[CPAP] CPAP + Central Apnea - Soundness Check

[JamesTun]

Hi!

I am a relatively new CPAP user, having been diagnosed with Sleep Apnea in the last couple of months. I have been experiencing significant daytime fatigue for quite some time and have not noticed an improvement in symptoms since starting the CPAP. My current NP insists that I am incorrect and that I am actually less fatigued during the day and that it will get even better if I resolve the leaks reported by the CPAP. For this reason, they will not offer any other activities (testing or treatment) until they are satisfied that my "REM sleep is not being interrupted by leaks that cause arrousing". They also do not want to follow-up sooner than 3 months from now.

I am not the biggest fan of my NPs communication style and it's causing me to not trust their expertise. This lack of trust is impacting my excitement/desire to closely adhere to their recommendations. I was hoping someone may be able to quickly look at my sleep study / Oscar data and reassure me that my NPs current approach is consistent with the data reported. 

I am currently mouth taping with a nose pillows mask (rio II).

Of specific interest to me was the central apneas and frequent leakage (though with a lack of large leaks).

Sleep Study:
   
   

Oscar data
   

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Additional Oscar Data
   
   
   

[SarcasticDave94]

Welcome to Apnea Board,

Wow, that nurse practitioner can actually determine whether or not your subjective attributes are better or not. Note the slight sarcasm. This NP said without saying they won't help you, and that your subjective comments and concerns fall on deaf ears. Congratulations.

If this AutoSet was bought with insurance, you need to have a face to face visit with prescribing physician within 90 days.

Also your sleep study has 24 total Central Apnea, zero anything else that I'm seeing. So, "when will they treat these?", is my question, and should be your question to these slackers.

Further, what are your AutoSet settings besides 5-15 pressure? I'm not too worried about humidity and heated hose, but Ramp and EPR specifically.

Your leak rate is a bit too constant to ignore. You may want to shop masks, either another sized cushion for the current, different adjusting, different make/model mask or type.

Your therapy is in the treated range, as in under 5 AHI. Is this OSCAR a representative of your normal showings? If you're not gaining sleep comfort, you will probably need a few things:

1. consider firing and replacing this medical team of doctor and NP, you'll want a doctor that listens, and knows how to treat Central Apnea

2. you might need to trial a ResMed VAuto enroute to a ResMed AirCurve 10 or 11 ASV which treats CA, others do not treat

[JamesTun]

Edit: I accidentally mixed screenshots in this reply but have now resolved it.

Thank you for your reply. I appreciate you taking the time. 

> Wow, that nurse practitioner can actually determine whether or not your subjective attributes are better or not. Note the slight sarcasm. This NP said without saying they won't help you, and that your subjective comments and concerns fall on deaf ears. Congratulations.

I found myself particularly frustrated during my appointment, follow-up call, and follow-up messages but I understand that my treatment can proceed without me liking my provider's communication style. I appreciate your candid response here -- I think it will help prepare me to be more direct during my next follow-up.

> If this AutoSet was bought with insurance, you need to have a face to face visit with prescribing physician within 90 days.

I have already had the 90 day face-to-face visit, this is when I had the conversation where they insisted my remaining fatigue is due to leakage causing REM sleep interruption.

> Further, what are your AutoSet settings besides 5-15 pressure? I'm not too worried about humidity and heated hose, but Ramp and EPR specifically.

Ramp Time is set to Auto and Pressure Relief is "On". I did not know I could adjust EPR settings until just now and I find that the machine is set to:
Response: Standard
Ramp Time: Auto
Start Pressure: 4.0
EPR: On
EPR Type: Full Time
EPR Level: 3

> Is this OSCAR a representative of your normal showings? 

I have only been recording for 7 days, 5 of which were while traveling, only 2 of which I have been at home. Here is the OSCAR data from two days ago (the other day I was at home):
   
   
   

[SarcasticDave94]

OK, you may want to turn off the Ramp, as it may add CA. And EPR may or may not enhance CA. The EPR 3 doesn't do anything until your pressure minimum goes to 7, so at min 5 with the increase to 7.1, you almost don't have EPR functioning.

You might want to trial this min 7, seeing if it feels comfortable.

[JamesTun]

OK, you may want to turn off the Ramp, as it may add CA. And EPR may or may not enhance CA. The EPR 3 doesn't do anything until your pressure minimum goes to 7, so at min 5 with the increase to 7.1, you almost don't have EPR functioning.

You might want to trial this min 7, seeing if it feels comfortable.

If I read this correctly, I will trial disabling ramp and adjusting minimum pressure to 7 (leaving the maximum pressure at 15) while leaving the current EPR settings and see if I notice a decrease in CA (and/or leakage?) reported in my detailed readings.

[SarcasticDave94]

100% correct.

You can do standard default OSCAR chart screenshot. I myself look for the following, which also should be the default F12 screenshot, Events, Flow Rate, Pressure, Leaks, Flow Limit. That should be good to cover most needs.

Settings will likely result in data and/or feel changes, maybe both. You'll need to decide if it's good or not. If it's really bad, you'll want to change it back.

[JamesTun]

I incorporated the settings changes and switched to a larger nose pillow for the RIO II. I also used mouth tape. I could definitely feel the pressure differential on exhale.

   
   

I did not awake at any time feeling like (or hearing) I had a leak but it looks like my leaks are still persistent. It's interesting to me that leakage drops to zero during a CA but perhaps that's the CA causing arrousal (or the leak causing arrousal?) which causes an adjustment which resolves the leak?

I will try a CPAP hose buddy and will inquire with my DME provider for a FFM.

[SarcasticDave94]

How did the feel change, if any? If it's decent, try staying with this a few days.

Certainly try different masks if you get them. Myself, leaks were constant as well during my ASV time from 2017-19, using ResMed F20 as I recall. I could keep it at 10 L/Min and seemed OK. Saying this to indicate you don't need zero leaking, just less with a more controlled aspect.

Try this on OSCAR next time, each graph within the OSCAR (Events, Flow Rate, etc.) have a horizontal dividing line that's editable via click and drag up or down. Using the first screenshot here as the example, drag up to squash Events, then progress to Flow Rate, etc. so first 5 are visible. Events, Flow Rate, Pressure, Leaks, and Flow Limit. It'll allow you to one shot screenshot, saving some attachment space for you.

[JamesTun]

I did notice I could squish the charts but I wasn't sure if having all of the squished as desirable -- good to know!

No auto-ramp makes it a little louder to start but I take trazodone to fall asleep so I was out pretty quickly. The breathing felt good too. It seemed like the machine maybe predicts when I'm going to exhale to lower the pressure and so if I inhale/exhale a little longer I notice the pressure change which was kind of fun.

I'll keep the adjusted settings for now as they don't seem to bother me at all. My DME supplier is recommending the Resmed airtouch f20 so I'll pick one of those up this week and transition to that and will report back if the leaks get under control with the Bane-style mask.

[SarcasticDave94]

I found the F20 to be frustrating. I'd get it OK then it'll leak a night later. Rinse repeat a lot. Finicky straps IMO.

I myself trials had sleep study with a Fisher and Paykel Simplus, and I was hooked on those F&P masks. I went with Vitera when released, then very recently on my VAuto fail, I used the Evora full, a hybrid full lower and nasal cradle upper. Very nice IMO.