Grant's CA Diagnosis Thread

[GrantT]

Edit 2: Just noticed this thread... http://www.apneaboard.com/forums/Thread-...-CSA-worse ...and found a lot of information that could be relevant. Will try to follow some of the advice there.

Hello all.  Backstory....Been browsing here as I have been having some AHI and sleep quality issues as of late.  I cannot go back to my DME as I did not get this machine from them.  I do have another sleep study scheduled, but that is a little time away due to insurance etc.  Unfortunately, because I refuse to pay the horribly inflated cost of machines and supplies from the DME, they will still not provide support, only do the study and report back to my GP who will also provide me the sleep study to the insurance company.  Assuming AHI remains over 15 in the study, they will cover a new machine up to $1200 (Canadian).

Anyways....I seem to be suffering from one particular issue I can see - CA events...but unsure how to deal with this.  My "old" machine - a Resmed S9 Auto I use as a backup and travelling, does not seem to cause me to have this same issue - but I am usually in hotels etc at the time too.  I purchased the VAuto as I got it for a crazy good price some time ago and thought it would provide more options and be an even better sleep quality solution than my old S9.  But, something is amiss.  Any ideas?

So....Resmed AirCurve 10 VAuto

Device Settings: Mode - VPAPauto   Min EPAP - 6.00 cmH2O    Max IPAP - 20.00 cmH2O   PS - 3.00 cmH2O    Trigger - High   Ti Max - 2.6

Climate Control - Auto   Essentials - Plus   Humidifier Status - On   Humidity Level - 4    Mask - Pillows   Ramp - Off   Smart Start - On   Temperature - 27 ºC   Temperature Enable - Auto

Edit 1 ...sorry, on ChromeOS the screenshot is not working (just a black box)....just took this using a screen grab...hope it is enough (until I get the proper screenshot figured out).

   

[Sleeprider]

GrantT, change you trigger sensitivity to Very High. I really don't know if you're going to control CA with the Vauto. If the very-high trigger sensitivity does not work to reduce CA, then you should reduce PS until the CA events are lower.

ASV may be a better solution, and if you are able to self-pay, Supplier #2 can provide the Resmed Aircurve 10 ASV for $1799 last I looked. I checked out DotMed and there is a RESMED S9 VPAP Adapt BIPAP #36007 LOW USE Bi-level PAP For Sale at $480. It's the older S9 style but the ASV auto algorithm is unchanged. This is a lot better idea than trying to make the Vauto work on CA. I'm pretty sure central apnea is not permitted in Canada and getting appropriate therapy is next to impossible. What has me puzzled is that you don't have this problem with the S9 Autoset. What are your settings on that machine? Do you have a chart from the S9?

[GrantT]

What is very strange is that I just noticed a very clear/distinct pattern in the Oscar data - I wonder if it is possible that a change in bed, change in air humidity, change in pillow could impact this? Perhaps computer usage? In Jamaica, we never touched a computer screen in the evenings (for example). I hear about sleep hygiene all the time, but never really applied it directly perhaps.

For example...we just came back from Jamaica and I slept amazingly well - for 20 nights - all very low AHI on the S9.  The first screen shot (below) is from while there....the bed was flat and HARD AS A ROCK, and the pillows thin and very malleable.  We were amazed we both slept as well as we did compared to at home on our luxurious pillow top memory foam bed.

Then I came home back to the AirCurve....sleep immediately got worse.  I forgot to mention as well, but for a couple days after we got back, I changed BACK to the S9 after as I was wondering about the sudden (poorer) change in sleep and it did NOT improve on the S9. I just looked at the all the data again and the CA's are their on the S9 too!  I only just noticed this because I only got my SD Card reader delivered today for my Chromebook and Oscar running...this is the first time I have visually seen this (other than the AHI number on the machine itself). Weird!! 

I just went back over each day as just before we left, then the 20 days away, then day returning home and since...and like a switch turning off/on, the CA's were there before we left (on BOTH the S9 and AirCurve), disappeared COMPLETELY while we were gone, and then immediately returned upon coming home again.

Second screenshot is the same S9, but at home (soft pillow top bed etc). Can body position, spinal positioning, neck position etc cause this? While away we were in separate double beds instead of our home king size bed..perhaps sleeping with a partner?

Can general sleep hygiene cause this...late night TV, more alcohol on vacation...and well...Jamaica...a little bit of marijuana involved too.

I would normally just call this a fluke or glitch in data analysis...except I just went through the data for 20 days (away) on the S9, there are almost no CA's, and here they are (at home) and started immediately...like WTF!

Note...We have a spare bedroom with a harder mattress (has a foam topper), but I just removed the foam topper and will be sleeping there a night or two just to see what happens...very curious. I'll try a need on the S9 to see what happens.

Sorry for the rambling post...this is just strange.

S9 away
   

S9 home
   

[Sleeprider]

What is the altitude where you live in Alberta? It is interesting that your CA is higher in Alberta, but there are significant climate and humidity differences and perhaps altitude Your respiratory statistics have a significant difference with higher tidal volume, respiration rate and minute vent on the S9, yet lower CA. The difference between Jamaica and Alberta make me think that there may be a solution for this that would give you enhanced expiratory rebreathing space (EERS) to increase respired CO2 just enough to stimulate better breathing. I don't know what factors account for the difference, but perhaps your CA problem is not a recalcitrant and we thought. So much for the S9.

Using the Aircurve 10, let's compare the difference in settings. I am going to use bilevel settings for both to hopefully make this clear
Autoset 9: EPAP min 4.0, IPAP max 10.0, PS2
Aircurve 10: EPAP min 6.0, IPAP max 20.0, PS 3.

Needless to say, you are going to have to lower EPAP min, cut PS and limit maximum pressure if you want to get back to something resembling the S9, and we might want to consider EERS for Alberta to deal with the residual CA. Your tidal volume and respiratory statistics are again significantly lower with the Vauto suggesting there is a strong correlation between increased ventilation and your respiratory drive. The CA is real, but might have an easy solution.

[GrantT]

Altitude here (Edmonton) is 645 m (2216 ft).  And air here is dry as dust.  Our house humidity is set around 40-50% (Jamaica was 75-80%), but it is still hard to stay hydrated in winter months.

So, here is the result of sleeping on the harder bed last night (with the S9).  I had a lot of problems getting comfortable but that was 100% a pillow issue, not the bed.   I actually feel a lot more rested this morning overall though (how I feel and my AHI are pretty strongly linked I have found)....I'll find a better pillow and try again tonight too.  Of course, could all be coincidence.

I am not sure I understand your comment regarding EERS (I just looked that up) in my case...are you saying you think we may be able to compensate using some machine settings initially?

What do you recommend for the AirCurve settings?

Note...that big cluster of CA's around 4:00 is when I woke up, had to use the washroom, could not get my pillow comfortable again, and then eventually fell back to sleep.

   

[Sleeprider]

We have a wiki on EERS http://www.apneaboard.com/wiki/index.php...ace_(EERS) Several members have used it successfully to treat central apnea with similar frequency and causes to your own. EERS can conserve humidity and CO2, and it's not a bad DIY project for handy individuals. It is clearly not in common use but it could completely clear your problem. You will need some corr-flex tubing or just plug your mask vent on the P10 mask and install a vent at the end of the mask tubing at the CPAP tube. We can talk about it in more detail if you choose to go that way. I think altitude plays a partial role, humidity maybe a bit, and those can be mitigated with EERS, but your Aircurve 10 settings are pretty far off from what you had with the S9.

[GrantT]

Thanks...I'll do some EERS reading. I am a "handy" kinda of guy and have lots of extra tubing and some other masks etc kicking around here.

So, just to try something quickly / directly on the AirCurve machine, do you have some setting recommendations to try? I have no problem experimenting on myself. To be honest, I have changed my settings on both machines so many times over the last 10 years, I really have no base to work with any more.

Disregarding any/all existing settings that may work in some setting, is there a "generic" AirCurve setting that would minimize CA impact - regardless of OSA etc? My original obstructive apnea is generally mild - and caused as much from sinus issues as well.

[Sleeprider]

In generic terms, low PS, and high trigger reduce CA. This is inline with the settings I reviewed earlier which would duplicate your S9...EPAP min 4.0, IPAP max 10.0, PS2.

[GrantT]

Appreciate your time. I'll try get a few nights in and report back on things...

Grant

[GrantT]

Saw another recent post and concerned me because I seem to have a similar pattern....time to find a new sleep clinic to analyze?  My existing one is useless.

I do have an irregular heart beat and take a beta blocker for it.

This pattern happens pretty well every night...for as far back as the Oscar records my data...about a year anyways.