[Treatment] Induced Centrals (5-8 pressure) Too Many to get Used to? Settings Change?

[suzdream]

Hello,

I have just received a resmed airsense autoset 10 for her with a airfit N20 small for her nasal mask. I have used it for two nights, and after approx 1.5-2 hours I start getting multiple clear airway events. 

The first night I kept completely waking up terrified and gasping for air, and after that happened about ten times I took the mask off for the night. The pressure was set at 6-16; EPR Ramp only 2 cmH20.

I phoned yesterday (I am renting a trial machine for this month) and she set the pressure to fixed 8, and EPR full time 3 cmH20.

Last night I did not have the repeated wakings where I thought and felt like I was going to die, but I did take my mask off after a couple hours. I was sleepy though and don't remember the same anger and awakening level as the previous night, but I must have been feeling crappy to take it off.

I will post some oscar charts, and if they are not the best ones please let me know and I can post whichever ones

Last night from 2am until 2:30 am (the worst part of the time I wore the mask) I had 20 clear airway events, 1 hypopnea (others at diff times), and 3 obstructive events. 

I am wondering if the pressure is too high and causing the centrals, and if the pressure is also too low to stop my obstructive events? It seemed like the events starte shortly after reaching that pressure, but that could have also been coincidence based on sleep cycle length?

I am not sure if I should try to change or remove the EPR setting (I dont actually know if it is on, but my reading on the forum people said that it usually is on my default now?). I read that this can help with induced centrals because it changes the actual pressure you have on exhale which is when obstructive events occur?

If anyone would kindly help I would really appreciate it I googled, but it doesn't sound like resmed has technical support on weekends  
Anyway, hopefully I didn't break any rules and I'm sorry if I did. I haven't slept in my entire life and now it is worse so my reading skills might be not awesome. 

Thanks for the help!

(also I am not sure on what people prefer vs attachments and inserting into the post... )

[jaswilliams]

Do you have a copy of your sleep study, to start with I suggest reducing EPR to 1 that may reduce the centrals give it a couple of nights to get used to the machine

[suzdream]

My sleep study was an at home version, and was "mild"  with a HI index of 7, and AI of 0.6 They said for the Apnea Index (AI) it was o.4 obstructive and 0.1 central. With a total of 4 apneas and 42 hypopneas. 

I can post the whole thing with redacted info if you need more info, but if this is all you need (just to know if I had centrals discovered during it), I wont bother

Thanks for the quick reply! I was just trying to edit my post to add this info and then got the ten min warning error, lol.

[Sleeprider]

It appears you have treatment emergent central apnea. Based on your sleep study results, you have far fewer events without CPAP, and it may require "adaptive servo ventilator" ASV therapy to remedy the central events. These kinds of central events sometimes diminish spontaneously as you adapt to CPAP therapy. CA events are typically made worse with varying pressure, high pressure and EPR. I don't want to get too personal, but if you are physically fit and of normal weight, then this makes obstructive apnea far less likely than central apnea. Also if you live at altitude that can greatly impact results.

In your chart, it would help to see the full night of therapy. We can only see from 1:42 to 2:30 because you zoomed in on that period of the flow rate chart. What we see here is the beginning of a second session with 30 minutes of ramp where events are not flagged or recorded. Ramp needs to be shorter or on auto. As soon as the therapy pressure is reached, we see many CA flags. It will be helpful to see a full night of therapy in future charts.

To reduce your events to the maximum extend possible I'm going to suggest you set the CPAP pressure to 6.0 and turn off EPR and turn off ramp. If this does not work and we still see CA events, you will need to request a clinical titration test which will attempt to find an effective CPAP pressure. The test should instruct the technician to move to bilevel and ASV if needed. Anyway, let's try the low fixed pressure without EPR or ramp and see what comes.

[suzdream]

If you would like alternate views from last night I am more than willing : (and if you already asked I am sorry). 

I had the EPR at 1 last night; but I will switch it off tonight, set the max pressure at 6, and turn the ramp off.

My bmi is 21; so I am not overweight, but I am probably not really "fit" either haha. 

I was diagnosed with ADD a long time ago, but was always tired as a kid. I slept in on Christmas multiple times, fell asleep in the car always- I didnt get my license until I was in my 20s I was so terrified of falling asleep driving, morning headaches that last all day lately, irritable, been told I snore, night sweats, concentration problems, fell asleep in movie theatres and always in front of the tv. 

I really wanted to try and pursue cpap related treatments for all of those reasons.  (I can't even describe how excited I was to wake up and feel like a new person hahah.)

I have also read about the exhale tube set up thing that lets people keep more CO2 to trigger their breathing. I might try to get figured out this week. I only have the trial for a month, and definitely don't want to buy one if they won't work, but I also don't want to go down the ASV path if I can avoid. 

The redmed lady said the adaptive machine required an in lab sleep study which had an 18 month wait, and it's also quite a bit over our coverage (but I think at that point I would try to get my own machine I guess, it's not like the resmed lady was around this weekend to change my settings.)

Thank you very much for your thorough and quick reply!!

Edit: I have been trying harder to get used to it. I wore the mask for most of the night last night to try and let my body adjust to the different (more efficient?) CO2 levels or whatever. 

I believe I was on my side last for awhile in the middle, but I can't sleep that way because my lower back hurts so much. So sadly it's not an option and I really need to make back sleeping work better for me.

[Sleeprider]

This is the Enhanced Expiratory Rebreathing Space EERS wiki http://www.apneaboard.com/wiki/index.php...ace_(EERS)

It's too bad that it takes 18 months to schedule a sleep study. Based on your low BMI, I think even your diagnostic study was probably mostly central in nature, so I'm not very confident EERS is a solution except to perhaps reduce events to pre-CPAP levels. You're giving it a good try and if it doesn't get sorted in a month or two, I think discontinuing therapy pending the sleep study may be the best course unless you procure your own ASV. Along those lines, keep an eye on the DotMed website. Sellers there often have the older model Resmed S9 VPAP Adapt #36007 which is a good ASV machine with data and I see them listed under $500 with low hours, and less with higher use hours, and there is one for $700 USD with zero hours. The Resmed Aircurve 10 ASV generally costs similar to Supplier #2. Any of those options would get you immediate treatment at a much lower cost than what you might obtain even 18 months from now.

[suzdream]

Thank you very much for the info!! 

It was going to cost us 700 out of pocket for the cpap through resmed, so I can prob convince my husband to spend the same on something better ourselves, if needed.

Last night was a little better. I had the pressure set to 6, and ramp was on auto (I just realized you said to turn ramp off, sorry and whoops).

Here a screenshot from last night. I don't feel as bad as usual. I dreamed more than normal, and I only had a mild headache waking up (usually my head hurts a lot more when I wake up). 

The pressure of 6 did reduce my clear airways even further (42 CI last night vs 81 CI the night before with max 8 pressure).

Thanks for the tip on used ASVs! 

Should I change anything for tonight? max 5? or 5.5? Or just leave it at 6 and try to ride it out and see if I get used to it, and if they will recommend a diff machine/process based on this. Or maybe the lady will just hope I don't complain since my CI index is just barely over 5 now? (It's going to be an interesting conversation today when that resmed lady phones me, lol.)

Thanks again!! You guys are the best!!

[Gideon]

Provide a couple of 3-5 minute zoomed images of the CA events so we can see the waveform in the flow rate and possibly determine the nature of the centrals.

A VAuto will let us set Trigger sensitivity to high or very high which helps initiate a breath with less effort.

If These are Treatment-Emergent Central Apneas they MAY significantly decrease over 2-3 months as your body adjusts.

Treatments are
1. Time 2-3 months
2. ASV: this will resolve the events now (Most expensive of the machines)
3. EERS, an method of re-introducinga small amount of your exhaled air to increase your pCO2 in your blood to consistently over your apneic threshold.
4. VAuto, will not cure or totally fix but with high/very high trigger sensitivity lowers the incidence of CA events in some individuals.

Read this Wiki to learn what is going on. http://www.apneaboard.com/wiki/index.php...tral_Apnea

[suzdream]

Thank you for the reply! 

Yesterday I noticed my respiratory rate and minute vent were higher than google said they should be, so I wondered if it was affecting my blood CO2 levels and ph, and then affecting my threshold for central apneas while I was sleeping. 

I don't consider myself an overbreather, but after reading a ton of info yesterday I wondered if I was and didn't know it. Last night I focused on breathing slow and not too deep (before bed, just to try to get my brain in the habit of breathing slower?). I have no idea if this is a thing, but it's easy and prob harmless.

Thanks for the wiki link! Lots of great info in it!!

Our insurance might cover a rental for 3 months, so I may just try to tough it out and see what happens. If I am nearing the end of this month and still at the same level, I may change my mind on that. I read that approx half of people with treatment emergent centrals will have them go away as their body adjusts, so, fingers crossed.

I am planning on asking about the Enhanced Expiratory Rebreathing Space, but I am not confident the resmed lady will have any idea what I am asking, lol. I will ask just in case though. I saw one random comment on reddit about someone's respiratory therapist and that they did that. I was planning on looking into getting the safety valve part in canada (it seemed the hardest to source?), just so I could try everything and know that I did fully try. Otherwise I will try to get it from the states, but it might take a few weeks :

Here are some charts. If I dont have some charts ordered correctly, please let me know and I will fix. I tried to grab some centrals where the pattern was different, since it didn't seem like much of a point to post the same thing 3x :

Thanks again for all the help : The people here are amazing and so useful (wish I could say the same for the medical field people here lol)

[suzdream]

Ughhh the resmed lady just called and said 6 is too low to overcome obstructions and she is turning it back up. It sounded like she will continue to increase the pressure because I described waking up not being able to breathe so she said my events being aren't managed yet  ?? ?

So I guess I will need to show her I am having lots (or more) events still? I didn't mention central vs obstructive, just that this felt different than before and felt new, and I wondered if a lower pressure would help my brain "get used to the machine".

Last night I had the lowest AHI yet too.  I wonder if she is even checking my real stats?

She is also turning EPR back on and asked if I went into the "clinicians" menu... I just said oh it was in a comfort menu I thought it was unimportant comfort stuff ??

I asked her what if this doesn't work? And she said we can try a new mask ??  I am not sure her rationale in that, but I guess asking her about an EERS is out ??

It's going to be a long summer I think ?