Need Advice about Central Apneas

[wxmcpo]

BLUF: Diagnosed with severe sleep apnea and placed on Bi-pap with an initial pressure of 5-9. That didn't seem to work as my AHIs were still in the 20's on a nightly basis so my doc put me on VAuto and that dropped my AHIs down to around 11. A series of back and forth pressures over the course of the next year didn't seem to be working either. Recently I dropped my pressure to 3-6 and it seemed to be working as my AHIs dropped into the 2's for about a month. Although over the last week my AHI has increased back up into the 6's. I upped my pressure to 3.6-6.6 last night and was back down below 3.

Here is a chart showing my last night at pressure setting 3-6


Here is a my chart showing last night when I upped the pressure to 3.6 - 6.6


Here are a couple screen captures showing more clear events so hopefully something can be seen in these.





As you can see most of my events are the clear air type and not obstructive. Was wondering if someone with more knowledge and the same issues could take a look and let me know if I am missing something that I could change to help out. Also for those using ASV machines did you use CPAP or Bi-pap previously and are you seeing better results with an ASV machine? Thanks

[Sleepster]

In your profile you list the pressure as "VAuto". We need to see the numbers, and in your case there are three: EPAP minimum, IPAP maximum, and Pressure Support. Having the pressure too high can induce centrals, and so can having the Pressure Support too high.

Also, I don't like the way your leak rate graph jumps up and down. Those periods of time when the leak rate is high could be times when you're mouth-leaking. Try a chin strap if you haven't already. And if that doesn't work try a full face mask.

[justMongo]

Sleepster: The OP posted VPAP Auto results in thread: http://www.apneaboard.com/forums/Thread-...ally-doing
He was leaking above threshold 32% of the night. Ergo, those results are not useful.
Also, the leaks in Auto mode look very much like mouth leaks.
He went to fixed bilevel. (Mode S.) Running IPAP=6 and EPAP=3, IMO is too low.

Master Chief: Here's the course I would steer if it were me. I'd run VPAP Auto and fix the leaks. The Auto mode does not increase pressure on Central Apneas. If, with the leaks under control, a reasonable result cannot be obtained because of CAs, then an ASV machine would be the next step.

[vsheline]

As you can see most of my events are the clear air type and not obstructive. Was wondering if someone with more knowledge and the same issues could take a look and let me know if I am missing something that I could change to help out. Also for those using ASV machines did you use CPAP or Bi-pap previously and are you seeing better results with an ASV machine? Thanks

ASV machines tend to eliminate all CA events by automatically adjusting Pressure Support on a breath-by-breath basis. They can also automatically slowly adjust the EPAP pressure to lower the number of obstructive events, similar to how obstructive events are treated by other Auto machines (APAP, VPAP Auto).

I think you need (and would qualify for) an ASV machine. I think most US insurance companies roughly follow US Medicare coverage guidelines for ASV, which require that when being treated by standard CPAP or APAP or BiPAP the central apneas are at least 5 per hour and outnumber the obstructive apneas.

Take Care,
--- Vaughn

[wxmcpo]

Master Chief: Here's the course I would steer if it were me. I'd run VPAP Auto and fix the leaks. The Auto mode does not increase pressure on Central Apneas. If, with the leaks under control, a reasonable result cannot be obtained because of CAs, then an ASV machine would be the next step.

I think I'll take your advice and switch over tonight. Just as I thought I was getting things under control, my AHIs jumped up again and have been above 5 for 4 of the last 5 nights. Maybe I'll set the ramp time though to provide a lower pressure initially, which is something I haven't done in the past.

ASV machines tend to eliminate all CA events by automatically adjusting Pressure Support on a breath-by-breath basis. They can also automatically adjust the EPAP pressure to lower the number of obstructive events, similar to how obstructive events are treated by other Auto machines (APAP, VPAP Auto).

I think you need (and would qualify for) an ASV machine. I think most US insurance companies roughly follow US Medicare coverage guidelines for ASV, which require that when being treated by standard CPAP or APAP or BiPAP the central apneas are at least 5 per hour and outnumber the obstructive apneas.

Take Care,
--- Vaughn

Thanks and I may have to speak with the VA about this as I am a very soon (as in less than 30 days) to be retired service member.

[Rcgop]

While my overall AHI was under 5 most of the time, most of my events were CAs. After a few minor tweaks, and a lot of patience (4 months), I have gotten my CAs down. 8 out of the last 14 days were under one. Last night my AHI Was ZERO
I think nasal pillows caused me to over breath, hence, contributing to the CAs. The advice I got here said CAs tend to go away on their own as you get used to the mask and the extra pressure.

Stay motivated and don't take no for an answer.

[ger365]

Master Chief: Here's the course I would steer if it were me. I'd run VPAP Auto and fix the leaks. The Auto mode does not increase pressure on Central Apneas. If, with the leaks under control, a reasonable result cannot be obtained because of CAs, then an ASV machine would be the next step.

I think I'll take your advice and switch over tonight. Just as I thought I was getting things under control, my AHIs jumped up again and have been above 5 for 4 of the last 5 nights. Maybe I'll set the ramp time though to provide a lower pressure initially, which is something I haven't done in the past.

ASV machines tend to eliminate all CA events by automatically adjusting Pressure Support on a breath-by-breath basis. They can also automatically adjust the EPAP pressure to lower the number of obstructive events, similar to how obstructive events are treated by other Auto machines (APAP, VPAP Auto).

I think you need (and would qualify for) an ASV machine. I think most US insurance companies roughly follow US Medicare coverage guidelines for ASV, which require that when being treated by standard CPAP or APAP or BiPAP the central apneas are at least 5 per hour and outnumber the obstructive apneas.

Take Care,
--- Vaughn

Thanks and I may have to speak with the VA about this as I am a very soon (as in less than 30 days) to be retired service member.

Congrats. short timer... for your service...

[wxmcpo]

Put my machine on VAuto again last night and my AHI went back down below 5. That is the first time in a very long time, if ever, that I have had an AHI below 5 on VAuto. Here is the graph of last night;


Now here are a couple graphs showing events;






Most events are still of the clear air type. My pressure setting is at 4-25 with a PS of 3.0. Would raising or lowering the PS help with the CA events? Also not sure why I got a large amount of mask leaks in the first 1 1/2 hours of sleep. The only other leak was when I got up to use the restroom around 0500.

Any and all advice is appreciated.

[justMongo]

The duration of CAs look short. Of the order of 10 to 12 seconds. You can see event duration in several ways -- one is to pull the slider down on the left screen and view listed events. If they are short duration, it may be a non-issue. Looks like you take a few deeper breathes after a CA to catch up.

The most likely source of leakage is via an open mouth. Sometimes increased PS will increase CA because it permits CO₂ washout. CO₂ being a primary trigger for breathing while sleeping. PS is helpful for people who have resistance upon exhale: such as COPD. Also, PS gives exhale relief when using large Inhalation pressure (like me.)

I'd leave the PS at 3. But narrow the 4 to 25 cm-H₂O pressure window.
If it were me, I'd set minEPAP to 6 -- which is your 95 percentile for 02JUL2016; and maxIPAP to 12. You only went to 10 last night, so that gives the machine 2 cm of headroom. That should take care of the HA and OA. The CA will bear watching.

Your Median Tidal Volume and Respiratory rate are very "normal."

Efficacy of treatment cannot be distilled into a single number like the AHI.
As long as the CAs are short duration and only occasionally hit the 5 per hour average -- you should feel OK.

Since you are now a short timer, you'll need to decide soon about whether you are comfortable with the amount of CA.
If it bother's you, then push for an ASV machine as they adjust on a breath by breath basis.

Kindest regards,

Mongo

Fair winds and following seas.

[wxmcpo]

The duration of CAs look short. Of the order of 10 to 12 seconds. You can see event duration in several ways -- one is to pull the slider down on the left screen and view listed events. If they are short duration, it may be a non-issue. Looks like you take a few deeper breathes after a CA to catch up.

The most likely source of leakage is via an open mouth. Sometimes increased PS will increase CA because it permits CO₂ washout. CO₂ being a primary trigger for breathing while sleeping. PS is helpful for people who have resistance upon exhale: such as COPD. Also, PS gives exhale relief when using large Inhalation pressure (like me.)

I'd leave the PS at 3. But narrow the 4 to 25 cm-H₂O pressure window.
If it were me, I'd set minEPAP to 6 -- which is your 95 percentile for 02JUL2016; and maxIPAP to 12. You only went to 10 last night, so that gives the machine 2 cm of headroom. That should take care of the HA and OA. The CA will bear watching.

Your Median Tidal Volume and Respiratory rate are very "normal."

Efficacy of treatment cannot be distilled into a single number like the AHI.
As long as the CAs are short duration and only occasionally hit the 5 per hour average -- you should feel OK.

Since you are now a short timer, you'll need to decide soon about whether you are comfortable with the amount of CA.
If it bother's you, then push for an ASV machine as they adjust on a breath by breath basis.

Kindest regards,

Mongo

Fair winds and following seas.

Thanks so much. I will probably adjust based on the recommendations. Although my AHI may be below (and has been for the majority for the last month) I still find myself getting tired throughout the day much like I was before I even started my treatment 15 months ago so I have always questioned if it really is working for me.

What I find interesting is that I've used VAuto in the past, never had a below 5. I changed to a set pressure of 3-6 in late May and had AHIs in the 2s for the next 30 days. When I am in VAuto though it appears I actually need a higher pressure than the 3-6 though so not real sure why that 3-6 pressure setting seemed to work for me (although my AHI went back up to 6+ causing me to set it back to VAuto).