Struggling with BiPAP AutoCurve VAUTO--Central Apneas

[Paul Massie]

Here is my story:
·       Working with a Pulmonary Dr. other issues, during this time period the Dr. kept after me as he felt I had many of the symptoms of sleep apnea.  Although I had at times awoken from sleep with breathing issues, I attributed it to my weight, sinus/allergy or bronchial issues. And, I felt my 3-6 trips to the bathroom were due to my prostate.  Although overweight, I do not snore unless I roll on my back which is almost never.
·       I finally conceded to an in-home sleep test when it appeared to me there was not much more he could or would do for me.  I had lost some weight, was over my bronchial issues so I set out to prove him wrong.  I had what I considered a pretty good night sleep so felt I had accomplished my goal.  Unfortunately, he was right.  Here are the results of my first in-home test.
·       1st Test—In-Home Test:
o   Monitoring time = 489.0 minutes
o   Overall RDI was 15.2/hour
o   Supine RDI = 71.0; with central apnea index of 3.1 per hour.
o   Total of 124 respiratory disturbances out of which 41 were apneas
§  7 Obstructive
§  25 Central
§  9 Mixed
o   Total of 83 Hypopneas
o   Oxygen nadir was 83% during sleep
o   Patient was supine for 3.8% of study
·       Physician Impressions:
o   Moderate Obstructive Sleep apnea (OSA)
o   Moderate Oxygen Desaturation
·       Diagnosis:
o   Obstructive Sleep Apnea, Supine Position Exacerbated
o   Nocturnal Hypoxemia
·       Recommendations:
o   Auto CPAP w/ settings range of 6 to 20 cm H2O then adjusted according to review, downloads and patient assessments
·       Started Auto CPAP early October 2018:
o   ResMed AirSense 10 Auto
o   Original setting 6-15 cm H2O
o   Adjustments were made but I don’t remember them.  I struggled to get to sleep with it due to constant pressure but once a sleep I sync’ed up with it.
o   I did notice improvement getting up less in the night, waking up earlier and with a bit more energy.
o   Direct injection of humidity was immensely beneficial and did not get my typical sinus infection, or more, this year which is almost an annual occurrence.
o   My AHI settled in around 8 per hour after two months and I was getting up about 2-3X’s per night which was about half as much.
o   I was using my Auto CPAP for an average of 8 hours (most nights I struggled to get to sleep with it but forced myself as I did see benefits the next day)
o   My Dr. felt we could do better and my Central Apneas were not being resolved.
o   He ordered an in-lab Sleep test for a BiPAP machine
·       2nd Test—In-Lab for BiPAP Machine:
o   I did have a sleeping pill to help (I do not use them otherwise)
o   Monitoring time = 426 minutes
o   Sleep architecture is abnormal with decreased stage REM sleep
o   Latency to sleep onset is 3.5 minutes (rapid)
o   Latency to REM onset is 257 minutes (delayed)
o   Sleep efficiency is normal 87%
o   Nasal BiPAP (I actually used my nasal pillow)
o   Titrated up to a maximum pressure of 15/11 cm H2O
o   At 14/9 H2O pressure, the Apnea-Hypopnea Index is reduced to 8.1 (all central apneas)
o   Oxygenation is maintained above 89%
o   Physician Impressions:
§  Study consistent with obstructive and complex sleep apnea optimally controlled by nasal BIPAP at 14/9 cmH20
o   I was placed on a ResMed AirCurve 10 VAUTO
o   Settings VPAPauto PS 5.0 over 7.0-16.0 (cmH2O)
§  Initial settings caused severe burping, belly bloating and passing of gas (my wife was not happy as I now was keeping her awake
o   You can see my following setting changes in attachment since going on BiPAP January 7, 2019.
o   With this new BIPAP my AHI count has jumped up substantially and lately my usage has dropped below compliance.
o   I say my Dr. who ordered a new In-Lab sleep test for possible ASV machine
·       3rd Test—In-Lab for ASV Machine:
o   I struggled with this test severally.  Even though I took a sleeping pill could not get to sleep.  Air was aggressively forced causing burping, bloating and passing of gas
o   Monitoring time = 464 Minutes
o   Sleep architecture is abnormal with increased stage 1 and decreased stage REM sleep
o   Latency to sleep onset is 1.5 minutes (immediate)
o   Latency to REM onset is 291 minutes (delayed)
o   Sleep efficiency is decreased at 63%
o   Initiated on nasal ASV and titrated upwards to a level of EPAP = 6, maxPS=17, MinPS=5cmH2) pressure.  At up to and including Maximal pressure, the Apnea-Hypopnea Index remains elevated at 60.0, while oxygenation is maintained above 92%.
o   Although not documented in test results I was switched to a full-face mask with similar results (a horrible night)
o   Patient is then initiated on a nasal BIPAP (actually it was using the full-face mask again) at his request and titrated up to a maximum pressure of 13/7 cm H20.  At 13/7 H20 pressure, the Apnea-Hypopnea Index is reduced to 0.0, and oxygenation is maintained above 92%.
o   I remained on BIPAP as I did not tolerate the ASV machine or settings and was switched to a full-face mask which as not proven to be effective.

Sorry for the long diatribe but felt more info would be better than leaving some clues out.  I have been back to my Dr. who seems stumped and is just guessing now.  They set my BIPAP and then forget about it and me until I call back which can take days for the next tweak.  Hence, I started searching the web.
 
I have tried switching between nasal pillows, nasal cushions and full-face mask with similar results.
 
I have found your forum very helpful along with SleepyHead software.
 
I’m going to attach my “Statistics” tab data first and let you advise me what else you need to see.  Unfortunately, I don’t have any of my Auto CPAP data other than what is on my ResMed MyAir report.
 
All adjustments to my AutoCurve have been from the sleep lab until April 3.  My original strategy was to look at my history and set it back to the best settings so far.  Seemed like I was on the right track the first two days but then went off the rail.  Last night I dialed my EPAP and PS numbers down which made it easier to breath and lowered my numbers, however, I still took it off as I felt I wasn’t breathing as well as when I take it off.
 
I would like to make this work.  In addition to the direct-injection humidity benefits, I am aware of the health benefits of getting a full night sleep which I have not had for years… and therefore the health risks that come from not getting enough sleep.

[Sleeprider]

Paul, thanks for joining. Your problem is primarily a high level of central apnea arising from the use of pressure support in your bilevel. I assume you previously used CPAP which did not separate epap and ipap pressure by the 4 or more cm of pressure support you are currently using. Normally when we see complex apnea, or CPAP onset central apnea, it looks a great deal like your results, with high mixed apnea.

When central apnea is present in this large amount, we will start looking at ASV as a solution, but as an interim measure, recommend lower pressure and lower pressure support. You are currently using PS 5.0 over 7-14 pressure. I would encourage you to consider PS 2 over 5-10 pressure and see where that takes you. With that said, your AHI has been consistently high over your history, and ASV is going to be the right answer. The thing is that ASV takes some time to get accustomed to and there is a lot of personal experience on this forum to help you with techniques to make the transitions easier.

Default ASV pressure is EPAP range of 4 to 15, PS range of 2 to 15 cm in ASVauto mode on the Resmed Aircurve 10 Vauto. The machine will automatically increase EPAP pressure if it detects obstructive apnea, and the pressure support is used to treat CA and hypopnea. You complained of aerophagia (air ingestion), and there are some techniques that can be used to help resolve that problem as well.

An alternative to ASV is to use CPAP in combination with an oxygen generator to offset the desaturation of central and obstructive apnea. An additional alternative that applies to a few individual is to use Enhanced Expiratory Rebreathing Space (EERS) to maintain CO2, even with bilevel therapy. http://www.apneaboard.com/wiki/index.php...ace_(EERS)

I would encourage you to pursue the ASV solution and work with that to treat the disruption and aerophagia that were a problem in your trial. Most of our members using ASV eventually or immediately find relief and comfort. You seem to tolerate pressures that should result in efficacy with the ASV, but it may be necessary to limit some of the default settings. If you're more adventurous, you can try EERS to see if your central apnea problem arises from hypocapnea and can be resolved by conserving the CO2 in your breathing circuit. Anyway, consider these as alternatives, and we can discuss how you want to narrow down your choices.

[Paul Massie]

Thanks a bunch! Let me go through all of this and see where we go. I'm afraid you are righty on the ASV but had a terrible night in the sleep lab with it. Not sure if it was me or the sleep lab techs experience? Not sure if Dr. or Insurance will prescribe it based on my results. I'll give the above a chance to see what happens and go from there.

When you are talking about default ASV pressure and then giving ranges did you mean the Resmed AirCurve 10 ASV or is this something my AirCurve 10 VAuto can do (I'll try the settings above first)?

Anything to do with these other settings:
-Ti Max = 2.0s
-Ti Min = 0.3s
-Trigger = Med
-Cycle = Med

[Sleeprider]

The Vauto cannot provide the adaptive pressure support and backup breathing rate of the ASV. The Resmed Aircurve 10 ASV works by keeping the airway patent against obstructive apnea using the exhale pressure (EPAP). That pressure can automatically adjust.  When you have a central apnea, the machine will provide as much pressure support as needed to cause you to take a breath.  If the airway is open and not obstructed you will breathe at your normal rate per minute and volume per breath.  Sometimes the ASV seems to provide a breath when you do not need or want it, and the users here on the forum have used what they call a "blow-back" technique to settle the machine down.  It can take several days or even weeks to fully adapt to the ASV pressure changes, but most users get very comfortable in a short period of time, and even describe the machine as learning their breathing patter. It's probably the other way around, but either way, it does eventually get easier.  I can show you lots of stories of other users of ASV here and show you how the pressure is titrated.  We don't know what method was used in your sleep study, and if the technician used manual control, it may have been a poor representation of what the AutoASV can do for you. Keep in mind the titration process trials various pressure settings, many of which will be wrong and uncomfortable, to find the one that works. This trial and error approach is rarely a wonderful experience, but once you have the machine and get it dialed in, it can do miracles.

Your experience has been shared by many others here. You are nearly there, getting the most sophisticated and amazing machine to treat complex apnea.  Please use this opportunity to get the therapy you need. It will work out and will become comfortable in spite of your brief uncomfortable introduction to it.

[Paul Massie]

Started the night just as suggested:
PS = 2 over 5-10; Breathing felt a bit restricted but tried to stick it out; unconsciously took off head gear a couple of times--had very few to no AHI/hr during short periods used (48/50/24 min sessions).
Changed settings to:
PS = 3 over 5-11; Breathing more comfortable and kept head-gear on longer than I have the last few weeks but AHI/hr jumped to 7.90; Still, over all best night I have had in a while with the BIPAP (4hr11min session)
Tonight I'm going to go in the middle:
PS = 2.6 over 5-10; lower pressure and variability seemed to make a difference... if I can keep the equipment on.

Full night AHI = 6.52AHI for 6hr17min combined usage

[Kosoku]

Just as an FYI, I was getting centrals on my Vauto until I made the following changes below. Now I am not saying it will work for you, just saying it might. To me Very High setting feels more natural than Medium. Again this is just me.

-Trigger =Very High
-Cycle = Very High

[Michaely6]

I too changed my trigger settings to very high and left cycle on medium and literally all of my central disappeared. I had more centrals at first than you did Paul. Very high cycle seems off to me which is why I kept it on medium. I recommend you try trigger very high and cycle medium first. Good luck.

[Paul Massie]

Thanks.  What are you setting your PS, EPAP and IPAP numbers to?

[Kosoku]

PS - 4
EPAP 13.6 so an IPAP of 17.6.
For me anything less than 13 I feel like I am not getting enough air.
But remember this is what works for me.

[Paul Massie]

Still struggling, what appears to be working or comfortable one night turns out to not work later that night or on another day.  I know I am not grinding it out like I did on the CPAP but I never felt like I gasping for air on the Auto CPAP like I am on the BiPAP.

4/11/19 tried SleepRider's suggestion of PS 2 over 5-10 pressure.  At first I thought I could slow my breathing down and it would work.  However, later in the night I unconsciously pulled off my headgear.  Tried to hook up and go again but same thing so later in the night I switched to PS 3 over 5-11 and was able to keep headgear on for several hours until late morning.  Had a better AHI night.

4/12/19 tried to stay at PS 3 over 5-10 and set "Trigger to Very High" and had fewer AHI, but only used for about 3.5 hours.

4/13/19 tried to stay at PS 3 over 5-10 but could not get to sleep.  Have to admit to fiddling with settings several times to see if I could get more comfortable.  Turned "Trigger back to Medium" and PS 3 over 5-11.  Seemed to make no difference but I was so tired I was able to sleep with my headgear/pillows for several hours.

Noticed on my 4/13 daily graphs my flow rate scale and reduced fairly dramatically vs. past nights???


Although I do feel the lower pressures help reduce my AHIs, I can't seem to stabilize.  What works one night doesn't the next.  What I think is happening is that breathing becomes labored or out of sync and I stay awake when I should fall asleep.  I finally start to doze-off and then have an apnea event that wakes me back up, I get into this cycle and event after event makes me feel like I am gasping for air and I take off my mask.  I am then able to sleep without the mask better and doze off.  Later in the night, I wake-up, go to the bathroom and start the process all over.  About 4am-6am I try again and this time get a longer stretch with the BiPAP system but I am sleeping in until 10am to 11am ET time to try to hit compliance (good thing I am retired.)  I'm in a viscous cycle of sleeping in too late and then going to sleep to late(or visa versa.)

I'll probably have to go back to my Dr. to talk about ASV, but hate to make the big financial move only to find out I have the same issues as the BiPAP and then I'm stuck either scrapping the whole program or starting all over on a 3rd machine.  I already have 3-months payments for CPAP and now 3-months payments for BiPAP.  I'll be starting all over when I have just about payed for a CPAP if I had stuck with it.  Also, he may not agree to put me on ASV due to my failed sleep test???  I do like the way the BiPAP breaths in and out with you as I struggled to fall a sleep with the constant pressure of the CPAP.  However, I had fewer AHI's on CPAP and just about 100% compliance with around 8hours average usage.