treatment-emergent central apnea?

[CyberSparrow]

Hi all,

First off, thanks to RippingLegos on Reddit r/CPAP for pointing me to this board yesterday.

I was diagnosed with mild sleep apnea after an in-person sleep study (AHI 11.4, Non-Supine AHI 3.1, Supine AHI 27.4).  Only obstructive apnea; no central apnea.  See the sleep study details down below.

I got my CPAP 5 days ago, and I'm doing my best to make it work for me.  The vendor fitted with a medium nasal pillow, but I switched to a large after the first night because I thought I wasn't getting enough air.  The large seems to work for me pretty well, though I might switch back to medium at some point when I'm more accustomed to everything.

The MD offered a titration study, but I didn't want to wait 6 weeks to start treatment, so I asked for the prescription right away using an APAP.  The prescription and vendor set me up with 5-20, EPR 3 and Ramp Auto, starting at 4.

Despite no central apnea on the sleep study, I'm consistently registering a large number of Clear Airway events.  Presumably this is treatment-emergent central apnea?

For what it's worth, I've feeling a bit more fatigued than usual since starting treatment.  Not sure of the cause.

Yesterday, RippingLegos recommended that I make the following changes:
 - pressure min/max of 8.8/13
 - disable ramp
 - EPR 0 or EPR 1
 - trial the settings 30 minutes before bed

Last night, I gave these 3 settings changes a shot.  For better or worse, I went with EPR 0.

In my 30 minute trial, I found this to be significantly more uncomfortable, though I'm not sure which setting change was the culprit (or perhaps it was the combination).  I felt like my breathing was strained, especially on the exhale.  But after 30 minutes, I went to sleep anyway with those settings, and I woke up ~1h40m later with dry mouth and air streaming out of my mouth.  I hadn't experienced air streaming out of my mouth previously.  I drank some water, went back to sleep, and woke up again 11 minutes later with the same thing.

At that point, I briefly off the therapy and set the EPR to 3.  That was far more comfortable.  I kept the pressure at 8.8/13 and kept ramp disabled.  I think I noticed a couple of mouth leaks over the course of the rest of the night (not sure).  But certainly no dry mouth noticed after that point.

Here are my questions:
1. Can you review RippingLegos' three recommendations?
2. Anything else I should be doing to avoid these CA events?  Or just have to wait for my body to adjust?
3. Any changes worth making at this stage for the mouth leaks?

See my OSCAR graphs attached.  The first two files are from before RippingLegos' recommended changes.  The third file is from after his changes.

Thanks so much!



Sleep Study Report:

ATTENDED DIAGNOSTIC POLYSOMNOGRAPHY REPORT

HEIGHT: 71.0 in
WEIGHT: 160.0 lb
BMI: 22.3 kg/m2
DATE OF RECORDING: 9/23/2024



--------------------------------------------------------------------------------

CLINICAL BACKGROUND:

40 year old patient is here for an Attended Diagnostic Polysomnography.

PROCEDURE:  
This attended polysomnogram montage using Polysmith Version 11.0 Software included recorded video, 6 EEG electrodes for frontal, central, and occipital monopolar recordings, 2 EOG electrodes, ECG, and chin EMG electrodes, snoring microphone, thermistor, airflow pressure, thoracic, and abdominal respiratory effort, pulse oximetry, leg movement, body sleeping position, and body movement.  The qualified scoring technician manually scored and analyzed the 30 sec. epochs according to the AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 3 and its updates.

SLEEP SCORING DATA:
Lights Out / On (clock times):  22:37:23 / 05:54:30
Total Recording Time (TRT):  437 minutes
Total Sleep Time (TST):  325 minutes
Sleep Efficiency: 74.5%
Sleep Latency: 05 minutes
Stage REM Latency: 92 minutes
Wake after sleep onset (WASO): 106 minutes

Stage N1 Sleep (min, % of TST): 19 minutes,  5.8%
Stage N2 Sleep (min, % of TST): 189 minutes,  58.2%
Stage N3 Sleep (min, % of TST): 86 minutes,  26.6%
Stage R Sleep (min, % of TST): 30 minutes,  9.4%
Supine Sleep: 111 minutes
Arousal Index: 12.5

RESPIRATORY ANALYSIS: (Index = Avg # of events per hour)
Apnea/Hypopnea Index (AHI): 11.4
     AHI w/ 4% criteria: 1.1
NREM AHI: 11.8
REM AHI: 7.9
Non-Supine AHI: 3.1
Supine AHI: 27.4

Respiratory Disturbance Index (RDI): 13.3
NREM RDI: 13.8
REM RDI: 7.9

Apneas (#, index): 5,  0.9
Obstructive Apneas (#, index): 5,  0.9
Mixed Apneas (#, index): 0,  0.0
Central Apneas (#, index): 0,  0.0
Hypopneas (#, index): 57,  10.5
RERAs (#, index): 10,  1.8

Mean Wake SpO2: 98.0%
Mean Sleep SpO2: 98.0%
Minimum Sleep SpO2: 94.0%
Sleep Time with SpO2 < 88% (min, % of TST): 0.0, 0.0%

Cheyne Stokes breathing: No
Snoring: Moderate

The patient did not meet the criteria for a split-night study and for this reason treatment with CPAP was not initiated during this night.

CARDIAC ANALYSIS:
Mean Awake HR: 66 bpm
Mean Sleep HR: 62 bpm
Highest Sleep HR: 89 bpm

Bradycardia: No
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (#, index): 0,  0.0
PLMS with arousals (#, index): 0,  0.0

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure activity was noted.



CLINICAL INTERPRETATION:
1. Polysomnographic findings are consistent with mild obstructive sleep apnea, most prevalent during sleep in supine position.  The overall RDI was 13.3 events per hour of sleep and the lowest oxygen saturation was 94 %.
2. Moderate snoring was present per technician's notes.
3. No periodic limb movements of sleep were present.
4. The most efficacious treatment modality for sleep apnea is continuous positive airway pressure (CPAP) and surgical treatment modalities are alternative options.  An oral appliance may be effective treatment in mild cases.  Non-specific treatment options include weight loss of at least 10% of body weight (if overweight), avoidance of supine posture (i.e. side-sleeping or elevation of the head 30 degrees is preferred), and avoidance of sleep deprivation, alcohol and nicotine.

Sleep study raw data was manually reviewed and the report reviewed, edited, and electronically signed by me.  Please feel free to contact me if you have any questions.

[Deborah K.]

I suggest you raise your minimum pressure to 7 for now and leave your maximum pressure where it is, as you are getting nowhere near it anyway.

If you can handle it, please turn ramp off.  You get no treatment during ramp, and likely feel air-starved.

Since you had no CAs in your sleep study you can ignore them.  They will lessen as time passes.  Some would say lowering your EPR would yield a lower AHI, which is true, but keeping your flow limits lower is more important and more comfortable.  Flow limits are short, unreported apneas, and we want as few as possible.

Best of luck!  

[CyberSparrow]

Looks like I goofed.  All three OSCAR screenshots in my original post were before the changes RippingLegos recommended.  Clearly I'm tired.  Sorry!  I'm attaching the OSCAR screenshot that shows my results after RippingLegos' changes.  I assume that this is just more of the same, but let me know if your expert eyes see something different.


And Debroah K -- just to confirm, you're recommending that I leave EPR at 3, right?

Thanks!