CA problems - good or bad therapy?

[morarasuradu]

Hello everyone,

First, congrats on this wonderful community. It's impressive to realize that you are not alone in the world and there are extremely many others who face issues like you. It's also great to be able to find answers to so many questions that many doctors just shrug their shoulders.

My story begins like this:

I am 33 years old, 76kg and 182cm. I have been snoring very very loudly for some years now and my wife has told me that I have pauses in my breathing during sleep. Given this and combined with the fact that I feel tired all the time, I decided at the beginning of April this year to do a sleep study. I was diagnosed with severe mixed apnea, AHI=33 (event distribution being CA=93, OA=23, MA=15, H=131).

I was prescribed fixed pressure CPAP 6cm with EPR3... it was a bad joke because with these settings I couldn't get out better than AHI=25. After about a week I spoke to the doctor and consultant and changed the pressure to 8, dropping the EPR completely. It was better but totally inconstant... resolved a significant part of the OA and H but not the CA... I still juggled with pressures 7, 8, 9 and 10 trying to find the right one... couldn't find it... had AHI in the range 8 to 15 with no logic to relate to, most proportion of events being central.

Finally, the doctor changed my machine from CPAP to APAP, hoping it would be better. I used/tried pressures 5-10; 6-11; 6-12; 7-12 and finally 6-13 the one I'm on now. With the later one it was basically the best, with an average over the last week of AHI=6. Still however most events are central, followed then by hypo, and still there is that big inconstancy of AHI from day to day. In the mornings I feel quite confused... I admit I feel a difference from when I was not sleeping with PAP, but I have days where I am still tired in the morning and feel strange. The very good part is that I am completely rid of the snoring.

On another note my doctor initially recommended FFM (Resmed F20) which I used for the first month... it was pretty bad.. I was waking up with a swollen face, sleeping quite hard with it, had problems with my facial hair in terms of leaks etc.. so I decided on my own to get a Resmed P10 pillow mask... And things are now MUCH better.. no comparison.. I don't understand why to traumatize a new patient at first with a FFM before trying a nasal one.. It's true that I don't have the same perfect seal anymore and there are still nights with some leaks, but basically things are under control (I open my mouth sometimes, hence the leaks...). I've also noticed that since I've been wearing the nasal pillow mask, the average pressure has dropped by almost 2 units.

Reading a lot on this forum and learning all the while, I tried to suggest to my doctor maybe a BiPAP... but he said it's not for me and my problems, it's harder to tolerate etc. and when I mentioned a possible ASV for my centrals he said that "I read a bit too much and I should let it go more easily".

Also, during this period, I have had various investigations and tests to find out where these problems I have come from:

·    Brain CT scan -> all good

·    ENT consultation -> slight deviated septum and hypertrophied turbinate but nothing out of the ordinary or particularly serious

·    Neurology consultation -> all good

·    EKG and echocord heart investments -> all good

·    Various standard blood tests -> all good

·    Various blood tests for some autoimmune diseases -> all good

I don't know what I could do and how to continue. Please help me with some advice.

I attached the sleep study and one of the first nights when it was very bad (now it's not so bad, but I see that there is a limit of 3 attachments)

Thank you very much! 

                

[Phaleronic]

Welcome to the forum morarasuradu, there are many helpful people here to assist

I see that your minimum pressure is too low right off the bat, please raise it to 8cm (keep EPR on at 3) and leave your max pressure where it is at @ 13cm. See how you feel for two nights, are you using a chin strap in conjunction with your nasal pillows?

[SarcasticDave94]

Welcome to Apnea Board, the club,

Thanks much for posting the sleep study, it will help greatly. With the high Central Apnea, you're thinking correctly if I were asked. Regular CPAP and BPAP won't do well by you.

One possible with a standard BPAP, in this case ResMed AirCurve 10 VAuto would be to run Trigger High or Very High, if you had that machine.

However, realistically you've got enough CA on OSCAR and that study to lead us to think the real answer is what you think. ASV. Specifically ResMed AirCurve 10 ASV. If you possibly get that, start on default ASV Auto mode. We'll help tune it from there with a few OSCAR charts. There's 4 pressure settings on ASV Auto mode, EPAP Min and Max, and PS Min and Max, IPAP is controlled by the former EPAP and PS.

With anything other than ASV, you have to avoid CA, with ASV you treat CA, avoidance treatment is where you're at now. Big difference between these.

[morarasuradu]

Thanks, Phaleronic, the oscar picture in the post above is from the beginning when I used CPAP fixed pressure 6. Now I use APAP 6-13 and the results are better. Regarding the EPR I don't think it's a good idea as every time I turned it on the CA number went crazy, sometimes even double... with the EPR on off I noticed it's more ok. I don't use a chin strap, only nasal pillows.

Thanks, SarcasticDave94, below I attach current results from the last days with APAP 6-13, where things are still better...but the problem of the centrals reporting on the other events remains the same, even though AHI has dropped.

                 

[SarcasticDave94]

I'm still acting in the belief right now that your reported CA are the real variant. You'll see the Obstructive Apnea, Hypopnea are fairly consistent lower, but CA are typically consistently inconsistent. CA will be randomly up, down, gone then return the next night. This is how CA act, unpredictable unless on ASV.

[morarasuradu]

Exactly, very well said, my CAs are consistently inconsistent, with better, worse or disastrous nights.. I've noticed that towards the end of the night, in the last 1-2 hours before waking up I have the most CAs... Obstructive Apnea & Hypopnea are under control indeed, especially since I don't snore at all, being epic in this regard before PAP therapy.

[morarasuradu]

These are the last 3 nights... as I said, the second part of the night is incomparably worse, with much more events, especially central clusters.

                 

[Jay51]

You are still having a lot of CA's.  One thing I see in your charts is large leaks happening wtih the CA's.  You can try to decrease these leaks to see if it helps.  If not, like Dave said, you may need to get a different machine to help treat the CA's.  CA's can occur with people new to therapy, but they usually go away in a few weeks or month or so.  

Mask Primer

[morarasuradu]

Thank you Jay51 for your reply.
These large leaks I have had since I switched from FFM (resmed F20) to pillow (resmed P10)... unfortunately even when I was using FFM and had no leaks the number and proportion of CAs relative to other events was the same. Given that the sleep study revealed a large number of CAs and I have been on CPAP/APAP therapy for about 2 months... most likely my CAs are not emergent and I probably really need an ASV.
My concern and fear is that I might have something medically serious that could cause these CAs.

[SarcasticDave94]

If you've gone through routine medical testing and nothing significant is wrong, you may still have CA. Typically CA are going to be found as idiopathic, meaning unknown medical causation.

However, despite this being true, if you feel you're in need to get checked, feel free to do so. I would suggest not going too far into the medical testing weeds though, for the defense of personal sanity. And financial stability.