[Treatment] ASV settings for treatment of complex sleep apnea

[JoeyWallaby]

Treating silent reflux going well, have to be really strict on the diet but it does work... 

I feel like a lot of my breathing issues stem from a narrow palate, my tongue feels like it barely fits in my mouth at times. These images are examples of maxillary transverse deficiency, basically a narrow palate as far as I understand. Mine is only somewhat wider than these...

[Geer1]

That would primarily cause obstructive apnea. Even your original sleep study indicates central sleep apnea being the issue.

What diet are you doing? Just low acid? Or on an elimination style diet?

They started me out using PPIs and low acid diet. Perhaps helped but came right back when finished.

Built stilts for the head of my bead so sleeping on an angle. That seemed to help.

Then I went dairy free. I don't get as bloated as I used to when consuming dairy and acid symptoms haven't been as bad. I think it was the bloating primarily causing reflux in my case.

After travelling a bunch this summer I felt like I didn't need head of bed elevated anymore so have changed it back. I haven't seen my ENT to confirm if scope still shows sign of inflammation like it used to.

If you aren't yet doing elimination diet then my recommendation when you start would be dairy, wheat, soy and nuts free if you can make that work. My understanding is they are the main culprits. Eggs and a few others can be secondary but might be too restrictive to do everything at once so can do a further test on secondary items later. At home I don't find it that hard to do, just stick to meats, vegetables, rice, potatoes etc. On the road it is hard to find good restaurant meals free of all this stuff though.

[JoeyWallaby]

How does the sleep study indicate central sleep apnea being the issue?

Spontaneous arousals
9.3/hr
Respiratory arousals
4.8/hr
Hypopneas
4.2/hr
Central apneas
1.1/hr

I'm doing low acid with mostly plant foods, I'll try reintroducing some common trigger foods later (citrus, raw onion, etc). I haven't got the head of my bed elevated but I was thinking about it.

[Geer1]

How does the sleep study indicate central sleep apnea being the issue?

Spontaneous arousals
9.3/hr
Respiratory arousals
4.8/hr
Hypopneas
4.2/hr
Central apneas
1.1/hr

I'm doing low acid with mostly plant foods, I'll try reintroducing some common trigger foods later (citrus, raw onion, etc). I haven't got the head of my bed elevated but I was thinking about it.

I actually couldn't see your sleep study (no longer available) and was going off Sleeprider's post but your numbers support that obstructive apneas were not present. Doesn't indicate they are a problem, just indicates there is a higher chance the hypopneas and reras were also central in nature if no obstructive apnea were present. 

http://www.apneaboard.com/forums/Thread-...#pid314971

You have tried pretty much everything and then some to try and treat apnea/flow restriction. It kind of surprises me that you still think it is the primary problem when there are so many other possibilities.

I think trying to figure out/treat the GERD is a good step. I personally believe PPI's and even low acid diet are just bandaids treating the symptom and rarely the cause. I believe both are meant to be more of a diagnosing test but most doctors don't know how to diagnose the cause so they just tell people to stay on PPIs or diet for rest of their lives... For example my doctor wouldn't do radiography to determine if I had a hiatal hernia, said they rarely do surgery now and even if it was present would just tell me to take PPIs so just keep taking PPIs...

[JoeyWallaby]

Sleep study https://imgur.com/a/v2hSfJa

I don't have GERD actually, I have LPR. I don't get acid reflux or heartburn, I get pepsin reflux up to the pharynx. Causes sore throat, hoarse voice, pain swallowing and more.

Here's the real question: What CAN I do? If you look at charts with normal CPAP, I have obvious flow limitation and some obstructive apneas (maybe a few clear airways). If I bump up the inspiratory support to eliminate most flow limitations, I get tons of clear airways. LPR related? Maybe... I don't know. Then if I use ASV, I get tons of pressure cycling and instability.

I've heard centrals are pretty rare in young people? More likely that the clear airways are from LPR IMO, so if I could get that under control then BiLevel might work okay. Obviously if I have flow limitation and obstructive apneas, I must have some degree obstructive apnea. Would palate expansion cure me? No idea but it would probably help... out of all the risk factors for sleep apnea/UARS, narrow and high palate is the only one I have to a significant degree (excluding sleep bruxism, which is more of a symptom than risk factor).

I'm really tired of messing around with CPAP and my sleep bruxism is severe, I go through mouthguards in like 6 months or less. I'm really concerned about it, which ironically probably doesn't help.

[Sleeprider]

We see central apnea in people of all ages, sexes, and body types. My FIRST suspicion when a healthy-weight, athletic individual shows up on the forum with an unexpected sleep apnea diagnosis, is that they actually have central rather than obstructive apnea. It happens all the time, and the only reason it is considered rare, is that it is relatively unrecognized and undiagnosed.

Your sleep study identified 4 central apnea, no obstructive apnea and 15 hypopneas. The hypopnea were unclassified, and can be either central or obstructive. Your doctor "assumed" obstructive. When I look at that alongside your CPAP results with nearly 100% central events and no evidence of flow limitation or classic indicators of UARS, I "assume" central apnea is the predominate problem. You were getting fantastic results on ASV, then mper6794 and Geer1 started advocating the VPAP auto and you are clearly not doing well with that. I feel like this has moved backwards, and I don't know why that was allowed to happen. You had achieved consistly less than 1 AHI therapy.

[Geer1]

Most interesting to me is the lack of rem sleep.

You have never had a titration study / second study while on cpap? Imo that is what you can do that would be most beneficial although potentially expensive depending on your coverage etc.

Trial and error self diagnostics has been inconclusive. You need polysomnogram data indicating if pap treatment helps and to confirm if rem sleep is actually reduced, and if so why, or was just affected that single night.

It is too bad PSG is so expensive. If we could all do it for a week straight would probably answer a lot of our questions. We need to figure out how to do diy at home PSG level analysis for a reasonable cost.

I have been waiting to get PSG all year, delayed/cancelled again and again thanks to covid. Same thing I want confirmation as to whether pap treatment actually helps my breathing. My cpap data indicates when I do have restricted breathing it often ends up in arousal anyways so not sur how much it actually helps. I feel most refreshed when I sleep with it initially and then sleep a couple more hours without it.

[JoeyWallaby]

No they didn't do titration or anything because my AHI is under 15

I've been on and off using CPAP (bilevel or ASV) because I haven't been tolerating either well. I get dysphagia with both. Open airways on bilevel. Wake up during night on ASV and sometimes take mask off as well. Improvements with symptoms on both but only mild to somewhat moderate, the dysphagia is so bad, I hate it.

Trying to get another sleep study but it'll be at least six months if I do.

Maybe I need a stronger airway or something to tolerate the high pressure bursts from the ASV???

[Geer1]

You had achieved consistly less than 1 AHI therapy.

And it wasnt good enough hence why he wanted to try more. He has probably tried more than any other member on here, almost every machine possible, eers, medication etc. A large part of that due to this forums recommendations to keep trying and eventually will find the magic answer. Get a Vauto, try eers, get an ASV, list goes on and most before I started commenting. 

As far as SDB goes he needs to get medical help in diagnosing efficacy of pap treatments plain and simple. Wondering about surgery options see a very knowledgable ENT specializing in sleep disorders and get his thoughts. So not do surgery unless doctor can explain exactly why it is your issue and why it will help, surgery isn't time for guess and check. Rule out SDB issues definitively or find the solution.

As I have been saying for quite a while I believe there is more at play then disordered breathing. Jmo

Look into rem sleep. Treat gerd and any other digestive symptoms, stomach is the basis of our immune system and it must work properly. If any other symptoms and especially family history dont write off autoimmune. Testosterone, cortisol, thyroid and other hormone testing if not already done. Allergies, sensitivities. Just a few ideas of other things to look into, all commonly related to fatigue and poor sleep.

[Geer1]

Maybe I need a stronger airway or something to tolerate the high pressure bursts from the ASV???

Have you tried handcuffing the machine? Ie lowering max PS so that it acts more like a Vauto with only a slight extra kick to help a bit with centrals. If your min pa is 3 try a max PS of 6 or something like that. 

Gerd/LPR and aerophagia issues make me wonder about hiatal hernia.