Losing hope feeling worse on CPAP than without. Any advice?

[AFAFAF]

Guys for some reason (1 week) my CPAP treatment has made me more tired and sleepy. Any advice? I am losing hope since so many people say they feel better even after one day. Here my results. Any advice?

[Gideon]

Welcome to the forum.
The first chart implies an increase in central apnea activity. I need to see a 10 minute zoomed view, click on the central activity several times until the duration as shown in the Flow Rate curve is 10 minutes. Other methods are outlined in the organized link in my signature.

Also post (redacted) copies of your sleep studies as these will help to pinpoint the types of apnea you are having.

Additionally your pressure increases are mostly driven by flow limits.

The correction to these two type of events are polar opposites so we look for a balance.

To improve the central apnea turn off EPR.
To reduce the pressure increases and the underlying flow limitations increase the EPR
I said it was a balancing act.
IMHO the best move with your equipment is to reduce or turn off EPR. I do not expect this to be optimal. We need to see how you react.

The other possibility, but it is too early to call, is to get an ASV. That is difficult to convince a doc to do.

I suspect that your Central Apneas are Treatment Emergent Central Apnea caused by increased flushing of CO2 from your body to below your apneic threshold but need the closeups and sleep studies to confirm. This is fairly common.

Decreasing EPR reduces this flushing of CO2 and should improve your overall AHI.

[SarcasticDave94]

Welcome to the Apnea Board,

Most of your events are CA which refers to Central Apnea. I'm not certain how your medical hierarchy works, but can you get your detailed sleep study data that got you the CPAP? I'm fishing for what events type and count you had prior to PAP to help determine if you Centrals are based on PAP use as in treatment emergent or if these CA are pre-existing PAP use.

2 possible routes your therapy goes from here, both may be encountered. First let's turn off EPR. If Ramp is on turn that off too. I think as well we may need to limit your pressure range, but let's see if these first 2 help any.

Learning about Central Apnea: these are Apnea events where you stop breathing due to a too low CO2 level. PAP use can create this, but it can be found in some for other medical reasons. It doesn't mean you've got a serious brain injury or similar. I have a high pre-existing Central Apnea level without the right machine and my CA are just there, medical cause not certain.

Again let's see if the elimination of Ramp and EPR change anything CA related. I don't think it'll be enough. Oh yes, do take note CA are consistently inconsistent, up and down event flags, up one night down the next, etc. If the CA can't be tamed, you'll need to progress to a ResMed AirCurve 10 ASV. This machine exists solely to combat CA.

Another action for general PAP success is working on leak control, they're sometimes a bit too high.

[Sleeprider]

The solution to this is a more advanced positive air pressure device called an Adaptive Servo Ventilator. This goes by the names Resmed S9 Adapt, Resmed Aircurve 10 ASV, and Lumis 150. The ASV treats central apnea and hypopnea by applying increased pressure during inspiration when you don't have sufficient spontaneous effort to take a full breath. The condition you have is called complex apnea which is a mix of central and obstructive sleep disordered breathing. This may have been evident in your diagnostic sleep study, or it may have not been apparent until you started CPAP therapy. As Gideon said, PAP therapy may reduce CO2 in sensitive individuals causing a diminished respiratory drive. The good news is the problem is easy to treat and many members here use ASV to achieve near-zero AHI.

[quiescence at last]

as the use of the machine is for such a low number of days, there is no certainty that you should make any changes.

but, I can gather a couple things from the 3 nights data.  

1. starting pressure is not reached again after start in 2 of the 3 nights, meaning the machine thinks your pressures should be elevated to combat the obstructive things: flow limitations, hypopnea, and obstructive apnea.  the machine did what it was supposed to do.
2. highest pressure the machine reached in 2 of 3 nights is under 12 cm where machine took care of everything it saw in the flow.

i would adjust the start pressure to 7 min, and set max pressure to 12 cm, and leave the EPR set to 1.  the narrower band may make sleep less disrupted.  then, of course, post the charts, and how rested (awful, worse than before, same, better than before, well)

QAL

ps. guessing you felt somewhat more rested from last night than you did the prior nights. also many many many do not feel good the moment they start, but let's hang on for a couple weeks.

[AFAFAF]

Welcome to the forum.
The first chart implies an increase in central apnea activity.  I need to see a 10 minute zoomed view, click on the central activity several times until the duration as shown in the Flow Rate curve is 10 minutes. Other methods are outlined in the organized link in my signature.

Also post (redacted) copies of your sleep studies as these will help to pinpoint the types of apnea you are having.

Additionally your pressure increases are mostly driven by flow limits.  

The correction to these two type of events are polar opposites so we look for a balance.

To improve the central apnea turn off EPR.  
To reduce the pressure increases and the underlying flow limitations increase the EPR
I said it was a balancing act.
IMHO the best move with your equipment is to reduce or turn off EPR.  I do not expect this to be optimal.  We need to see how you react.

The other possibility, but it is too early to call, is to get an ASV.  That is difficult to convince a doc to do.

I suspect that your Central Apneas are Treatment Emergent Central Apnea caused by increased flushing of CO2 from your body to below your apneic threshold but need the closeups and sleep studies to confirm.  This is fairly common.

Decreasing EPR reduces this flushing of CO2 and should improve your overall AHI.

Thanks for you response. Ok here is the ten minute zoom of the CA. Redacted sleep study attached. I will try turning off EPR and see what happens.

---

The solution to this is a more advanced positive air pressure device called an Adaptive Servo Ventilator.  This goes by the names Resmed S9 Adapt, Resmed Aircurve 10 ASV, and Lumis 150.  The ASV treats central apnea and hypopnea by applying increased pressure during inspiration when you don't have sufficient spontaneous effort to take a full breath.  The condition you have is called complex apnea which is a mix of central and obstructive sleep disordered breathing.  This may have been evident in your diagnostic sleep study, or it may have not been apparent until you started CPAP therapy. As Gideon said, PAP therapy may reduce CO2 in sensitive individuals causing a diminished respiratory drive.  The good news is the problem is easy to treat and many members here use ASV to achieve near-zero AHI.

Ok I'll bring it up with my doctor and see what they say. I think it is complex apnea since the attached sleep report has more central than obstructive, and a lot of Hypopnea. Will take a month till visit, so I'll guess I'll try the other advice for a while first.

[AFAFAF]

Welcome to the Apnea Board,

Most of your events are CA which refers to Central Apnea. I'm not certain how you medical hierarchy works, but can you get your detailed sleep study data that got you the CPAP? I'm fishing for what events type and count you had prior to PAP to help determine if you Centrals are based on PAP use as in treatment emergent or if these CA are pre-existing PAP use.

2 possible routes your therapy goes from here, both may be encountered. First let's turn off EPR. If Ramp is on turn that off too. I think as well we may need to limit your pressure range, but let's see if these first 2 help any.

Learning about Central Apnea: these are Apnea events where you stop breathing due to a too low CO2 level. PAP use can create this, but it can be found in some for other medical reasons. It doesn't mean you've got a serious brain injury or similar. I have a high pre-existing Central Apnea level without the right machine and my CA are just there, medical cause not certain.

Again let's see if the elimination of Ramp and EPR change anything CA related. I don't think it'll be enough. Oh yes, do take note CA are consistently inconsistent, up and down event flags, up one night down the next, etc. If the CA can't be tamed, you'll need to progress to a ResMed AirCurve 10 ASV. This machine exists solely to combat CA.

Another action for general PAP success is working on leak control, they're sometimes a bit too high.

Ok thanks for the response. I'll try turn off ramp and EPR and see what happens. I've attached my sleep study too in another reply. Hopefully I won't need to go through hoops to trying the ASV but I guess we'll see what happens.

[AFAFAF]

as the use of the machine is for such a low number of days, there is no certainty that you should make any changes.

but, I can gather a couple things from the 3 nights data.  

1. starting pressure is not reached again after start in 2 of the 3 nights, meaning the machine thinks your pressures should be elevated to combat the obstructive things: flow limitations, hypopnea, and obstructive apnea.  the machine did what it was supposed to do.
2. highest pressure the machine reached in 2 of 3 nights is under 12 cm where machine took care of everything it saw in the flow.

i would adjust the start pressure to 7 min, and set max pressure to 12 cm, and leave the EPR set to 1.  the narrower band may make sleep less disrupted.  then, of course, post the charts, and how rested (awful, worse than before, same, better than before, well)

QAL

ps. guessing you felt somewhat more rested from last night than you did the prior nights.  also many many many do not feel good the moment they start, but let's hang on for a couple weeks.

Yeah haven't been on it too long. Might just try the other people's suggestions to turn off EPR for now and see how that goes. Seems like I don't go over 12 and min goes to around 5. Doesn't this mean the machine thinks I need these pressures, so going to 7-12 has not too much point? Just trying to see if it's worth changing because I go through my sleep nurse to make changes and idk if they think it'd be a good idea.

[SarcasticDave94]

I hope the Avoidance plan works, but with Centrals at nearly twice Obstructive, it seems that you're headed to ASV at some time. Keep us updated on how the edits are working.

[Sleeprider]

Your CA was recorded at twice the rate as OA in your diagnostic study, and with the huge number of hypopnea, it is safe to assume the majority of that is central. We can discuss how and why central apnea occur, but the important part of this is that CPAP cannot treat CA and central hypopnea, however, with ASV, you will achieve an AHI less than 1/hour. The next step as you note is a pointed discussion with your doctor. You are now armed with the knowledge that your problem, based on your diagnostic study, and confirmed by your trial on CPAP, is predominately central apnea. In fact with CPAP, any obstructive component is treated and near zero events. As you know, the residual CA leaves you fatigued, frustrated and dysfunctional and is a high priority to resolve.

To better prepare you for a discussion with your doctor, I am going to link the Resmed Clinical Titration Guide. This is the decision-tree for problems in therapy and offers an excellent discussion of the alternative therapies. You should read the sections on CPAP and ASV. Also look at ST and note that ST is NOT appropriate for central and complex apnea. https://document.resmed.com/en-us/docume...er_eng.pdf The more you know, the faster and better you will be able to get things pointed in the right direction. While your results with CPAP are unacceptable, it is better than the 30 events per hour you had in the diagnostic test. I encourage you to stick with it as best you can, but you do need to move to ASV therapy to get back to experiencing normal good health.