Looking for help in refining settings

[TBrobbs]

Hello, 

Hello,
I started on CAP in late November, 2023 after a sleep test determined I had severe sleep apnea (33 events p.h). The test results indicated obstructive apnea but from day 1 of CAP therapy, obstructives have never been an issue. The sleep test was recommended by my cardiologist after I was diagnosed with an arrhythmia which he wasn't too concerned about.

Since starting on CAP, the only times my events are below 5 are when I've only slept a couple of hours. If I sleep well, the events usually range around 7 to 10, though they've been slightly lower in the past week. The typical pattern is hyponeas and clear airways and often, but not always, Cheynes Stokes Respiration. I felt my sleep therapist was guessing at pressures to try, and after she missed the CSR, I asked for an overnight sleep study, which I'm now waiting on. Since then, I've tweaked my settings a little, dropping the pressure very slightly from 12.4 to 12.2 and adding EPR of 1 (she said I don't need EPR but anything over 12 I was having trouble exhaling). I have to make gradual changes because my body seems to overreact to the slightest change. 

I did invest in an 02 ring but haven't been able to upload the data to Oscar yet. Typically, my 02 levels drop anywhere between 6 and 22 times a night with a range from 99 to around 88 or 89. It has been lower but only a couple of times in the three weeks I've been using it.

I'm wondering if there is any fine tuning I can do while I wait for the overnight study and to meet with a respirologist. 

I'm wondering too if an ASV machine is likely in my future. 

What I'm hoping for is to feel well rested and clear-headed regularly. And sleeping 7 hours a night more often would be great too

I've attached a recent night of data which I hope show the right info.

Thanks in advance for any advice you can offer.





   

[TBrobbs]

One more question: can CSR be triggered by CPAP therapy? It didn’t show up for the first week or so of therapy back in late November when I was on a range from 5 to 14 pressure, but my events were higher, around 12.

[BoxcarPete]

Yes, it's called TECSA: Treatment Emergent Central Sleep Apnea. CSR is the name for any sort of periodic breathing according to the ResMed reporting. It's likely that your body is experiencing CO2 washout from the different sort of ventilation you are getting with the pressure. This typically goes away within a few months if no or very few Central Apnea events were noted on your initial sleep study. Both CA events and periodic breathing (labeled CSR) can be associated with this phenomenon, and considering that you have green segments on both clusters of CA and H flags I would guess that most or all of your recorded events are related to this.

You can try reducing pressure and/or EPR to see if a reduced level of therapy helps you adjust (even if we reintroduce a few OA) and then creep back up in pressure until all the obstructive events are gone, or try to get accustomed to the machine at a fully theraputic level if the CAs aren't bothering you terribly. For people with treatment emergent centrals it is usually a balancing act to lower CA events without reducing the PAP therapy so much that OAs become a problem again.

[TBrobbs]

Thanks for this explanation of TECSA -- I’ll do some more reading up on it.

My original home sleep report showed ODHI as a total of 234 (but there’s also ODIs at 55) Would that be the obstructive apneas? pRDI was 249. Apologies, I’m not familiar with those acronyms.

I’ll try gradually lowering my pressure over the next week or two and see how that goes. My EPR is only at 1, and that was recent. It felt better when I adjusted that so maybe I should leave that as is for now?

Thanks again.

[Deborah K.]

You need more, not less EPR.  I advise that you set it full-time to 3.  Also, you appear to have positional apnea.  This is where you sleep with your chin tipped towards your chest.  It's like a kink in a hose and causes loads of apnea events.  Most on here advise a soft sleep collar like people use for neck pain.  I used about five different ones.  I found the Caldera Releaf Collar (available on Amazon) the most comfortable.  Then I bought a child-sized pillow that tips my head slightly back.  This works perfectly for me.  My pillow is no longer made, but some on Amazon look like they would work in the same way:

https://www.amazon.com/MLILY-Adjustable-...r=8-5&th=1

https://www.amazon.com/Hcore-Adjustable-...=8-16&th=1

These are both made with the foam in three layers, so you can remove some if you want it flatter.  Also,  

[TBrobbs]

Thanks so much, Deborah. I wondered about positional apneas but wasn’t sure how to identify them. I just got a Velpeau cervical collar last week but have only used it once. I think I must have worn it incorrectly because I woke with a really stiff neck and massive headache. I’ll try playing with it again, or try the Caldera you suggested.

I have a travel sized Tempurpedic pillow that might work as it looks like those you suggested. I might be sleeping too high right now as I have another good-sized pillow under that. 

I’ll also increase the EPR. Would I still also reduce the maximum pressure slowly in addition to increasing the EPR? 

Thanks again!

[BoxcarPete]

Two things I will note:

The O in your acronyms is obstructive, so if that along with the RDI accounts for all your events in the sleep study then we can consider your CA events and periodic breathing to be treatment emergent.

The other thing is that it's hard to say if you have a positional problem or just variations of periodic breathing. Increasing EPR may make TECSA worse, though the effect may be minimal. EPR also happens to be a form of pressure support, which is a good way to address your flow limitations that are persistent across the whole night. You mentioned that you seemed to feel better when you added EPR in at 1cm H2O, so I would move it in the smallest increment available to you to 2, and see if it helps the FLs without making CAs worse. If the results are good then move on to 3, the maximum your machine will allow.

If you zoom in on a couple event clusters it will be easier to tell what's going on. 6-8 minutes of the action around 00:30 and 03:30 (include the RERA here please) should help shine a little more light on the situation.

[TBrobbs]

        Thanks, Pete. 
I’ve changed the EPR to 2, and dropped the pressure a touch to 12 from 12.2, and will try that for a night or two.

Hopefully I’ve attached the two sections you asked about correctly.

[Sleeprider]

Even though there is a pattern of periodic breathing, it looks obstructive to me with flattened inspiratory peaks and better expiratory flow. The real giveaway is the longer inspiration time than expiration on your median Daily View statistics. I don't think even your central flagged apnea are central, but a highly restricted airway that falls below the 30% flow for flagging apnea. Because the airway remains open as you struggle to get a breath, the flag is CA, but it's a blatant error. If you zoom into a 2 to 3 minute zoom resolution we would clearly see the form of flow limitation taking place.

This requires correction of the positional obstruction, https://www.apneaboard.com/wiki/index.ph...onal_Apnea and some changes to your settings. Your current settings are fixed pressure at 12.2 with EPR 2. I think you should be looking at Autoset mode with minimum pressure 12.0, maximum pressure 15.0 and EPR 3.

[BoxcarPete]

And just like that, Sleeprider swoops in with the answer. That breathing isn't quite periodic enough to be fully CO2 driven, and the partial obstructions are sprinkled throughout the whole segment, which can explain the variable drive and/or ability to breathe. You also started in November, which means we'd be at the tail end of when we'd be expecting treatment emergent centrals to be, so if that was the case, they should have started getting better by now. I never thought to consider that the CAs were false flags due to an incomplete obstruction, but I think it's likely.