mentioned earlier.
3) Ability to stay asleep throughout the night, if possible. You'll notice that my usage hours per night are generally not very high. That is because I frequently wake up throughout the night (whether using the machine or not), and although I'm able to fall asleep initially, it is very difficult for me to fall back asleep with the CPAP once I have woken up. So unfortunately my options are either to just get up for the day, or take the mask off and go back to sleep. Sometimes - as you will see on 4/29 - I'm able to wake up, take the mask off, fall back asleep for a little bit, and then put the mask back on the next time I wake up. But this situation of repeated awakenings is very frustrating.
4) Reduced daytime fatigue. (Using a CPAP for the past 5 months has not helped even a little bit with this.)

Any suggestions are appreciated.

Thanks!

[EnigmaticToad]

Here are screenshots of the previous 3 nights of use as well (4/24, 4/26, 4/27).

Advice will be greatly appreciated. Thanks!

[Dormeo]

Welcome! I'd appreciate seeing a zoomed-in view of a series of CAs, including maybe the 6 or 8 breaths that come before the start of the series. Maybe a 10-minute snippet.

I have some initial thoughts, but it'd be good to see a snippet or two before diving in with suggestions.

[PeaceLoveAndPizza]

If you have a sleep study handy, it would help to post it with your personal data redacted. If not, no worries, we can still work through things.

What pressure ranges and EPR have you already tried? My instinct is you need to reduce EPR to help with the CA’s and a bit less pressure for comfort.

I suggest starting with a lower pressure and EPR. Something like:

Min pressure 8
Max pressure 15
EPR 2 full-time

This will give us an idea of how much pressure you may need for the H and OA events, but because of flow limitations driving up pressure you may need more EPR. I want to see how your FL’s are handled by the machine. If you have already tried this, let us know.

Given how the CA’s cluster together, there may be some positional apnoea (chin tucking) going on. Even though we typically see it in OA and H events, some have it show up in CA’s. A flatter or CPAP pillow, and/or soft cervical collar, may be worth a go as it will keep your neck aligned and stop your chin from dropping.

In the end you may need to move to a different machine like a bilevel, but before we go there there is a lot we may do with your current machine. One step at a time.

I see Dormeo and I posted about the same time. I think she is going where I was but got there sooner.

[EnigmaticToad]

Thank you both for your replies.

@Dormeo, I have attached three zoomed-in screenshots from 4/24, 4/26 and 4/29. Please let me know if there is anything else you would like to see.

@PeaceLoveAndPizza, I have a short summary of results from the at-home sleep test a couple months back, but I was not given any results from the recent in-person titration. I will upload what I have shortly.

The only pressures that have been tried so far are those that were prescribed by the sleep clinic - min 5 / max 20 for several months, and recently fixed 14, 15 and 16.

I have a CPAP pillow, but only tried using it for one or two nights as I did not find it comfortable. I originally purchased it because I was concerned about pushing the mask off when I sleep on my side, but that has not been an issue. That being said, since you think it may help, I will give it a try for the next couple nights and post results.

I will follow your suggestion on pressure and EPR settings tonight and let you know how it goes.

Thanks again!

[Dormeo]

I am thinking along similar lines, PeaceLoveAndPizza, and I agree the sleep study could be useful. I'd like to see those snippets, though, before we make recommendations.

[Dormeo]

Ah, the posts are coming fast and furious!

Most of the CAs in the snippets come after arousal breathing or a deep sigh sets off a period of unstable breathing. There are two theories about why deeper-than-normal breathing is followed by CAs; one concerns controls regulated by CO2 and another concerns controls tied into sensors in the chest muscles.

Whatever the cause, the effect is what you're wrestling with. And I think PLAP's suggestions are very good. Because your obstructive events are being so well treated, and because you're having mask and aerophagia discomfort, I think you could safely try experimenting with a narrower range, say 8 min 12 max. Try it first with EPR of 3; if you're still having a lot of CAs after a couple of nights, then lower to EPR to 2. By making just one change at a time, we'll have a better chance of figure out what will help the most.

[EnigmaticToad]

Here is the sheet I was given after the at-home sleep test. I'm not sure if it contains the information that you're looking for, but at the moment it's all I have.

Thanks!

[EnigmaticToad]

I tried min 8 / max 12 with no change to EPR as suggested. I also used a CPAP pillow. The result was 12.8 AHI. Whilst that is an increase, it is not at all outside the historical norm for me. This change is due to central apneas as usual; obstructive apneas do not seem to have changed much.

Unfortunately I was not able to fall back asleep after waking up for the first time, so this is all the rest I got.

On a positive note, there appear to be no aerophagia symptoms.

I've attached results for the night with two zoomed-in views.

[PeaceLoveAndPizza]

Thanks for the patience and willingness to give things a go.

Less pressure and EPR of 3 does not seem to yield better results. I suggest the next step is to try dropping EPR, then depending on how you respond possibly removing it altogether. Also, I think a soft cervical collar is well worth the expense of < $20 USD as a further experiment. You can read up on how the SCC helps here.

https://www.apneaboard.com/wiki/index.ph...cal_Collar

Note that you may experience aerophagia without EPR and one way to help with that is wear the mask under pressure for a bit whilst watching TV or reading. One thing I found helps as well is to relax and breathe with the machine, not fight against it. It takes a while to get comfortable with doing that, but it does help quite a bit.

So, consider for tonight

Min pressure 9
Max pressure 14
EPR 1 full-time

If that does not help much, then the next step is to try it with no EPR or try a fixed pressure (CPAP mode or APAP with min=max) like

Pressure 11
EPR off

The fixed pressure of 11 seems to be your 95%, so a good place to start.

If none of these help with the central’s then we have to consider a bilevel with trigger control to deal with the CA’s. Still a ways to go before that, but it may be the best thing for you.

Let’s see if Dormeo has other ideas as well…