[Pressure] New xPAP user - Question about Centrals on OSCAR

[AeroM]

Hi, I am new to sleep apnea treatment, and I was hoping someone could help me interpret my OSCAR data (end of post). I am particularly interested in why my first sleep study was mostly hypopneas, whereas my follow-up CPAP titration study and my first night of APAP at home were mostly central apneas. Any suggestion on how to reduce the number of central apneas/clear airway events would be greatly appreciated.

Note, I am a new user, so I will post images from the sleep study summaries and graphs in follow-up posts if I can shrink the files enough or if my image storage limit is increased. 

Background:
 After years of poor sleep, morning headaches, occasional brain fog, and struggling to stay awake, I was sent by my doc to  a sleep lab for an overnight multi-channel polysomnogram, and the following are the results from that study.

Initial Sleep Study: 
I was diagnosed with mild sleep apnea (AHI = 8.9; Supine AHI 11.3/h). My SPO2 went to a low of 91%. During the study, I slept for 6.3 hours and had 3 central apneas and 53 hypopneas. If obstructive apneas, mixed apneas, and RERA's happened, they weren't recorded. There were 0 periodic limb movements (PLM = 0), 14 limb movement events with an index of 2.2. Finally, there were 32 spontaneous arousals with an index of 5.1 arousals/hour of sleep. Snoring was noted. Heart rate was fine and everything else was normal.

CPAP Titration Sleep Study: 
Over the course of the night, my pressure was titrated up from 5 cmH2O to 9 cmH2O. The study states that I "responded well to 9 cmH2O, but there continued to be some respiratory events along with flow limitations, so a pressure of 10 may be more optimal." I slept for 7.2 hours with an AHI = 8.4. They noted 3 obstructive apneas, 0 mixed apneas, 55 central apneas, and 3 hypopneas. Total AI was 8.0. There were 5 RERAs for an RDI of 9.1. Cheyne Stokes was not noted. SPO2 went to a low of 88%. There were 48 periodic limb movement events (PLM = 6.6). 6 of these were associated with arousals (0.8 events/h) There were 108 limb movement events with an index of 14.9. Finally, there were 28 spontaneous arousals with an index of 3.9 arousals/hour. 

First night on APAP: 
 I used a ResMed Airsense 10 Autoset for Her with the standard algorithm and a standard response. I am using an AirTouch F20 Full Face mask because I tend to wake up with my mouth open. I used an EPR of 1 (ramp only). Min pressure was 10 and max pressure was 13. Ramp was set to auto. My AHI was 14.9, all of them apparently centrals/clear airway events. I woke up feeling foggy (no better than before treatment) and my chest has been a bit sore all day. I think this is due to the air I must have been swallowing last night.

   

[staceyburke]

There are no settings (on an autoset) that can treat centrals you need a special pap machine to treat them. With that said you can try to avoid them.  One thing that helps is a constant pressure.  I would set min at 9 and max at 9 with epr off. That would give you the best chance to avoid them.

[AeroM]

Which pap machine would be best suited for treating centrals that mushroomed after using a CPAP?

Also, I saw that the AutoSet set my median pressure to 10.24 with 95% below 11.24. Do you still recommend going with a pressure of 9?

[staceyburke]

RESMED S10 ASV is the pap of choice on this board. I have a bipap so I’m not the one to give much info on them. 

You only had 2 minor events and that was due to mask leaks so I don’t think you need that high but if you want to try higher that’s no problem. You also mentioned pain in your chest and some first time users have that and we advise a lower pressure to help.

[SarcasticDave94]

I think that with the data presented, the diagnosic study might have been predominently a Central Hypopnoea issue and then under titration pressure Central Apneas presented. And now your AutoSet shows CA as well.

Actions I'd consider is turning off both Ramp and EPR, and maybe also going with a straight CPAP pressure of 10 or so to see how many CA can be avoided. You'll need to note the CA issue, along with the chronic fatigue and you'd need to report this to the physician. You would then need to get the doctor to consider the ResMed AirCurve 10 ASV as it's the only machine that treated Central Apnea.

[AeroM]

Awesome, thanks to you both for the feedback. I will try out your suggestions.

[AeroM]

Here is the OSCAR screenshot from last night after turning off Ramp and EPR and setting the machine to a fixed pressure of 9. Looks like the number of clear airway events/central apneas is relatively unchanged, but there were more hypopneas compared to last night. I will try again tonight with a pressure of 10 to see if the hypopneas can be eliminated. I have read that "treatment emergent central apneas (TECA)," apneas that appear after treatment with CPAP, sometimes go away as the patient becomes accustomed to CPAP treatment. Does anyone have any experience with this or know someone who does? I am wondering how long it typically takes for TECAs to resolve if they are going to resolve and also by how much these events tend to decrease over time (I know everyone is different and I need to be patient, just looking for some additional info). Thanks! 

   

[Gideon]

I would like to see a 10 minute zoomed view of your CA clusters.

Reading your post I think of treatment emergent. Central Apnea. These typically go away in 2-3 months as your body adjusts to the CPAP treatment.

This occurs, only to a 'lucky' few, because a PAP machine improves your breathing. Improves the intake of oxygen and improves the flushing of CO2,. Sounds all good doesn't it. The issue is that in the lucky few the CO2 gets flushed out of the body to below the apneic threshold. When this happens you have a central Apnea and stop breathing. Now that you have stopped breathing your CO2 levels slowly build up and you begin breathing with small breaths, gradually increasing until you have enough CO2 and your breaths start to slow down as the cycle repeats.

That said you had a small amount of CA that is likely of ideopathic or unknown cause and identified in your diagnostic study and is likely to stick around without an ASV.

Your doctor will say you need to wait it out.

For now turn off EPR, because EPR facilitates the flushing of CO2, you have it on ramp only so your clusters of CA are not caused by this. And go to a CPAP, single pressure mode to reduce pressure fluctuations. The next step is to try to reduce pressure, but after we see what happens

[Gideon]

Let's now reduce pressure to 7

[kappa]

The emergence of PLM in your titration study (after not being reported in your baseline study) is interesting. It may be that they did not score leg movements during Hypopnea events - perhaps using AASM scoring guidelines where leg movements just before, during, and just after a respiratory event are not counted.

It may be that you have underlying PLM. While an ASV will probably get your breathing in order it may not help you feel any better if PLM is still causing arousals.