Please Review The Data & Give Recommendations

[Gideon]

You need an alternation to a "Comfort" setting, EPR.  I suggest you turn EPR off.  here is why.

In general higher pressures cause CA events in CPAP use.  You indicated that in the past you had significant CA events and in this chart they are greatly reduced.  Therefore the current therapy IS working for this.

It is the EPAP pressure that supports Obstructive events.  Since CPAP (Auto CPAP too) is considered a single pressure treatment, setting EPR is considered to be a comfort setting and NOT impact treatment.  In most cases (not yours) this is easily compensated for.  EPR is Expiratory Pressure Relief, the lowering of the Expiratory pressure to make CPAP pressure more comfortable for the patient.  This results the the lower line on the pressure graph.  In your case it looks like 2 cmH2O.  This means thhat your EPAP pressure is 2 cmH2O lower than your set pressure.

To reduce your obstructive events you would raise your CPAP pressure, BUT this would likely cause an increase in your CA, Clear Airway events, not good.  So I suggest that we raise tour EPAP pressure without changing your IPAP or set CPAP pressure, and do this by turning off your EPR.

You can always turn it back on if it is not comfortable for you, and maybe lower your EPR to 1.


Fred

[Hojo]

Fred:  That makes sense if I'm understanding this correctly; EPAP helps to keep the airway open but if I have the EPR set too high (yes, it is set at 2), then my airway can start to close, allowing some airway closure and hence, more OA's. 

But then I'm still wondering why a much lower CA level, yet a much higher H level, I guess more time will tell.  I think I will lower the EPR to 1 first, the last time I turned it off for a night I woke up feeling like I was gasping so I'll see if I can wean myself down.

[Sleeprider]

Hojo, something I'm seeing in your results is an extremely high respiration rate. I suspect this is an error, and that if we look at your flow rate wave form up close, we will see a very irregular inhale/exhale flow that the machine is picking up as individual breaths. We have seen this before on the forum. What happens is that with that pattern, the machine has trouble properly detecting whether you are actually inhaling or exhaling and the EPR actually gets crossways to your respiration. That is one of the reasons we advise minimizing it or turning it off.

If you cold take a couple close-in screenshots including while you are having events such as at 23:20, and one where you are not having events such as 00:00 on Sept. 20, maybe we can see something useful. No more than 2-minutes in length so the individual wave form is clearly visible.

[Hojo]

Sleeprider:  I'm not sure if these are in the right order, it looks like they came up in reverse order;  00:00 first, then the 23:20 events, of which I took screen shots to show what was going on just prior to an OA, during an OA, and after an OA.

Many thanks.

One of the other things I'm pondering is that if my main issue is central apnea (that is what my DX was), and we went from 10 to 5/20 to try to minimize blowing off so much CO2, wouldn't I have more central apnea.  On the other hand, perhaps having more hyponea episodes off set the decline in central apnea episodes.  Just thinking out loud.

https://imgur.com/a/nzQHg

[Sleeprider]

What were your sleep study results? Did you do a titration study?

Some of that respiration is almost indescribable. In the period from 00:0030, your respiration rate is nearly 2 breaths per second (120/minute). There are 20 peaks in the first 10 seconds. That is not breathing, it's pantng!

In the next example at 23:19:10 the beath rate is closer to a normal 12 BPM but very shallow, irregular and flow limited. The 4th and 5th examples show very long apnea and uncharacteristic of OA, there is no recovery breath.

I am very concerned about your oxygen saturation levels at any time during the night. I cannot advise you what to do with this other than get back to the doctor for some further analysis as soon as possible. Consider getting a recording oximeter. CPAP does not appear to be your answer, and I can't judge whether you might be a candidate for AVAPS or ASV. You need a device that is going to increase your volumetric rate and provide a more steady breathing rate. This pattern is unfamiliar to me, and perhaps is related to central apnea or a lack of respiratory signal. I don't know what to do with it other than encourage you to get help, and ensure that the person doing analysis can interpret this irregular and rapid respiratory pace as well as the periods of inefficient respiration and complex apnea.

[Hojo]

My sleep study results weren't that bad but I told the doc that I believe the one study doesn't give a complete picture as I felt it was a good night for me...I didn't wake up and I certainly didn't feel as though I had just run a marathon after waking up every couple of hours.  From my original study, my AHI was 6.61 with mostly central apnea and the lowest my saturation fell was 83%.  I too noticed from Sleepy Head that last night my tidal volume was lower than usual and I wondered if it was because I was fighting to get a normal breath from all the pressure. 

When I went back for the (second) sleep study they said I needed a pressure of 10 and that is where I started.  After a few day I told the DME that I was having too many CA's episodes and so the doc switched me to 5 and 20.  Now that it has been a month, instead of trying me on BIPAP, which I'm not sure would help, the doc wanted to try me at 12 since while on 5-20, the pressure went to 12 a lot of times.  The doc did hear me and agreed that I may need to be put on ASV but that he probably needs to satisfy insurance and make more changes before an order can be placed.

Physically I feel much better than without any CPAP, my blood pressure is down, I'm getting a bit more sleep, and I'm not waking up drenched in sweat and feeling like I've been running.  Ultimately I think I'll end up on ASV but wish that (simple) CPAP would do the trick.

[Sleeprider]

How can we help you expedite the ASV? It sounds like your doctor is trying different things with pressure, that may actually be making things worse. Not his fault, this is a trial and error process for the most part. Have you ever provided some close-up views of the respiratory flow that shows problems like you posted above. I think he might be surprised by that. Also, your event rate was low, but it would be interesting to see the actual data. It seems you are breathing so that apnea would not be scored, but the way you breath is why you sometimes feel like you woke up from an all night run. That looks exhausting!

Have you ever tried a fixed pressure like 8.0 (pulling that out of a hat)? Many people with complex or central apena seem to do better at that pressure. As much as anything, I'd like to see that rapid, ineffective respiration not occur. Anyway, hopefully that chart is not typical and we can find a pressure that minimizes some of those artifacts.

When you look at the Daily data and highlight the Events tab below the date, what kind of times are you seeing on the apnea events?

[Gideon]

Some of that respiration is almost indescribable.  In the period from 00:0030, your respiration rate is nearly 2 breaths per second (120/minute).  There are 20 peaks in the first 10 seconds.  That is not breathing, it's pantng!

In the next example at 23:19:10 the beath rate is closer to a normal 12 BPM but very shallow, irregular and flow limited. The 4th and 5th examples show very long apnea and uncharacteristic of OA, there is no recovery breath.

I am very concerned about your oxygen saturation levels at any time during the night.  I cannot advise you what to do with this other than get back to the doctor for some further analysis as soon as possible.  Consider getting a recording oximeter.  CPAP does not appear to be your answer, and I can't judge whether you might be a candidate for AVAPS or ASV.  You need a device that is going to increase your volumetric rate and provide a more steady breathing rate.  This pattern is unfamiliar to me, and perhaps is related to central apnea or a lack of respiratory signal.  I don't know what to do with it other than encourage you to get help, and ensure that the person doing analysis can interpret this irregular and rapid respiratory pace as well as the periods of inefficient respiration and complex apnea.

Please get these questions answered.  They are very important.

It is not very often when I see anyone get a specific recommendation to see a Doctor ASAP.  

and please let us know what happens when you see the Doctor.

[Hojo]

Last night was pretty much the same although this time I remember waking up right around 02:30 to the 'panting like a dog'.  I actually woke up a second time panting but don't remember exactly when. 

With 32 days of data my time in apnea has averaged 10.78 minutes with 6.34 hours of use.  The last two night with the new settings the apnea time is 13.5 minutes with 6.5 hours of use.  Probably another important point is that I've woke up feeling that I had a bad night the last two nights with the new pressure of 12, with the settings of 5/20 I have felt better and sometimes actually stunned to see my AHI elevated, which is probably actually lower than my normal AHI score prior to CPAP.

A couple of things I'm wondering about ASV and bare in mind is all I've been doing has been reading up on central apnea, how will an ASV machine respond to hyponea?   Does the machine sense a low tidal volume and kick in, possibly making me buck (giving me a breath while I'm exhaling), or are the machines good enough to deliver the breath at the right time?

I'm thinking I should try another night of this new pressure to be certain of a trend and yet I'm also wondering why my CA's have dropped like a rock while my OA's and hyponeas have gone sky high (for me).  I thought having more pressure (more air blowing) would blow off too much CO2 and I would compensate by not breathing, but perhaps the difference is instead of not breathing I'm just taking too little of a tidal volume all night long.  Thoughts?

Oh, last night I did cut the EPA down from 2 to 1, I wanted to see if I could tolerate a reduction before eliminating it completely and my numbers were pretty much identical.

[Sleeprider]

I think reducing EPR will eventually be needed. Your AHI is only a small part of the equation in your results. I think the bigger problem is that even when you don't record events, your respiration is abnormally rapid and shallow. The inefficiency of this is that you end up inhaling mostly the air you just exhaled incompletely.

The reason I didn't go all in on the idea you need ASV, is because for someone with this problem, AVAPS is often preferred to provide pressure support targeting a minimum average ventilation rate over several breaths. In the case where you are "panting", AVAPS or iAVAPs will kick in and hold IPAP pressure long enough to cause you to take a real breath of "normal" volume, then return to EPAP to encourage a full exhale. The machine targets respiratory volume which part of the problem we see here. On the other hand, it is not a great solution for central apnea. For central apnea, the ASV is the gold standard. To be honest, we don't know if you actually have a central apnea or a more complex issue we can't understand based on CPAP machine data, and this is the reason you're going to end up back with the doctors.

Some of your other questions regard hypopnea. The ASV provide pressure support during inspiration to increase volume and prevent hypopnea, periodic breathing and other breathing abnormalities. It would take a trial on ASV to see if it could resolve your short-wave respiration. As I said before, I have not encountered your particular issues on the forum before, so I don't know the approach and outcome for different therapy options. I am very interested to see how his in fact resolves, but I don't think we can help you on the forum, especially with the current auto CPAP.

The rest of your post deals with the changes you feel with pressure at 5-20 vs fixed 12, and that CA has gone down, while OA has increased. You might try a soft cervical collar to prevent the OA and H events. Higher pressure seems bad for you, lower pressure may further reduce CA. You clearly show signs of central and complex apnea and I just don't know how the "panting" was missed in your titration study, since it surely was performed at fixed pressures. Do you have the titration results?