New to CPAP and not experiencing relief...

[Extrospect]

Hello everyone,

I've been newly diagnosed with severe sleep apnea; my AHI was around 40 during my study at the end of August and featured mostly obstructive events. What's curious about the diagnosis is that I'm young (early 20s) and thin (around 110lbs). An earlier sleep study in May showed no presence of apnea, but it did log 50 arousals and 25 awakenings over about 3 hours of sleep.

Treatment began roughly 2 weeks ago with a Resmed S9 Autoset. The range was set to 4-10 with an EPR of 3. Data seems to indicate the machine has drastically reduced my obstructive events; though, it shows quite a few central events have begun. For example, I had 36 CA and 6 OS events last night, yielding an AHI of 4.13. What confuses my analyses of the data is the fact that I consciously wake frequently, every 90-180 minutes of sleep. It then takes me another 15-90 minutes to get back to sleep.

I've had these frequent nocturnal awakenings for quite awhile and suspect sleep quality is impacting my cognition. Memory, attention, and fatigue issues shouldn't hit me this early in life! Both sleep studies showed my time spent in REM sleep is about half that of normal people.

My neurologist saw me yesterday and made some minor adjustments to treatment. The range was expanded to 4-15; he also prescribed gabapentin to be taken nightly.

What are your impressions of this situation? I'd really love to hear your thoughts!

Thanks for your time.

[trish6hundred]

Hi Extrospect, First of all, WELCOME! to the forum. Sometimes CPAP therapy can take LOTS of TIME and PATIENCE so don't give up. It takes a while for some people to feel any relief. I just encourage you to stick with it. Hang in there for more suggestions, best of luck to you with your CPAP therapy.

[PaulaO2]

If you are waking up enough, that may be where the 'central' events are coming from. The machine doesn't know if you are awake or asleep, it only knows how the air is rec'd. When we are awake, our breathing is quite different.

With only 2 wks of treatment, you've only just begun. It could take a while for everything to settle down. You'd need to get used to the mask, the air pressure, the noise, etc etc.

Also, with 2 wks of treatment, you've only got 2 wks of data. Give it a little more time before you fully trust the data, especially if/when you start to actually sleep the entire night.

Hang in there! Keep going. Every night you use the xPAP, the better you will be. It may take a while, but it will work.

[Extrospect]

Thanks for the warm welcome!

I'm not sure that the machine is reporting false positives on the CA events... For it to recognize the existence of an event, doesn't that event need to last at least 10 seconds? It's safe for me to say I'm not pausing breathing for 10 seconds while conscious... In fact, the periods without any events sync up pretty well with those periods I'm awake.

The clear airway events are troubling because of their potential indication of central apnea. I understand treating obstructive apnea can cause central apnea, right? Would another machine be more appropriate if this continues?

[zonk]

My neurologist saw me yesterday and made some minor adjustments to treatment. The range was expanded to 4-15; he also prescribed gabapentin to be taken nightly.

What are your impressions of this situation? I'd really love to hear your thoughts!

Thanks for your time.

why are you seeing the neurologist and why Gabapentin?
also how did the doc figure out the maximum pressure ought to be increased from 10 to 15 and leaving the minimum pressure at 4?
AHI 40 indicate severe sleep apnea. AHI with PAP below 5 indicate good treatment.
I think you need to find a good sleep doctor who specialize in sleep medicine (Not GP or neurologist)

imo first you need to figure out what waking up and concentrate on sleep quality.
what is the leak and pressure shows on the machine sleep report?

learn about the machine, humidifier/climate control, ramp, EPR
let us know if you need the manual or software so you know whats going on with your PAP

congrats on the first two weeks. its a step in the right direction
[a journey of a thousand miles begins with a single step]

[Dawei]

Extrospect--A couple thoughts come to mind in addition to what other board members have already mentioned. One thought is that apnea can and does happen to folks who are not at all overweight. Also, I have not read that apnea cannot (does not) occur with young people, although I believe it's true that many times it hits older people.
As you mentioned, treating apnea can cause CA events. This, I've heard, is a danger if the pressure is set too high for a pt. My sleep doc's primary concern whenever he's thinking about adjusting my machine's top pressure higher is the fear of causing CAs. As a result, he makes any increases in only small steps. You described your doc making minor changes in your therapy including upping your machine's top pressure from 10 to 15. I certainly would not consider that jump a minor one! My DME tells me that making a pressure increase of 1 cm is typical of what docs do when increasing pressure. Whenever mine has done this, he'll tell me to try it out for at least 2-3 weeks and see what's happening. As Paula wrote, this is the same advice experienced board members offer to others who join the board.
Finally, it's a good idea to keep an eye on your mask leak rate, since a too high leak will skew the machine's reporting numbers (AHI, CA, etc). I like the ResScan software for watching leaks because it shows unintentional leaks after already subtracting intentional mask leaks.

[PaulaO2]

This, I've heard, is a danger if the pressure is set too high for a pt.

It's not that the setting is too high, but more that the change was too big. And this is all anecdotal as various studies (for some reason) have never proven this happens. Many of us can say it does and even a few sleep docs say it does. It is why we encourage folks who wish to fiddle with their settings to do so in small steps. But, at the same time, we regularly hear from users of docs that increase the upper pressure by 2 - 3 cm.

Yes, events are noted when they happen for longer than 10 seconds. Look at the data and see what the time stamp is for those 'clear airway' events. See if they coincide with times that you are awake. And it is very possible for you to hold your breath or breath shallow or more than 10 seconds and not know it, especially when half-asleep or when occupied by something else.

No, another machine would not make it different. You have a very good machine.

[Sleepster]

What are your impressions of this situation? I'd really love to hear your thoughts!

I think if I could wind the clock back 30 years I might be you!

I'm in my 50's and started CPAP therapy almost a year ago. Like you my CPAP therapy induced some central apneas when I started. It's a well-documented effect and it does tend to go away with time.

Also like you I was in the habit of waking several times a night before I started CPAP therapy. It continues afterwards but gets better with time, too.

You're in good shape. You've got a good doctor, your AHI is below 5, and you are tolerating CPAP therapy. Those are all very good things in your plus column. With time your problems will subside. You'll feel better and your cognitive abilities will improve, too.

Your CPAP therapy is going to improve the quality of your life. I wish I could have done that thirty years ago when I was your age, but CPAP therapy just wasn't available back then.

[Extrospect]

why are you seeing the neurologist and why Gabapentin?

The neurologist is one of the staff doctors at a sleep center within a pretty reputable hospital... He prescribed gabapentin after noting incidence of a few limb movements on my sleep study in August. He hypothesized these movements may also be disruptive for sleep. Further, he mentioned Gabapentin can help promote deep wave sleep and reduce awakenings on its own.

also how did the doc figure out the maximum pressure ought to be increased from 10 to 15 and leaving the minimum pressure at 4?

Think this was based on my hitting the upper limit of 10 multiple times in a night. Guess the rationale is the machine would have calibrated higher if it could.

AHI with PAP below 5 indicate good treatment.

Odds are good I'm only asleep for 50-70% of the time each night. That skews the data, given the machine bases the calculation on its usage and not on my state of wakefulness.

imo first you need to figure out what waking up and concentrate on sleep quality.
what is the leak and pressure shows on the machine sleep report?

That's the problem! I can't isolate these awakenings to any external sources. My room isn't noisy or otherwise uncomfortable.
Based on last night's data, my median L/min is 0.0; 95th percentile is 28.8; max is 38.4
Pressure median is 8.3; 95th percentile is 11.3; max is 12.6

Finally, it's a good idea to keep an eye on your mask leak rate, since a too high leak will skew the machine's reporting numbers (AHI, CA, etc). I like the ResScan software for watching leaks because it shows unintentional leaks after already subtracting intentional mask leaks.

How do I know what leaks are too high? My rate is often low, but it pops above 20 several times.

Look at the data and see what the time stamp is for those 'clear airway' events. See if they coincide with times that you are awake.

I don't believe they do. However, I'll start keeping a log from now on. I'm also considering a Zeo purchase.

[Moriarty]

Hi Extrospect

Welcome to the forum...

I am a bit surprised that the minimum has been left at 4 although the top pressure was increased...

I am not widely experienced but the procedure in my case was to prescribe the upper limit as wide open (20) and increase the lower limit until the the AHI was optimised.

This is purely my experience and your case may well be different but I found that when my lower limit was too low (initially 7) once the apneas started the machine wound up quite high (to about 16) before the apneas settled. The AHI was about 5. The interesting bit came when the lower limit was increased. when the lower limit went to 8 then to 9 the apneas reduced and the 95% pressure dropped to about 12 wih the median around 10.5. The AHI is now under 2 - although I also changed from a Hybrid mask to Nasal pillow during the same period.

I also do not think it is a safe assumption to equate Clear Airway Apneas with Central Apneas - especially if you have EPR enabled. That link can only be accurately made with a neurological sleep study.