Help with TECSA

[sleepyguy17]

Hi,


I was diagnosed with moderate OSA (AHI 22, all obstructive, no central) a few months ago. I've been on APAP therapy for about three months so far. I'm feeling better overall but still not great.

I think I've developed mild Treatment Emergent Central Sleep Apnea (TECSA). I began having central events when I started therapy (up to 15/hour) but they have decreased and stabilized over the last month to 1.5-4 central apneas/hour. I finally got an SD card reader to upload my data to OSCAR. I've attached data from two nights ago. I don't know much about interpreting this data, but I do know that I don't have any substantial leaks and my obstructive events are really under control (0.0 or 0.1/hour every night).

I have two main questions:

1. Does anyone have advice on setting adjustments?
   
2. Is my residual fatigue explainable by my 1.5-4 central events per hour? I know that <5 events/hour is considered treated. If pressure adjustments fail to eliminate my central events, would I benefit from trialing BiPAP or ASV?
   

Thank you very much for the help!

[SarcasticDave94]

1. The Central Apnea might account for some of your fatigue. What counts more would be how long did you have Apnea before getting CPAP treatment.

2. Your Central Apnea may be treatment emergent due to just being on CPAP. All would have a few Central Apnea if you monitored them overnight.

Bilevel? Maybe it'll be better, but you're not using the AutoSet to its fullest now. EPR 2 with Min pressure 6 or EPR 3 with Min 7, either at full time, might help you feel more comfortable.

ASV? I don't see enough here for it. Show us the redacted of your personal info version of the detailed sleep study, the sections of the recommendation and the table with events count and type.

If you didn't request this detailed report, do that ASAP.

[Jay51]

That is strange in that you had no CA's on your sleep study, but are having them now 3 months later (even with EPR turned off).  You state that your leaks are under control.  

Do you remember what pressure(s) you used on your sleep study?  Is there any way to get a copy of your sleep study, redact all personal information, and upload it here to compare with your current settings?  Also did you use a different mask during your sleep study?

[sleepyguy17]

SarcasticDave94, why do you recommend turning EPR to 2 or 3? It is my understanding that EPR worsens central events, which is why I've turned EPR off. 

I've attached my sleep study report. Here's my physician's interpretation of my sleep study that I found in my chart:

Technical Summary: This was an unattended home sleep study (HSAT) done through [redacted] using the WatchPAT device utilizing Peripheral Arterial Tonometry (PAT). WatchPAT Recording Channels
included: peripheral arterial tonometry (PAT), heart rate, oximetry, actigraphy, body position, snoring, chest motion.

Results: Test was started at 9:40:36 PM and ended at 6:01:32 AM. TRT was 8 hrs, 20 min. TST was 7 hrs, 31 min.
Sleep Efficiency was normal at 90.20%. Sleep latency was 16 min and REM latency was 195 min, with 5 awakenings.
Sleep stage Distribution (as % Total Sleep Time): showed NREM (Light 76.0%; Deep 16.9%), REM sleep (7.1%).

Respiratory: There were a total of 170 apnea/hypopnea events. Of these, 4 were central apnea/hypopneas. Using the
current AHI guidelines, overall Surrogate Apnea-Hypopnea Index (pAHI 3% was moderately elevated at 23.2/hr. CSA
index (pAHIc 3% was 0.9/hr. REM AHI was 25.0/hr and NREM AHI was 23.1/hr. AHI by body position was as
follows: Supine: 24.8/hr, Prone: 9.8/hr, Left side: N/A/hr, and Right side: 17.1/hr. Time spent by body position was as
follows: Supine: 87.5 min, 19.4%, Prone: 91.0 min, 20.2%, Left side: 0.0 min, 0.0% and Right side: 178.0 min, 39.4%.Indices are calculated using technically valid sleep time of 7 hrs, 18 min. Central-Indices are calculated using technically valid sleep time
of 4 hrs, 41 min.

Oxygenation:
a. Time with SpO2 < 89% was 0.0 minutes.
b. Oxygen Desaturation Index (ODI 3% was 6.2/hr.
c. The minimum Oxygen Saturation (nadir) was 89% and the mean was 95%.

Snoring was recognized for 6.2 minutes (1.4% of total valid sleep time).

Cardiac: The average pulse rate was 67 bpm.

IMPRESSION:

1. G47.33 - Moderate obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 23.2/hr.

RECOMMENDATIONS:

1. Given the clear-cut presence of moderate OSA, based on current insurance guidelines, patient could attempt a trial of autoPAP set between 6-20 cm with EPR of 3/tolerated settings, with mask fit of choice and be brought back to the clinic for follow up in 4-8 weeks post set up of PAP therapy to document efficacy of treatment, evaluation of initial compliance and AHI data.

2. On follow up, if AHI remains inadequately controlled, or if there is lack of improvement of symptoms or development of a new issue such as central sleep apnea (CSA), then patient may require a supervised titration with CPAP or Bilevel PAP or alternate modes.

3. Alternative options in management of OSA include a trial of Bilevel PAP if there is intolerance to and/or ineffectiveness of CPAP, or the use of an adjustable dental appliance, provided there are no contraindications. Typically, when oral appliances are used in management of OSA, a follow up sleep study on therapy is recommended in about 4-6 months of use following adequate satisfactory manipulation by the dentist, to document efficacy. The other alternative is INAP therapy. If there is intolerance to PAP therapy, the patient may benefit with inspire therapy evaluation provided there are no contraindications.


Thanks for the help!

[Deborah K.]

You only had 4 CAs in your sleep study, so yours are treatment-emergent. Don't worry about them.

Your median pressure is 7, so you should use 7 or 8 as your starting pressure and set EPR full-time to 3.  Doing so will probably raise your CAs, but I think it's more important to help you breathe more comfortably and, more importantly, to lower your flow limits.

[SarcasticDave94]

Yep, 4 CA on the test strongly indicates these on OSCAR are treatment emergent. You're correct EPR, and also other pressure variances, might enhance CA. Try EPR 1 then. You also might benefit from a tighter pressure range.

Edit... You've been on CPAP about 3 months, which is likely when treatment emergent Central Apnea should diminish.

Also, it's really up to you, but the ResMed VAuto might be better to much better for you. You can try complaining the therapy isn't good enough, uncomfortable, etc. to try to switch. The VAuto has a CA trick up its sleeve, it's called Trigger. So this may be really helpful.