[Treatment] Newly diagnosed - mostly centrals & hypopneas - advice please :)

[sleepymum81]

Hi
I am new here, but have learnt a lot of helpful advice just from reading over the last week.

A bit of a background on me. 41 year old female, diagnosed with mild-moderate obstructive sleep apnea and started on apap with a Resmed Airsense 10.

I was referred for sleep study due to chronic fatigue, and unexplained tachycardia. I notice regular episodes of waking during the night, shaking, confused, disorientated with extreme racing heart. Often not knowing where I am, also often choking/coughing. Wake with chronic headaches. Also feel myself stopping breathing whilst drifting to sleep. Sleep tech has advised these were periods of hypoxia. Which greatly concerns me, as it has been going on for atleast 4 years.

Although my AHI was only 11.3 (indicating mild apnea), my oxygen nadir was 84% with 1% of the night spent below 90% saturation. Oxygen Desaturation Index: 13 /hr

I am confused about my diagnosis of obstructive sleep apnea and am wondering if it should be central sleep apnea. How can I tell if the hypopnoea's were central or obstructive?
My apnea stats were:
Obstructive: 3
Central: 8
Mixed: 2
Hypopnoea: 70

All apneas were almost exclusively during REM sleep.

Since starting on apap, I have been recording mostly centrals. The first night was terrible, my central's were almost constant whilst in clusters of periodic breathing. I think the max pressure of 20 that had been set as default was way to high. I lowered to 10, and switched from "For Her" mode to normal auto, turned off ramp, it's been a lot better. Last night I decreased EPR to 1, and got the lowest AHI so far of below 3.72. I have a pressure set minimum of 6 - max 10. 

I am noticing that most of my hypopnoea's are happening when I am below 7 pressure, and most centrals are happening when there is any air leak at all (even small). Can anyone help me improve on these settings? Last nights report attached.

Also I am finding I am swallowing a lot of air, with bad pain and burping as a result. Not sure what to do about that! I am using a faull face mask, as I seem to be a mouth breather.

[staceyburke]

I would not worry about the centrals because most people get them when they start therapy.  It happen because the cpap is doing what it should do...  CA happens when the body gets rid of more CO2 and  as your body gets use to the cpap therapy they will lessen a lot.

Your pressures are still high and that is because the ResMed machine you have raises pressure when it gets flow limits.  Flow limits are obstructive apnea just like Oa and H events are.  Fl are smaller and do not last as long but can cause you to wake up or not able to get into deep sleep or raise the pressure and give you air in your stomick.

I would suggest to try the following

Min 8
EPR 3

And see how you sleep, again not worrying about centrals - you will have them for a while.

[jwest]

hey sleepymum81,

when you ask how you can tell, it depends where we're looking, but typically we can tell. If it was your sleep study, and some tech scored your night of data, then it's unlikely they messed up that bad, and that the OA, H, CA, etc numbers you listed truly are correct. If you're thinking you might have primarily CA and not OA because of your OSCAR data you shared, as stacey mentions above, you could just be dealing with treatment-emergent CAs, which is common for patients starting out on PAP therapy.


I agree with raising the min to 8.

Bring us some more charts when you can and we'll go from there. Feel free to ask any other questions you might have.

[sleepymum81]

Thank you for your replies and advice staceyburke and jwest. I did as you suggested and raised min pressure to 8, and increased EPR to 3 last night, with what appears to be good results. I am still exhausted, but realize it can take time to get the benefits. I notice the flow limitations are a fair bit lower with these settings. 

It does take me a while to fall asleep, because as soon as I start to drift off it feels like I forget to breath, often I get that rush/tingly sensation as result, and jolt to fully awake again. This was for a long time before I started apap too.

jwest the confusion I had regarding my results was due to the Hypopnoea's being the main problem recorded, and I was under the impression that they can be either central or obstructive events? I am probably mistaken here, as I am still learning. My sleep study was assessed by a sleep and respiratory doctor and sent back to the clinic. I get the impression I am just misunderstanding what a Hypopnea is, and I do have Obstructive apnea. 

I have attached screen shots of last nights promising results. Also a zoom in on a few central apneas that were between 14 and 22 seconds long, as mostly I am curious what the common spikes in flow before these events mean, if anyone can tell me what might be happening here? 

I am still getting some leaks into my eyes, I can't seem to get a good seal with the mask across the bridge of my nose.

[staceyburke]

Looks good - the ca will decrease as your body gets use to the Cpap.

[jwest]

Ahh I see, that is a question for your sleep study results or the method of how they scored it, but if I had to guess, the centrals include central hypopneas and central apneas or just central apneas, and then the hypopnea score is for obstructive hypopneas only. That's typically the case. You could share your study here, or reach out and ask your doctor/sleep tech.

What I can see in your zoomed-in pictures is quite common. You're experiencing gradual resistance before the spike, which will slowly lower your O2 sats, so you become aroused and take a big breathe, which expels all of your CO2 and kills your respiratory drive (it's CO2 build-up that gives us our urge to breathe), so you stop breathing for a few moments until CO2 builds back up and you then resume breathing. You could also just be switching positions/waking up a bit/sporadically breathing in the process. There are very few throughout the night, so I wouldn't worry. Aiming for 0 isn't necessarily the goal. Overall, your data looks very good, for what it's worth.

Leaks are tough. Your levels are low, but I understand if even trace amounts are bothering you, as they do me. Try playing around with the tightness, your sleep position, using something like a sock or mask liners to change the way it contours your face and head, etc. Sometimes you just have to get a different mask. Personally, very few work for me.