sleep study attached, looking for advice

[jgrizz80]

So i broke down and purchased a used Aircurve 10 Vauto this past week  with 700 hours on it for $300.  I think i got a pretty smoking deal considering most people seem to want that price for a used autoset.  my current prescription from the doctor is straight cpap at 15cm.  I set up the new machine in Vauto mode, min epap 13.0, max ipap 25.0, PS 0.0, so it should act as basically an auto cpap and i figured 2 below my prescription would get me a good starting point.  This is the chart from my 1st night with it, although i am battling a pretty nast head cold right now, so i don't really know how effective any of this is at the time being until i get over this.  It seems like an awful lot of centrals still, but zooming in on them, they have the large breath taken before them, so i'm guessing i was awake for a good portion of them.  At least i finally have a machine where i can see what is going on at least.  

here is my entire night zoomed out.  let me know if there is anywhere i should zoom in on.

[Sleeprider]

You got a great deal on the Vauto, but lots of centrals in the results. Do you want to try some pressure support to see if the hypopnea can be reduced? The potential risk is that CA events may increase. If you want to give it a try, we can use a fairly low PS 2.0 and see how that works out. I am completely uncertain how you will respond as you have had a history of CA events. If you want to give it a try, I would go Vauto mode, EPAP min 10, EPAP max 14.0, PS 2.0.

[jgrizz80]

I had actually been thinking about trying out 12-16 with a ps of 2 since the machine took it near 18 on it’s own last night. Ignore you think 10-14 would work better I’ll give it a try. 

I know there has to be a magic setting somewhere that will work for me, but at least I have a machine now that I have options with.

[jgrizz80]

So here is last nights disaster of a night.  I think i really need to get over this head cold before i am ever going to get any kind of real data to work with, but this is at least some data none the less.  

the large break in the data is from waking up a second time and having a coughing fit, then laying back down figuring i would wait a few minutes before putting my mask on to see if it would subside.  I ended up falling asleep and my wife said i was snoring, and she did hear me gasping for air at some point i guess.  I zoomed in on a bunch of areas for you to take a look at.

[Sleeprider]

I'm impressed! All categories of event increased. I don't often see that. I don't think the answer is more pressure. Let's review what you have tried so far. We started with a sleep study that showed you actually have a considerable percentage of central apnea. Your doctor recommended CPAP at 9.0 which was shown in your titration study to have an AHI of 8.8. Your BEST titration result was actually a pressure of 5.0 cm which resulted in an AHI of 1.8 and a minimum SpO2 of 92.

You were issued a "brick" with no data, but encountered numerous problems tolerating the machine, probably due to events you could not see. Your sleep study results clearly indicate a correlation between pressure and increased apnea, and last night's results were consistent with that finding. Even though you have a really nice machine that is capable of all kinds of tricks, I think we need to go back to the beginning and use low pressure. My preference would be to use CPAP mode at 5.0 to see what happens and get a baseline. According to your sleep study chart, you were evaluated for 1:08:22 at CPAP of 5.0 and you only had one hypopnea. The AHI was incorrectly calculate at 1.8 and should have been about 0.9.

You probably have complex sleep apnea and need ASV for the best treatment, but if we can get your AHI near 1.0 using low pressure, that is going to tell us a lot. More importantly, we need to find out if you can be comfortable and tolerate such low pressure.

BTW, if it isn't already obvious, you need to find medical assistance that didn't get their sleep study credentials from a Cracker Jack box. I hope you have returned the original brick CPAP and informed your insurance that it should not be reimbursed.

[jgrizz80]

the bad part is i've tried lower a couple of nights with the old machine, at 5 i felt like i was suffocating and never felt comfortable, but i powered through it and still had an AHI of 5.something.  9 cm netted me a constant AHI over 5 and multiple awakenings throughout the night.  The latest prescription of 15cm i'd like to actually give more time with this data capable machine and see where it ends up once i'm over this cold.

Even during the second titration study, which i haven't got the results from yet, I never felt like i slept well, although they did tell me i got to rem sleep with 15cm.  Still, it's in an awful sleeping environment, with a very limited window looking at how i'm actually sleeping.  


I've also thought about trying it on 7-25 with PS of 0 (so basically just an autoset) and just see where the machine wants to take it for a few nights.  


The zoomed in areas of centrals, do they look like true centrals to you, or just SWJ?



As far as the brick goes, i haven't returned it, because after 7 months, i'm sure the DME has already been paid for it, and if anything, i'll sell it online and try to recoup some of my money from buying the Vauto.  And with the Vauto, it was a good price, figured it offered me more options that just an autoset, and if this machine doesn't work out, i'm only into it for 300 bucks, so i'm sure i can sell it for that again or even possibly make a few dollars on it.

[Sleeprider]

If you have tried the lower pressure, then I'm all game to try higher pressures. Do you want to try higher pressure support? Pressure support is a common treatment for hypopnea, but again may increase centrals. It resolves flow limitation which is present in your results when obstructive apnea and hypopnea occur. As far as results from last night, you had two periods where the machine was decreasing pressure at 23:20 and 04:15 that look pretty good. I don't know if that is helpful, but at least is was a quiet time for events.

[jgrizz80]

how much pressure support would you go?  4? keep the min and max epap the same?

[Sleeprider]

4 is typical in bilevel and you will learn very quickly if it increases CA. If not, then I would expect more comfort and improved hypopnea and FL results. This is kind of uncharted territory for complex apnea, and the usual advise is limited pressure support and a narrow or fixed range of pressure.

[jgrizz80]

with that in mind, would i be better off to go back to the prescription of 15cm straight and 0PS  or maybe 14-16 0 ps and get a few nights data to see what is really going on before i start messing with adding pressure support?