Nearly 2 months in on CPAP, mostly hypopneas and centrals - not improving

[lazysunday]

Hey all, 

Intro
I'm new to sleep apnea and have been using a CPAP machine for nearly 2 months now. I seem to have more centrals with the initial 5 to 15 pressure settings which was recently changed to 5 to 8 due to most of my apneas being centrals. My AHI has hovered around 7-9 since I started back in February. The last couple of nights, since the pressure range was reduced saw a marked reduction in centrals, but the hypopneas persist. The last couple of nights, my AHI has averaged around 6. 

Overall I haven't been able to really break 6 or 7 on the AHI scale. Those numbers aside, on the symptomatic side I am dealing with cognitive issues with word-finding difficulties, memory issues, mixing up names of friends, years & months & days, fatigue, anxiety, depression etc. Pretty disturbing for someone in his mid 30s.

OSCAR Data is Attached
If more data is needed, please let me know.

Periodic Multi-Day Periods of Increased Oxygen Desaturations that Spontaneously Resolve and Return
I also wear a pulse oximeter at night, and the data shows that the reduction in flow rate has reduced oxygen desaturation counts over 4% with the 5 to 8 flow settings. What's odd, however, is that the oximeter data shows periods where I'll go a few days with oxygen levels consistently above 94%, and then randomly I'll have nights where it dips into the high 80s with a significant amount of drops over 4%. When those oxygen levels dip, obviously my AHI gets higher - into the low teens. 

These periodic multi-day 'dips' seem to come and go without any obvious explanation. I'll get a false sense of hope that I'm out of the woods and my body has corrected itself somehow, and then wham - back to square one. Typically when the saturation rates go down, I'll somehow get more obstructive apneas as well, which I rarely do in general.

Medical Testing for Central Causes
This is 'Mild' sleep apnea according to diagnostic criteria - but I've heard centrals are a bit more serious since it points to either a neurological or heart issue. I've had a head CT, MRI, EE, MRA done - all normal, as well as heart stress test, ECG, TEE, and 2 week-holter monitor - all normal with some marked bradycardia/slow which is sometimes symptomatic when I'll wake up struggling to breathe and it feels like I'm about to pass out. Those symptoms have started to subside, but the centrals and hypopneas persist. 

CPAP Not Improving Condition, Will likely Switch to BiPAP Soon
I'm scheduled to undergo a titration study next week as my sleep Dr. thinks due to my CPAP failure (still tired, cognitive symptoms persist, don't feel better) that I'll need BiPap and possibly eventually ASV (though she didn't mention ASV, I'm pretty sure that's the direction I'm going).

Difficulty with Nasal Breathing
I'm using a full facemask as I've always had difficulty with breathing through my nose and have a hard time breathing against the pressure using nasal pillows -- seems like my airway gets 'inflamed' or closes off in my nose. I went to an ENT doctor and I have large tonsils, nasal passageways seem normal. Not sure what's going on there...we're considering removing my tonsils, but I'd rather not have surgery unless I know if the hypopneas are central in nature or obstructive. Again - the hypopneas seemingly stick around no matter what the pressure. I also have TMJ issues and sometimes sleep with a splint/occlusal guard to prevent my teeth from clamping down.

If you're made it this far, I applaud you. Any comments on my data? Any suggestions for how to improve my treatment? I'm not impressed with my current sleep doctor/clinic as they're very unresponsive and seem to just be a CPAP machine mill without really caring to investigate the root cause of the apneas. I'm talking to another sleep clinic in a couple of weeks for a second opinion, possibly to switch treatment. Thanks for reading, and sleep well. 

[staceyburke]

It looks like you have positional apnea and no adjustments to your Cpap or change to a bipap will help. Positional apnea is what it sounds like. You are getting in a position wher you are cutting off your own airway causing more apnea and lower O2 levels. 

Many times sleeping position is the problem. Sleeping on your back or to high of pillows can be a problem. Any time your chin drops to your Sternum (chin tuck) you cut off your own airway.  You need to find out WHY you are chin tucking 
And fix it. If simple changes are not enough many many people have found a collar is the answer. See my link to collars at the bottom of the post. In it is shows people without and the same people with a collar. A huge improvement in their events and O2 levels.

[lazysunday]

Stacey,

You bring up a good point - and I've actually been looking at cervical collars for the past few days myself. 

My neurologist has me scheduled for a cervical spine MRI since we've ruled out most of the major stuff. I've received comments by others that while I'm sleeping, my neck gets into a 'weird' position. I've also had issues with intermittent neck pain throughout the years, either while I'm sleeping or during the day. I don't really snore either, but sometimes my breathing gets 'high pitched' and strained. I work in front of a computer most days and notice that my posture isn't very good either. I'm trying to set up a way to take timelapse pictures of myself while I sleep from above to see what my body is doing at night, maybe that will help me root out the issue.

I believe that I do naturally chin-tuck, so I'm trying to train my body to be more straight when I go to sleep. I do know that my sleep apnea is particularly bad when laying down flat on my back, so that could well be the issue. Hopefully I can get some photos that would correlate to what's appearing in OSCAR and my oximetry data. Who knows, when all's said and done, maybe I'll start my own sleep clinic? 

Thanks for your response - I'm probably going to order a cervical collar to try and experiment a bit. If that resolves the issue, then it becomes mainly a structural/skeletal and behavioral thing, which I hope can help my numbers and sleep quality.

[Dormeo]

PR Dreamstations are not so good at treating the pesky stuff like hypopneas, flow limitations, RERAs, and snores. You might see improvement with a ResMed Airsense 10 Autoset, which has a more nimble algorithm and true pressure support (aka EPR, for expiratory pressure relief).

But it'd be great if you could get a bi-level machine, ideally a ResMed VAuto. The pressure support could be a real boon to you: its the difference between your exhale pressure and your inhale pressure. Basically, you get a boost when you inhale, and with a bilevel machine, you can have larger boosts than with the Airsense 10 Autoset.

I also hope you have some luck with a cervical collar. Sometimes low-tech solutions really work!

[lazysunday]

Dormeo,
Thanks for the heads up regarding the Resmed VAuto - I'll keep that in mind as I go in for my next sleep study. Like I said, I think I'm tracking towards getting a BiPap anyway so there's a good chance I may end up with that Resmed machine. My sleep clinic works with a variety of DME providers (when they respond to my calls anyway), so hopefully we can get that arranged. Crossing my fingers on the cervical collar here!

[Gideon]

See if OSCAR is compatible with your oximeter, I'd like to see how it corresponds to your night.
Centrals often increase with increased flex, But with your CAI around 1.0 you are in good shape. You can set flex to off and see how that feels. Also note that Centrals are consistently inconsistent, that means they jump all over the place with no apparent reason.

[lazysunday]

Gideon,

My Pulse oximeter isn't compatible with OSCAR, but I did install the app and have data for last night which I've posted. Unfortunately it's not inline with the OSCAR results, but the timestamps can be matched up. I also bought a soft cervical collar last night and it didn't seem to help any...I'll try again in the future. It doesn't have the greatest fit, and seemed to cause breathing issues when I was lying on my right side, not so much on the left. That's too bad, but I'll keep trying. Maybe I have to break the thing in and adjust the fit a little, or buy a different one. Also, Flex is set to '1' at the moment, which I believe is supposed to lessen the effects of centrals. I had previously set it to '3' and had noticeably more centrals so it did help things along.

From the data, it looks like the SpO2/pulse drops seem to correlate with motion incidents in the bottom graph. I really need to take some timelapse video of myself sleeping to get a clearer picture as to what's happening. I do know from my first sleep study that my apnea was really bad in the supine position/laying on my back as it is with most folks.

The variable breathing during what appears to be deep or REM sleep isn't normal, right? I noticed on the other graph that the algorithm picked up Cheyne-Stokes respiration which is not good.
   
   

[Dormeo]

A couple of things worth keeping in mind.

The number of CAs you're experiencing is negligible -- not a cause for concern. You will see CAs go up and down, as has already been noted. Some may well be "sleep-wake junk" -- pauses in breathing that occur when your are awake or partially awake. (We breathe less regularly while awake than while asleep.)

Cheyne-Stokes breathing is a very specific type of periodic breathing. It is characterized by a sinusoidal curve in the flow rate (top and bottom) before and after the pauses in breathing. You can zoom in on a green area to reassure yourself that's not what's going on.

Finally, central apnea can be treatment-emergent. The increased efficiency of ventilation with PAP can wash out some CO2, which may briefly reduce your drive to breathe. Treatment-emergent CAs often resolve with time (can take several months).

[SarcasticDave94]

Welcome, you've already gotten some great advisement. The CA on the chart is very likely treatment emergent, and at 0.83 it's near nothing. Yes CA can and will be consistently inconsistent. Basically, note the CA level and I'd avoid flex level 3. Almost nobody does even fair on Flex 3.

So you're not doing bad in the Central department, but you do have Hypopnoea to concern yourself. With the ScreamStation that's pretty easy to solve, turn up the pressure.

[lazysunday]

Thanks guys, I'm a lot less concerned about the centrals now. 

When I first started with my CPAP machine, it was a major struggle to learn how to breathe against the pressure. So I increased the Flex to 3 and that made it easier, but I think was also causing an influx of CA's alongside the treatment emergent CA's. Good to know that I have less to worry about. I'm now used to a Flex level of 1...not sure if I can turn it off or not since I have some weird restrictions on the device.

Hopefully an increase in pressure will help resolve those hypopneas, maybe a move to a BiPap will too? The good thing is that my AHI has gone down the last couple of nights to 7.37... Still trying to crack 5. I have that titration/sleep study coming up this week so hopefully I'll have some information on how we'll proceed going forward. Thanks again for all the advice and info.