First night worrying, data even more so

[orand]

I was recently diagnosed with mild obstructive sleep apnea, AHI 13.1, via a home sleep study.

Central Apneas: 2.4/hr (mean duration 20.2 sec)
Obstructive Apneas: 7.6/hr (mean duration 20.7 sec)
Mixed Apneas: 0.2/hr (mean duration 33.8 sec)
Hypopneas: 2.9/hr (mean duration 47.3 sec)
Apneas + Hypopneas: 13.1/hr
         

Reasonable initial hypothesis: this is primarily OSA.

I received my Resmed Airsense 10 Autoset yesterday and used it for the first time last night.  I also used a Wellue SleepU (Viatom) pulse-oximeter, which I've been using every night for a few weeks now.

Initial machine settings:

Autoset at 5-15
EPR=2
5-minute ramp starting at 4
Humidification set to auto, with heated hose

I bought both the P30i  and N30i masks.  The N30i seemed slightly more comfortable, so I started the night with the N30i.

I started the machine at 9:55pm.  My first impression after a few minutes was "wow, I'm getting a lot of oxygen!"  I almost felt light-headed.  My SpO2 was solid at 99%.

All was good for the first 40 minutes, and I started feeling like I was getting used to the flow, and how EPR works.  Then I had my first event, a CA, at 10:34pm.  I felt a fairly rapid pressure oscillation, like vibrato.  I didn't know what has happening at first, but I soon learned that this oscillation was a sign that I had stopped breathing. When I breathed in again, the oscillation would stop after about 1 second.

According to the data, I had about 40 or 50 of these episodes in the first hour after they started.  Many of them caused SpO2 drops below 89%, which caused my pulse-oximeter alarm to buzz, sometimes for extended periods (15 seconds straight), which has never happened to me before in all my weeks of using the device.  Taking deep breaths made my SpO2 go up fairly quickly.  Pretty soon I subconsciously started taking deep breaths as soon as the CA pressure oscillations began, to try to ward off the inevitable SpO2 alarms.

Eventually I remembered that folks on this forum had mentioned that EPR can contribute to CA events, so I turned off EPR around 11:45pm, and that made things better for a bit, but soon the CAs returned.  I also turned off the ramp.

I tried sleeping in all sorts of positions, but eventually the CAs would come whether I was sleeping on my back, 90 degrees on either side,  45 degrees on either side, or on my stomach.  (The N30i / P30i masks are pretty amazing for allowing easy unobstructed 360-degree rotation.  Also, virtually no leaks even on my stomach. I'm impressed.)

At 1:42am I got up to go to the bathroom.  I noticed that my nose was starting to become stuffy, even with the mask off.  I used some saline spray, which didn't make much of a difference.

At 2:40am I switched from the N30i cushion to the P30i pillows, and changed the machine settings to reflect that.  I was able to breathe much more easily, and some of the stuffiness started to go away.

From 3:15 to 4:30 I actually kind of dozed I think, including 15 minutes of "deep sleep" according to my AutoSleep app.  I remember feeling more restful during this phase, but unfortunately the data shows the CAs kept going strong throughout.

Around 4:56am the pressure jumped sharply upward from 6 and climbed to 11, staying there until I turned the machine off at 5:13am.  Interestingly, my SpO2 stayed higher during this phase of increased pressure, and I had a new mix of events, including hypopneas, RERAs, and a few CAs, but none of them set off SpO2 alarms, unlike earlier in the night.  I had no awareness of this increase in pressure.  I must have been really out of it.

After turning off the machine, I slept for another 3.5 hours, and my SpO2 levels smoothed out considerably, without any of the big drops that occurred on CPAP.

According to Oscar, there were zero obstructive apnea events last night, which were supposedly at 7.6 during the sleep study.  So... yay?  OAs are now managed, but at the price of insane CAs??  I felt some of the CAs, but the data shows far more than I noticed/realized, probably by a factor of ten.

The Oscar data shows increasing AHI rates with a peak of around 58 at 4:57am, coming almost entirely from CA events.  An AHI of 58 seems ridiculously high, especially compared to 13.1 from my sleep study.

I'm actually kind of afraid to go to sleep tonight, for fear of triggering even worse CAs, or stopping breathing entirely.  Any recommendations on things I can try to reduce the CAs?  Should I immediately start pursuing an ASV machine?

Here's my main Oscar data.
   

[orand]

Here's a zoomed-in section where my SPO2 dropped to 84 several times, and toward the end I basically stopped breathing for 1 minute 15 seconds.
   

[SarcasticDave94]

I am guessing, but with personal experience to help shape what I'm going to say. Despite the terrible CA flags thrown at you, the insurance will likely not be quick to hand out an ASV. Insurance and Doc Dolittle will say these are treatment emergent, and they might be. Idiopathic sounds nice if you want to name them, for now anyway. They will point to the sleep study CA and then see 2.4 vs. the 7.6 OA. OSCAR they may not even permit as evidence. Just be aware, even if CA showed greater or equal to the OA on the sleep study, you will have to fight like mad to get an ASV.

On the N30i and P30i, just so you know, both are ran with setting Pillows on ResMed PAPs. And both N and P variants, they are only different in the cushions. So if you stock up on P, just grab an N cushion and voila a N30i. Or vice versa. I have these BTW so they are swappable as I say.

Therapy looked nasty. You did the right thing on killing off the EPR. Both EPR and Ramp will make you get lots of purple CA flags. We need to work on minimal pressure swing regimen which includes nix on both EPR and Ramp. I think given that your EPAP 95% was 6.9 and the Max was at 11, I would consider shortening the pressure range to maybe something like 6-12 and see how much purple flags come out. The rest is looking pretty good, leaks and FL were not bad, but it's all undone by that nasty mess of CA.

See what pressure gurus say about it, but I think it's safe to keep with the nix of the EPR and Ramp. Good luck, because your PAP road is gonna be interesting. Don't despair though, others like myself got through the CA minefield. It can be done.

[orand]

Thank you so much, that gives me a thread of hope.

I agree, a higher minimum pressure does seem worth trying.  It's interesting that toward the end when the pressure went above 8, the mix of the events noticeably changed.  That does correlate with increased flow limit on the graphs.  I'm not sure what that means.

Yeah, I just swapped out the P30i/N30i pillows last night, not the entire mask.  Pretty convenient.  I didn't know they both should use the Pillows setting, so thanks.

Regarding getting an ASV, I'm the guy with the weird insurance.  It's actually a cost sharing plan, technically not true insurance.  So I just used up my one shot at getting a machine on "insurance".  Getting an ASV would be entirely out-of-pocket, most likely via Supplier #2.  Not sure if I'd need a new prescription for that, or if I could just go rogue.  Ideally it would be with my sleep doc's blessing and support, but this seems too serious to allow the system to stand in the way of making rapid progress.

Pressure gurus, any additional recommendations?  Any Oscar details that might be useful?

[Sleeprider]

Your events are all central, and CPAP cannot treat it. You need ASV. Just call the doctor and let him know this is not working. Your relatively low rate of central apnea in your diagnostic test of 2.4 per hour has increased 10 times with CPAP therapy. Stop using CPAP and call the doctor. Your results are far worse with treatment that without. You need ASV.

I'm dead serious here. Do not use your CPAP. Your event rate is twice the rate of untreated testing. You have the wrong therapy and need a titration test that includes ASV.

[orand]

Thank you, Sleeprider. Stopping use was the first thing that came to mind, but then I thought that half of CPAP users quit, so I should persevere. Thank you for giving me the confidence to do so because it’s actually the right thing to do in my case.

[Sleeprider]

Your doctor should understand what we saw here in your first night of therapy. The temptation is to see if this will pass, but I have rarely seen a more clear case of needing a clinical titration. Just make sure that the titration progresses through bilevel to ASV (adaptive servo ventilation). If you have questions about why that is needed or how it works, please ask. This is going to take a while to get scheduled.

[orand]

Thanks, I would very much like to understand the importance of the titration progressing through bilevel to ASV.  Pretty much every time I've heard people mention bilevel on this forum, they all said it was terrible and didn't work for them, but ASV did.  I think I read somewhere a theory that the need to do bilevel first is due to some ancient CMS rule that was put into place before ASV existed.

So I would love to have a more informed, fact-based perspective on how bilevel is a useful part of the progression.

[SarcasticDave94]

I agree, I was being a bit too cautious before, but hadn't thought to mention that CA that bad then it's a good idea to pull the plug on CPAP. Yes certainly, as Sleeprider has mentioned goes. Do your homework and write all negative symptoms about this CA catastrophe of "therapy". OSCAR data may be useful as well. MAKE the doctor listen that it's a train wreck of a mess. FWIW I was erring on the side that it might have been a one-off. But no I should have known as I've been on the creating end of charts like this. Sorry, but yes definitely pull the plug on this now.

When you're up to choosing the ASV part of the process, the ResMed AirCurve 10 is best in the business against CA.

[Sleeprider]

Not to over-simplify the process, but, moving to advanced positive pressure therapy (PAP) is a progression dictated by insurance, not medicine. Unfortunately, it can be costly to titrate a patient for CPAP and require that they fail that, then move to bilevel and fail that then move to the torture device known as bilevel ST for some god forsaken reason, before finally arriving at ASV.  It is important to have confidence that your doctor recognizes your problem and has a plan to expedite the path to the best therapy.  This will be the discussion you must have with him/her, and if your doctor stumbles or is hesitant, you need to find one that is expert at central or complex apnea and will support your expedited path to good therapy.  You have demonstrated CPAP is not only a failure, but it is worse than your baseline diagnostic.  The next step should be a clinical titration study that starts with a bilevel titration which you will again fail and includes ASV titration which will work.  That is sufficient for insurance to cover the ASV and you really don't need to survive a month of failure of each mode of PAP.  Make sure your doctor is onboard, and move forward or follow one that will.  A good starting point is to have your doctor change your diagnosis from "obstructive sleep apnea" to "idiopathic central or complex sleep apnea".  He may also require additional health screenings, in particular an echocardiogram for left ventricular ejection fraction.  It's a waste of time for most people, but a CYA due to an identified risk factor for ASV.

A good start for understanding the progression is to read the Resmed Clinical Titration Protocol https://www.resmed.com/us/dam/documents/...er_eng.pdf  This shows how CPAP, bilevel (VPAP), VPAP ST and ASV are titrated by clinicians.  Note the PURPOSE of each device.  CPAP is for obstructive sleep apnea, and the protocol recommends ASV when central apnea are present. The same for VPAP.  Many medical practices make the error of trying VPAP ST (spontaneous/timed) to treat central apnea, but you will read that ST is intended for pulmonary dysfunciton, neurological disorders, COPD and other pulmonary diseases that you don't have. Instead the doctor must be redirected to ASV which is specifically designed to treat central and complex apnea. If the doctor knows his stuff this won't be an issue, but I think at least 50% of members here have had to deal with doctors that quack like a duck.  Anyway, this document is a very straight-forward and simple guide to the types of machines, their appropriate use and the basic decision-making process.

Let's start from there and move on with any questions you have.